Summary : ACSI/CCCD sustainability assessments in Guinea, Lesotho, Nigeria, and Rwanda -- 1992-1993

At the time of assessment, projects in Guinea, Lesotho, and Rwanda had been completed while the project in Nigeria was ongoing. Evaluation covers the period 1992-1993. Despite deteriorating economic and political conditions, activities have been sustained to a surprisingly high level in Guinea, Rwanda, and Nigeria, and to a lesser degree in Lesotho. Direct service components (i.e., control of diarrheal disease (CDD), malaria, and, in Lesotho, acute respiratory infection (ARI), and extended program in immunization (EPI), have been sustained to a greater degree than have support components (i.e., health education, information systems, operations research, and training. EPI and training have been the most sustained in the service and support components respectively. In Nigeria, health information systems and operations research have been sustained to a high degree. It is uncertain why there are such clear differences in sustainability among project components. One clue is that perceived effectiveness has been consistently higher for EPI than for most other components, especially CDD. Differences may be due to a higher level of other-donor support for some components, the fact that the more mature components had more time to build experience in the country, or simply the fact that some components are inherently more effective than others. However, external factors, political and economic, had the most influence on sustainability. In Guinea the following lessons were learned. (1) An articulated political will and commitment from the highest levels of government are necessary for sustainability. (2) Inexperienced managers in the project or in the USAID mission can seriously decrease the prospects of sustainability. (3) Sustainability must be addressed at the conception and throughout the life of a project by all concerned. (4) Development of support systems must keep pace with development of direct services. (5) Individuals rarely take personal responsibility for project sustainability. (6) Program managers often see new activities or proposed changes in terms of effect on their power base rather than effect on the public interest. (7) Regional and global objectives (e.g., vaccination targets) may be unrealistic in some countries. Failure to achieve these objectives is then not a program failure. (8) Decentralization improves the delivery and efficiency of services. (9) Failure to involve communities hinders sustainability. (10) Integration of project components into a national PHC program supports sustainability. (11) Support services require the same priority, time frame, and dynamism to succeed as direct service components, but generally they do not have these attributes to the same degree. (12) The phasing out of a project is difficult and important, possibly more important to sustainability than what goes on during the project. The following lessons were learned in Nigeria. (1) Responsibility for achieving project success must be assigned to particular individuals right from the start. (2) Projects that depend on one or too few key technical people are less likely to be sustained because these key people often leave. (3) Projects that depend on a heavy inflow of external capital are unlikely to be sustained. The rise and then the fall of vaccination coverage in Nigeria as a result of the infusion of short-term donor funding is a case in point. (4) Donor projects should actively foster and carefully avoid obstructing local initiatives. "Bottom up" planning with local communities helps. (5) In Nigeria, people who do not pay toward something do not feel any ownership for it, even if they have been involved from the start. Thus, the sense of ownership is intimately linked to financial inputs. (6) Training programs are an effective way to communicate information that enhances project credibility and sense of ownership. There is evidence that this has increased budget allocations at the state level. (7) Unstable project leadership seriously diminishes the chances of sustainability. (8) TA should always have the objective of building local capability in order to achieve sustainability. The following lessons were learned in Rwanda. (1) The private health sector, which is demanding but well-equipped and rewarding, is attractive to many public sector health professionals. (2) Extensive cooperation between the private and public sectors has maximized project sustainability. (3) Top priority programs such as EPI perform better at all levels, but particularly at secondary peripheral levels. The status associated with high priority from the central level confers priority at the periphery. (4) Health personnel motivation is essential to project success and sustainability, including motivation due to per diem payments. Elimination of such incentives can reduce sustainability. (5) Personnel skills are not sufficient to sustain activities. Support resources are also needed. Problems in sustaining the malaria control program due to lack of educational materials is a case in point. The following lessons were learned in Lesotho. (1) User fee schemes can be feasible, if the fee is substantial, and can significantly strengthen sustainability. (2) Affordability is central to any analysis of health benefits in Lesotho, and therefore to sustainability. (3) Outflow of skilled workers to other sectors or other countries is a serious impediment to sustainability. (4) Health education is key to sustainability of PHC projects. (5) Continuing training of health personnel and their awareness is another key. (6) Community health worker programs can be the key to delivery of PHC services. (Author abstract, modified)