Strengthening rural health delivery

The evaluation, based on document review, site visits, and interviews, covered the period through 11/86 and was conducted by a MOH/consultant/World Bank team. A strong and technically sound R&D unit was created within the MOH; this unit successfully developed and tested new interventions and in doing so created a positive climate for such strategies. In general, the interventions improved health delivery and seem, although this is difficult to quantify, to have raised rural health status. Outreach (home visits) and in-facility maternal child health activities were especially effective, although outreach activities should include the traditional midwife. Upgrading of service quality was found to depend on supplementing staff income with performance-based incentives and providing systematic and supportive supervision. Logistic support, especially the provision of vehicles, was also a crucial factor. Information collection and dissemination was less satisfactory and of limited use at higher levels of the delivery system; the multiple recording requirements of diverse MOH departments and programs constrained productivity. However, the project"s development of a replicable family health record demonstrates the impact of good information coordination. The project also developed proposals - accepted by the host government - for a national rural health strategy covering 5 areas: personnel development, financing, alternative health care, logistics, and primary health care. Replication will depend on strengthening supervision and management from the health facility level through the national level. Consideration should be given in particular to the high costs of vehicles and the problems experienced in procuring them. Still, it should be noted that despite the high costs of project interventions, overall costs were lower due to expanded coverage. The project has shown, inter alia, that: effective health education depends more on staff commitment than on educational methods; inservice training is a valuable motivator, but cannot compensate for inadequate pre-service education; and planning among and with decentralized government units requires superb coordination of resources. USAID/E criticizes the evaluation for neglecting some genuine achievements and for not assessing the effects of project assumptions on replicability; the evaluation"s major conclusion - the feasibility of nationwide replication - was inconsistent with some findings. USAID/E also feels that the impact of "human infrastructure" projects cannot be adequately assessed until 5-10 years after completion.