Primary health care financing project evaluation, USAID/Bolivia, May 5-May 30, 1986

Midterm external evaluation covers the period 8/83-5/86 and is based, in part, on document review. The project has had a troubled history and is far from achieving its goals. Irreconcilable differences among the three participating co-ops, although recognized during PID revision, were not adequately addressed in the Project Paper. After a long power struggle over the ownership and control of PHC delivery modules (i.e., assets, personnel, and operations) - a struggle which began among the co-ops and later involved the emergent project Management Support Unit (MSU) - USAID/B temporarily assumed direct responsibility for project management, and then, in 9/85, it deobligated the project, eliminating any role for the co-ops, and reobligated it through a cooperative agreement with Management Services for Health (MSH). The 9/85 cooperative agreement introduced some important changes in the project, opening participation to virtually any community organization, while concentrating power in the MSU, which became a separate legal entity known as Proteccion a la Salud (PROSALUD). However, due to the haste with which it was drawn up and changes in key USAID/B staff, the 9/85 agreement retained some elements of the original design which had proven unsuitable and failed to reconceptualize other key areas, e.g., ownership of the modules, responsibilities for marketing activities and research, PROSALUD"s long-term role, and the identification of preferred self-financing mechanisms. Notwithstanding these problems of conceptualization and the operational problems created by Bolivia"s economic situation, PROSALUD, which is staffed with competent personnel, has been able to successfully screen several community organizations for their willingness to participate in and finance PHC services. By 3/86 PROSALUD was delivering PHC services in two level III facilities and restoring a level II center for operation in 5/86. The project will not be able to meet its targets unless it is extended through 4/90; the extension should have two phases, the first to demonstrate the economic self-sufficiency of the PHC modules, the second to prove PROSALUD"s self-financing capacity. Other recomendations are to: determine PROSALUD"s long-term relationship with the community organizations and set a schedule for MSH disengagement; make PROSALUD responsible for project research; improve marketing efforts; and reinforce health promotion at the community level.