Primary health care II : final evaluation

Final evaluation covered the period 1983-9/87 and was based on document review, site visits, and interviews with involved personnel. The project has met its quantitative goals for coverage and for pre-service training of two categories of volunteer health workers (VHW"s) - auxiliary midwives (AMW"s) and community health workers (CHW"s) - but the quality of both training and VHW performance has been uneven. AMW training appears much stronger than CHW training for a variety of reasons: AMW selection is stronger, and their training is task- and skill-oriented and it is longer. CHW training is based on an inappropriate academic, top-down approach. Likewise, the quality of AMW performance appears very good, while that of the CHW"s may be declining (although it is difficult to be sure due to a lack of reliable data). In general, VHW performance varies significantly by geographic area. It seems that VHW"s continue to emphasize curative over preventive care. Other project areas proceeded less well. (1) Supervision and management have been the weakest components. There are not enough Public Health Supervisors, and Township Medical Officers have little time for supervision; no guidelines or curricula were developed, and no training conducted for supervision. (2) Health education materials were unavailable to VHW"s (nor have VHW"s been trained in health education). (3) Information system development was inappropriate and should be discontinued. The approach is conceptually, methodologically, and technically flawed; it is also economically unfeasible. (4) Some 10-12 research and evaluation studies on relevant topics have been undertaken by individuals, but only one of these could be located by the evaluation team; thus, no assessment of their quality and utility was possible. No evaluation system has yet been designed, and it is still not possible to assess the project"s impact on health and VHW performance, to identify and analyze project problems, or to develop and test practical solutions to operational problems. The Rapid Survey and Operations Research workshops are steps in the right direction, however. (5) Finally, quantitative targets for participant training were not met due to delays in processing applicants (TA was delayed as well). The project was extended to permit completion of scheduled overseas training. It is recommended that A.I.D. support continue, with particular emphasis on improving service delivery, training, and supervision, and on developing an information system and a viable research and evaluation capability.