Primary health care project

The evaluation covered the period 9/82-12/85 and was based on site visits and interviews with project personnel. Activity to date has focused on the initial training of medical technicians and in-service management training of medical officers and other clinical and administrative personnel. But the obstacles to improving the health of the rural population cannot be addressed by formal training alone. There are limits in the coverage and quality of health care, yet the basic health program lacks the mechanisms to explain why. Incentives to motivate personnel are lacking at all levels. Medical officers exhibit and openly acknowledge poor preparation in the medical, management, and supervisory skills needed in their roles. Neither medical officers, technicians, nor community health workers were able to adequately describe their role in delivering priority health services. Except for the staff of the Expanded Program for Immunizations, realistic strategies for complete coverage of the target population have not been developed. While the provision of oral rehydration therapy has been mastered to a large extent by service personnel at every level, still there are examples of questionable quality and lack of completeness for each priority health service. Also, case follow-up has been conspicuously negelected. First-level supervisors have a low level of understanding of management methods for solving individual service delivery problems and generally lack a defined approach to addressing the coverage and effectiveness of priority health activities. The component to upgrade the management capacity of the integrated rural health complex (IRHC), an administrative unit consisting of a rural health center and four basic health units (BHU), is impractical. IRHC recurrent costs are unlikely to be sustained, since they account for a large portion of the per capita operating budget of provincial health departments. Moreover, the wisdom of replicating the IRHC approach is questionable because physicians are now being posted to BHU"s and reported patient loads in rural health centers are extremely low. The chief value of the project lies in a lesson for the design and implementation of a delivery system for selected services - that the role of basic health services cells should emphasize expanded field-based evaluation and epidemiologic analysis on services and their health impact. (Author abstract, modified)