Nicaragua decentralized health services project : midterm evaluation

Mid-term evaluation covers the period 3/93-12/95. Project performance has been mixed, with some components achieving all expected outcomes, while others have been delayed or had problems with the quality of products developed. In addition, project management has had some serious difficulties -- difficulties which have at times overshadowed real progress. In the accelerated start component, designed to provide analytical underpinning for the project, almost all studies have been completed and found acceptable. These include: a survey of ongoing and proposed donor activities; a cost containment and cost recovery assessment report; a preliminary analysis of the financial administration system for Ministry of Health (MINSA) services; an assessment of the MINSA's compliance with the financial conditions of its P.L. 480 Title III Agreement; an assessment of commodity needs; a study of tracking systems for commodities; and a financial management systems report. However, the human resources assessment has not been completed, and USAID/N has decided that further revisions would not be productive. The largest amount of disagreement on project emphasis has been in the MH/CS component. Major accomplishments in this component include: (1) community surveys in the four (now five) targeted Local Integrated Health Care Systems (SILAISs) to determine the nature and extent of health problems; (2) development of a permanent registry for children to facilitate delivery of services in the integrated model; (3) a survey of 57 oral rehydration units in the SILAISs to assess location as well as supplies and equipment available; and (4) a study of current acute respiratory infection (ARI) treatments, which led to changes in the clinics involved in the study. Other achievements have included surveys of care quality for pregnant women, an analysis of maternal mortality data, a workshop on family planning (FP), growth chart revisions, a nutrition study in Boaco to identify age where nutritional problems start, the introduction of DepoProvera in Jinotega, training in FP counseling in all the SILAISs, a review of MINSA's model for integrating MH/CS services in the SILAISs, and an analysis of the health problems in Ciudad Sandino. Despite these achievements, controversy remains over the direction of the component and the strategic role of immunizations. Though immunization is generally accepted as an entry point to MH/CS care, questions remain regarding how much immunization should be going on and who (the project or the lead PAHO agency) should be doing it. Further, workplans lack specificity needed to focus interventions in each SILAIS clearly on MH/CS priorities. restructuring the component to advance work in ARI, diarrheal diseases, and maternal health seems indicated. In the training and IEC (information, education, and communication) subcomponent, significant progress has been made in training key groups, although the lack of a human resource assessment impedes the development of a targeted training plan. The out-of-country training strategy appears to follow a demand driven approach tied to needs of the SILAISs. Care should be taken to ensure that requests continue to stay close to project priorities. Also, since IEC itself has not yet begun, USAID and MINSA should re-assess its utility for this project given that major World Bank funding is being provided for IEC. Performance on the commodities and logistics subcomponent has been of high quality. Stockouts are a problem, though less so in project-supported SILAISs. There is a high rate of FP product stockouts, and the high price of U.S.-sourced commodities is a concern. Also, a survey of warehouse conditions may be needed. The alternative sources of finance component has made limited progress; only two of four planned studies completed, one of which was submitted late and in draft form. Since financing MH/CS services is apparently a high government priority, all planned studies should be completed as soon as reasonably possible. Should project resources be limited, financing from other donors should be found. Progress towards the objectives of the management, finance, and decentralization component has been systematic and sustained. The products delivered meet MINSA's needs. As for project management by Management Sciences for Health (MSH), some deficiencies may be due to the assignment of too many tasks to the Chief of Party. Reporting for the MH/CS component could be improved, and in some cases, notably immunization policy and the acceptability of key studies and certain workplans, communications can be dramatically improved. Also, there is need for increased donor coordination.