Sustainability assessment of the Africa child survival initiative (ACSI) combatting childhood communicable diseases (CCCD) project, Guinea, 1993

The project ran from 6/85 to 12/87, and then some 18 months later, in 7/89, was extended to 9/91. Although the project ended on a less than favorable note (USAID/G discontinued bilateral funding after an outside review confirmed Mission concerns about financial and material mismanagement), there are more positive indicators of sustainability than negative ones. Thanks to the national primary health care (PHC) program, the three CCCD interventions -- vaccinations, diarrheal disease control (DDC), and malaria treatment/chemoprophylaxis -- are not only being continued but are being expanded. Although CCCD was not integrated into the PHC program (to the disappointment of many), it collaborated closely with PHC, and toward the end of the project, about half of the 48 CCCD-assisted health centers in Conakry, Kindia, and Telimele Prefectures were gradually integrated into the national PHC program. The non-integrated health centers are now less used by communities and even the staff are looking for more interesting work. Some centers have even shut down. The project made several contributions to health service sustainability. Specifically, it: provided trainers to launch the PHC training of trainers program; provided senior, mid-level, and peripheral training for more than 600 Ministry of Health and Social Affairs (MOHSA) personnel; helped establish policies and plans for immunization, DDC, and malaria control; provided experienced members of PHC's technical review committee; helped develop a health information system (though a good deal of assistance is still needed); and contributed to the establishment of an integrated and greatly improved (but still struggling) health education service. Overall, the project's core health services of immunization, DDC, and malaria treatment have a relatively high potential for sustainability, but its support strategies did not fare so well. Training, health education, and the health information system will most likely continue to function as long as PHC services are provided. However, the quality of these activities will surely erode without further expert assistance. Of the three, training is most able to stand on its own. The fourth planned support strategy, operations research, never really got underway (nonetheless, MOHSA is currently considering initiating operations research). It would be a mistake to interpret the positive findings in this report as a guarantee that PHC services are secure. Guinea, rebuilding its infrastructure for the past 10 years under the constraints of structural adjustment, remains economically vulnerable and infrastructurally weak. Should the government be unable to fund or to find external funding for the $10 million needed to maintain and expand PHC services during the next 5 years, the results could be devastating. PHC resources are already being strained with the integration of the former CCCD health centers, especially in Conakry. Moreover, UNICEF plans to phase out its support for immunization. Due to the heavy consumption of drugs in Conakry, replacement drugs for the rural areas are in jeopardy. If the drug system (the pillar of PHC) falters, the whole system could break down. The following lessons have been learned. (1) Political commitment and leadership emanating from the highest levels of government and made visible to the public are indispensable to the success and continuity of health projects and programs. (2) Appropriate management skills are crucial. USAID/G did not have an experienced health project officer to manage the project, and CCCD/G had neither a project coordinator nor a technical officer experienced in USAID administration. As a result, project management suffered. (3) Sustainability must be sought by all parties from the very beginning of a project and continuously thereafter. From the outset, one must ascertain present and future financial and material resource needs, and the durability of those resources. (4) Development of support structures such as Guinea's Office of Studies, Planning, and Research (OSPR) must keep pace wit the development of health programs. OSPR, charged with providing training, research, and statistical support to health programs, does not demonstrate the same dynamic force or aggressiveness as do the programs. This may be because of its position within the health hierarchy, or it may be a problem of resources, of mandate, or of leadership. (Author abstract, modified)