Project assistance completion report : child survival project (391-0496)

Despite unprecedented challenges -- delayed start-up, evacuation of the TA team due to the Gulf War, loss of two Chiefs of Party, frequent turnover in counterparts, and a 73% budget reduction and shortened life span due to the Pressler Amendment -- the project was remarkably successful. Under the planning and management component, the project established federal and provincial Child Survival Steering Committees, which played an instrumental role in providing consensus and coordination; initiated a Donor Consortium to develop additional funding sources after passage of the Pressler Amendment; developed a computerized project monitoring and administration system; and recommended improvements in the medical supply depot procurement system and in critical areas relating to financing (rural health delivery, private managed care insurance, autonomy for government hospitals, and quality assurance in hospitals). The training component realized its goal of improving child health care through development of an integrated child health services package for any child coming to first-level health facilities. A training package was developed for medical officers and paramedics, and another package for supervisors of these two levels of personnel; training materials were translated into local languages. Federal and provincial Continuing Education Cells were formed. Under the information management component, a comprehensive Health Management Information System was developed for first-level facilities, although due to lack of funds it was instituted in only 40% of facilities. Training and consensus-building workshops and discussions were held, although it required funding from other donors to complete the training nationwide. Under the communications component, radio and TV messages were developed regarding diarrheal diseases, immunization, acute respiratory infection (ARI), and breastfeeding and nutrition; the messages blended health education with entertainment and targeted mothers with children under age 5. The project also provided training in interpersonal communication and counseling skills to health workers. Research efforts were mostly conducted under the Applied Diarrheal Disease Research project and had two foci: (1) 40 studies which helped to improve diarrheal disease, ARI, and nutrition programs; and (2) development of a research and policy network of over 90 child health professionals, in which scientists were trained in research proposal writing and given TA for their research as well as post-research training in biostatistics and data analysis. The result has been to establish, in a short time, a cadre of trained younger scientists who will benefit Pakistan for years to come. The following lessons were learned. (1) Consensus-building is lengthy and time-consuming, but well worth the effort, since it galvanizes the support that helps to guarantee ownership and hence sustainability. (2) System changes in a complex bureaucracy require in-depth understanding of decision making in that bureaucracy; involving government officers in the project from the beginning helps them to understand the process as a whole (not just from the perspective of their unit) and helps to ensure that their particular needs are addressed. This lesson was demonstrated in several project components. (3) In the communications component, exciting public-private ventures in radio and TV opened the way for future endeavors. The complementarity of mass media and interpersonal communication were clearly illustrated. (4) The silver lining of the Pressler cloud was that it made donor coordination and attention to cost absolutely essential. Several activities were implemented with the support of other donors and are being continued by other donors. Sustainability is likely because both the Pakistan government and other donors have a deep feeling of ownership.