Midterm evaluation of the PROFAMILIA [Asociacion Pro-Bienestar de la Familia Nicaraguense] diversification, sustainability, and social marketing grant : executive summary

Midterm evaluation covers the period 1998-8/01. Achievements have been modest but impressive, given the turmoil in leadership and management that has characterized the grant since its inception. Specific achievements in the grant"s seven areas are noted below. (1) PROFAMILIA is very active in promoting reproductive rights, but seems to be avoiding conflict with the Catholic Church on controversial issues and positioning itself more as a family health provider than as a champion of reproductive rights. (2) The 1997 evaluation (XD-ABP-408-A) strongly criticized PROFAMILIA for emphasizing sterilization to increase CYPs. The new policy has been excessive in emphasizing temporary methods and limiting permanent ones. The grant target was to achieve a balance of 52% temporary and 48% permanent methods by the end of 2002. It is now at 84% temporary and 15% permanent, a trend unlikely to be reversed anytime soon. (3) PROFAMILIA clinics now provide 21 diversified services, and volume has grown significantly. Laboratory examinations, gynecology, and other medical services are the most popular. Although services have expanded rapidly, the motivation has been more to increase revenues than to address health needs. Quality of care has been enhanced and client satisfaction has improved significantly. A quality assurance system is being developed, but much more needs to be done in developing clinical standards and guidelines. There is not enough attention to RH services, especially gynecology and prenatal services. Delivery, even normal delivery, is restricted by PROFAMILIA regulations that are more oriented toward avoiding liability than improving health. As a result, the volume of deliveries is too small to maintain quality, be financially viable, or reduce maternal mortality. No steps are being taken to improve home deliveries. The community-based distribution (CBD) network is not involved at all. Weaknesses are also evident in supervision, laboratory procedures, clinical management of Pap tests, medical training, and physician recruitment. (4) Based on the 1997 evaluation, PROFAMILIA reduced the number of CBD posts and supervisors and actually experienced a rise in the number of visits and new users. Since sterilization has been de-emphasized, the CBD program now accounts for about 60% of PROFAMILIA"s contraceptive sales (excluding social marketing), up from 25% in 1997. The major problem is that CBD needs to be at least partially subsidized to be sustainable. (5) Ten youth clubs have been formed, 701 youth promoters have been trained, and 220 mini-clubs have been established. There were 4,335 youth members as of June 2001. Qualitative assessments indicate that these activities are successful in educating youth in sexuality, family planning, and HIV/AIDS. However, like CBD, the program must be subsidized if it is to survive. One group that seems to have been overlooked so far is out-of-school youth, especially those engaged in high- risk behaviors. (6) No strategic plan to improve management capacity and sustainability has yet been developed. Management and organization are significant problems. Leadership changes have affected operations. The current structure is unsustainable, marked by a lack of consensus on PROFAMILIA"s direction, role conflicts, a top-heavy central administration, overlap, duplication, and disputes about responsibilities. Fortunately, PROFAMILIA is about to have new leadership in September or October. Further, management capacity at PROFAMILIA is improving. TA over the past few years has been very helpful in building up essential management systems and in strengthening managers" knowledge and skills. Relations with USAID remain strong. Financial sustainability is 46% at mid-year. The regional centers currently average 69%, and the commercial market strategies project (CMS) clinics are at 87%, so it is likely that the organization as a whole can reach the 2002 target of 60% if it can bring costs under control and if social marketing is allowed to implement its programs. (7) Social marketing was to be the focal point of the grant. Unfortunately, it was combined with communications, which has confused much of the leadership of PROFAMILIA. However, the social marketing staff has produced excellent materials and campaigns for both components. It has increased sales and demand for services and generated revenue and has great potential. Nonetheless, due to interference from management and delays in contraceptive registration, it is well behind its 2002 target of 100% sustainability.