USAID’S health evaluation and applied research development (HEARD) project: final evaluation of the USAID Guinea health service delivery (HSD) activity: integrated health service delivery in the post-EBOLA context

Evaluation questions focused on quality of care, community-focused interventions, health systems strengthening, fistula prevention and care, genderbased violence, and leveraging of USAID and other development partner activities to advance RMNCH+ results in Guinea. Primary mixed-methods data were collected from key stakeholders and a subset of health facilities. HSD activities contributed to substantial progress in strengthening the system and actors to provide the integrated care package through provider training and supervision, environmental and materials support, and advocacy efforts. Continuing challenges included training needs and managerial support, human resource deployment and retention, lack of essential medicines and commodities, appropriate space for service provision, and inadequate equipment maintenance. Systems strengthening achievements contributed to increased community member utilization, especially for ANC, family planning, and child health; however, important disparities and equity gaps remain. Ministry of Health (MOH) governance, leadership, and ownership of quality improvement at the facility level remained insufficient to sustain HSD-supported improvements. HSD activities contributed to building fistula surgical capacity and coverage; however, the investment was small compared to the need and sustainability remains a significant concern. Similarly, gender-based violencerelated health and legal services and prevention activities were made available in targeted areas, though greater investment and stronger governance is needed. While HSD activities built on prior USAID achievements and concurrent programming, flexibility in USAID programming, and strong government leadership and coordination is needed. The Standards- Based Management and Recognition program was an important driver of quality improvements in family planning, emergency obstetric care, and infection prevention and control, and SBM-R recognition represented high-quality services to health staff and communities. Evaluation recommendations include: target client engagement throughout the continuum of care and institutionalize functional referral systems (1.1), augment support for integrated critical services for vulnerable populations (1.2); support the Government of Guinea to implement the Community Health Policy and integrate community health services (2.1); strengthen community engagement through supporting the community action cycle, community groups and health posts (2.2); strengthen social accountability for removing financial, gender and cultural barriers for vulnerable groups through addressing service fees and supporting community health mutuals (2.3); require accountability, leadership and ownership from implementing partners for sustainability through results-based accountability measures (3.1); align SBM-R with existing governmental quality improvement measures and advocate for an institutionalized quality improvement approach (3.2); continue supporting the DHIS2 health information system to achieve full implementation to facilitate evidence-based decision making (3.3); scale up support for pre-service midwifery and nursing education and skills labs (3.4); strengthen facility-based equipment, infrastructure, and supply management (3.5); leverage USAID health sector investments for improved collaboration, communication and impact between its projects/activities and others in the health development field (4.1); incorporate flexibility in project design, and adapt implementation and outcome measures to changing needs (4.2); design projects collaboratively to increase ownership and devolve responsibility to government partners (4.3); consider demonstrating the full effectiveness of investment activities by prioritizing depth of investment (4.4).