Rural health services development project : final report

Report focuses on Phase II conducted from 11/83-6/85 in Koro Cercle. During Phase I, numerous implementation problems were experienced due to such factors as the GOM"s inability to provide funding, poor contractor performance, poor site selection, and inadequate infrastructure (i.e., administration, facilities, supplies, and personnel). The major lesson of Phase I was that a PHC program which focuses on training village health workers (VHW"s) without strengthening the health infrastructure is inadequate. Phase II, designed to incorporate lessons from Phase I and to utilize remaining funds, accomplished most of its objectives. Facility renovation and construction were completed at the cercle and arrondissement levels; simple, durable, and repairable equipment was installed; administrative improvements were introduced; training and retraining of VHW"s and traditional birth attendants were continued; and PHC services were strengthened throughout Koro. The greater availability of health facilities in particular increased local confidence in the health system. On the negative side, several problems were encountered in obtaining supplies from UNICEF. An unplanned activity was the use of $110,000 for emergency meningitis and measles vaccinations in response to drought-related refugee problems in Timbuktu and Gao Regions. Two important factors in the success of Phase II were its focus on upgrading health infrastructure and its transfer of increased responsibility for planning and management to Malian staff. There is a good possibility that the Phase II model can be replicated elsewhere in Mali, given donor support, TA, and, most important, the development of a community financing scheme. A survey conducted in 2/85 indicated that people in Koro Cercle are willing to pay for health services and medications, and in fact, currently spend significant amounts on useless and/or dangerous treatments. This and other donor projects have proven that VHW"s, though useful in certain roles, cannot meet a majority of a population"s health care needs. Their training is extremely expensive and attrition can be as high as 90% only one year after training. A solid infrastructure, however, can reinforce VHW effectiveness and credibility. Other lessons are: (1) an agent should be hired to procure all medical supplies to avoid delays; (2) construction should be closely monitored to discourage dishonesty, wastefulness, or carelessness.