World Vision/South Africa : final evaluation report -- Bergville District child survival project, Kwazulu/Natal Province

Specific objectives focused on improvements in nutrition (growth monitoring and breastfeeding); HIV/AIDS (awareness among school children and adolescents); control of diarrheal diseases (continued feeding, oral rehydration therapy [ORT], home-available fluids, and case management); immunization (increased coverage and reduced drop-outs, and disease surveillance); acute respiratory infection (ARI) (caretakers' health-seeking behavior for childhood respiratory infection); and maternal health and family planning (improved antenatal services, mothers' awareness of danger signs, and strengthening of referral services). The project's approach to achieving these objectives was to strengthen the nascent DHS in KwaZulu-Natal and develop community-based health partnerships. By mid-term, the project had developed a highly successful community-based program in development, with major contributions to the development of the DHS just starting to emerge. The technical impact on health facilities was less dramatic, probably because of the established and sometimes entrenched nature of clinic and hospital services. At the final evaluation further substantial changes had occurred. The community health workers (CHWs) have been widely recognized both locally and nationally for their contribution to the communities and are now becoming an important part of the formal health system. Their success has generated rising pressure for them to provide additional services to the community, at the risk of diluting their effectiveness. There is considerable scope for further strengthening of the community partnerships. Perhaps the most remarkable achievement has been the project's contribution to the development of the DHS, which is now having a major impact on the management of health services in the Bergville area, with further development in process. Bergville was recently named South Africa's best rural health service. The project played a major role in the development of the DHS by introducing the concepts of objectives, indicators, surveys, data collection and use, and the principles of quality assurance. In fact, the project and the DHS are so closely integrated that many interviewees had difficulty differentiating them. Further evidence of the project's sustainable impact has been World Vision's selection of Bergville for an Area Development Program. Lagging behind have been several technical issues in the health facilities and the supervision system, which need major attention. The project's impact on HIV/AIDS awareness, through training teachers and peer-educators, has been substantial, as measured recently in a detailed qualitative study. Evidence of behavior change is harder to find, and additional or alternative methods are recommended for the follow-on HIV project. The qualitative survey methods used will make it possible to monitor project impact. Several technical interventions have been incorporated into an integrated management of childhood illness (IMCI) package. Immunization objectives were all met, and most of the ARI and nutritional objectives as well. The diarrhea objectives were mostly not met; it is not exactly clear why. Although IMCI is now adopted, the pace for training has been generally slow and should be accelerated. Maternal health objectives, too, have been too limited to have much impact, although positive change was noted in a number of indicators. Achieving major impact will require improving access to maternity services and strengthening the capacity of trained staff to reduce perinatal deaths. Numerous lessons learned are detailed. (Author abstract, modified)