Mid-term evaluation : immunization/oral rehydration therapy services for child survival

The evaluation covers the period FY85-9/89. The project has significantly improved immunization coverage for children and pregnant women as well as the use of oral rehydration therapy. Coverage rates are 53% for polio, 49% for DPT, and 59% for measles for children under one year of age. The project has also made improvements in the cold chain, training capability, decentralized financing, and the health management information system, logistics, and administrative development. Despite these advances, the project is facing a major management crisis. The project administrative unit (PAU), which was initially effective in managing an increase in spending and an innovative decentralization of funding, is now a major bottleneck. In the last two trimesters, it has inhibited implementation by significantly reducing spending of project- managed funds. These problems are largely due to five separate audits, which resulted in the revision of financial control procedures and a reduction in PAU personnel. The project has also been plagued by design problems, highly politicized conditions in Guatemala, and staff shortages. The administrative crisis has severely constricted TA by both HealthCom and Management Sciences for Health (MSH). Nevertheless, the MSH team has made advances in improving the central-level health management information system, implementing an effective self-directed training program, developing logistic systems, diagnosing donor coordination problems, improving administration, and establishing a workplan. The MSH team has been less effective in broadening the planning process and has not participated directly in decentralization and reorganization efforts. This is primarily due to time pressures and the lack of clearly designated counterparts. The project has supported several strategies for delivering immunizations and ORT, but considerable uncertainty exists regarding the effectiveness of many of these, some of which may be duplicative and/or competing. The benefits and costs of the national vaccination days, channeling, mini-concentrations, and accelerated vaccination programs have not been sufficiently evaluated. Confusion over the role of homemade solutions for ORT should also be addressed: currently training includes a variety of homemade solutions, which if mixed improperly may be toxic. The fact that most health promoters are men has limited their effectivenss -- women are reluctant to have a man visiting their homes or to seek help in the homes of men. Also, addressing the particular problems of the Mayan population requires attention to beliefs about "hot" and "cold" illnesses and remedies, in addition to health education messages adapted to various languages and to illiterates. Training has been one of the more effective aspects of the project. Participants have been sent for overseas training; courses in oral rehydration therapy and immunization have been provided to community volunteers and institutional health workers; and training curricula, manuals, and guides have been developed and distributed. However, while skills and knowledge among many health providers have improved, many weaknesses remain. Efforts to evaluate and supervise training are seriously deficient, and the appropriate means for educating mothers have not been developed. Moreover, since the project focuses solely on oral rehydration therapy and immunizations, to the neglect of other child survival interventions, project-funded courses must be limited to these two topics or risk losing funds.