REDSO/WCA project assistance completion report for Mauritania rural health services project (682-0230)

The project suffered from an inordinately complex and overly ambitious design and was scaled back following a mid-term evaluation in 6/86; fewer studies were performed and the vast Expanded Program of Inmunization (EPI) extension component was curtailed due to transportation constraints. Problems with personnel in key TA roles delayed implementation and necessitated the first of three PACD extensions. Nonetheless, the project eventually met its reformulated objectives. Basic health services (which were previously concentrated in urban areas) were significantly expanded in the target regions, hundreds of health care workers received training, some studies were performed, and primary health care (PHC) was accepted by the Ministry of Health and Social Affairs (MOHSA) as the preferred way to provide rural health care at all levels. One of the project's greatest achievements was to facilitate the EPI program. Substantial EPI operations were begun in Trarza and Guidimaka, and operations were maintained in the Assaba region. More than 200 villages in the three regions received services. The project helped establish both mobile teams and fixed facilities, reaching 60% of the target population. EPI and community health worker (CHW) teams cooperated in activities, providing supervision and referrals. The EPI Documentation and Statistical Unit is now capable of producing annual report on EPI activities. In all, 25 mobile team nurses were retrained, 30 EPI fixed centers re-equipped and made functional, 10 regional EPI and central EPI depots equipped and established, and 13 dispensaries re-equipped. Functional PHC systems were proved to be feasible and technically acceptable in Mauritania. The project produced the following outputs: 600 village health workers trained or given refresher courses; central, regional, and departmental supervisors and trainers trained; 60 fixed center nurses re-trained; and over 300 new CHWs and traditional birth attendants (TBAs) trained. PHC is now well-integrated in the MOHSA and is likely to be sustained. Ministry personnel benefitted from training in management, epidemiology, computers, health information, training, supervision, and service delivery. In addition, supervision and village sensitization programs were made operational, and a National Commission for Primary Health Care was formed and was instrumental in integrating the various levels of the PHC network. Cost-recovery initiatives have provided funding for the activities of CHWs. Project-funded studies and data collection yielded information on topics such as morbidity rates, treatment, immunization, and pharmaceuticals. Lessons learned include the following. (1) Project designs must be realistic in defining goals and the resources and time required to achieve them. (2) The project suffered from the late arrival of key advisors. Also, advisors to the EPI and health information system programs departed at the end of their contracts, but their expertise was still needed. (3) The EPI program did not establish a reliable transportation system. This hurt efficiency.