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The Sustainability of Us-Supported Health

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The Sustainability of Us-Supported Health THE SUSTAINABILITY OF U.S.-SUPPORTED HEALTH, POPULATION, AND NUTRITION PROGRAMS IN HONDURAS: 1942-1986 A.I.D. EVALUATION SPECIAL STUDY NO. 58 (Document Order No. PN-AAX-211) by Thomas Bossert, Team Leader (University Research Corporation) Lois Godiksen, Social Science Analyst (Bureau for Program and Policy Coordination, A.I.D.) T. Dwight Bunce, Economist (University Research Corporation) Michael Favin, Public Health (University Research Corporation) Carol Dabbs, Family Planning (Bureau for Science and Technology, A.I.D.) John Massey, Human Resource Development (USAID/Guatemala) With the assistance in Honduras of Ramon Alcerro Castro, former Vice-Minister of Health Rigoberto Alvarado, former Vice-Minister of Health Alberto Guzman, former Director General, Ministry of Health U.S. Agency for International Development December 1988 The views and interpretations expressed in this report are those of the authors and should not be attributed to the Agency for International Development. TABLE OF CONTENTS Acknowledgments Preface Summary Glossary 1. Introduction 2. Honduran Context 3. Epidemiological Trends 4. Factors Affecting Sustainability 4.1 National Commitment to Project Goals 4.2 Project Negotiation 4.3 Institutional Organization of the Project 4.4 Financing 4.4.1 Project Financing Characteristics 4.4.2 Contextual Aspects of Financing 4.5 Technical Assistance 4.6 Donor Coordination 4.7 Training 4.8 Community Participation 4.9 Effectiveness 5. Conclusion: Lessons Learned and Policy Implications 5.1 The Need for Comparative Studies 5.2 Factors Related to Health Project Sustainability in Honduras 5.3 Other Factors Appendixes A. Methodology B. Malaria Eradication Projects C. Rural Water System Projects D. Family Planning Projects E. Nutrition Projects F. Rural Penetration Program G. Health Sector I Project H. Financing I. Persons Interviewed Bibliography ACKNOWLEDGMENTS Perhaps more than most evaluations, this report depended on the goodwill and assistance of a great many knowledgeable colleagues and informants in Honduras, the active participation and guidance of A.I.D./Washington and USAID/Honduras staff, and tireless administrative support in both Honduras and Washington, D.C. We must particularly acknowledge the essential contributions of our Honduran counterparts, Drs. Ramon Alcerro Castro, Rigoberto Alvarado, and Alberto Guzman. We hope that this project will assist them in their plan to write a history of the Honduran public health system. Our report depends heavily on their detailed accounts and long historical experiences, as well as on the many other Honduran informants noted in our list of interviewees. In addition, Lic. Elia Pineda and Lic. Mayra Chang of the Facultad de Ciencias Medicas, the National Autonomous University of Honduras (UNAH), and Lic. Gertalina Cerrato, Ministry of Health, provided reports on auxiliary nurse training; Carlos Tabon, eonomics student at UNAH, assisted in the economic analysis of this report; and Breny de Mendosa, faculty member at UNAH, helped identify and collect background reports for the team. A special acknowlegment is due Dr. Rolando Godoy and Dr. Cathy Overholt for their assistance. The support of A.I.D. staff was also critical to the success of this project. The study was sponsored by the Bureau for Program and Policy Coordination/Center for Development Information and Evaluation (PPC/CDIE), under the guidance of Lois Godiksen, coordinator for evaluations in health, population, and nutrition. She played a central role in initiating this line of inquiry, helped shape the conceptual issues in the analysis, and oversaw all aspects of the evaluation. Ellen Boissevain, PPC/ CDIE, provided an exhaustive literature search and a careful analytic review of documents available in Washington, D.C. Other members of the PPC/CDIE staff contributed to the design of the evaluation and provided thoughtful, constructive reviews of earlier drafts. Carol Dabbs, Bureau for Science and Technology/ Office of Population, participated in the fieldwork and subsequently critiqued report drafts. John Massey, USAID/Guatemala, Office of Population, was an inspiration for this project and a valuable source of knowledge and insight; as the former health officer in Honduras, he gave us easy access to the many Hondurans who counted themselves his friends. He participated in the initial design effort in Honduras and subsequent field investigations and played a central role in designing and implementing the workshop in Honduras. We also gratefully acknowledge the generosity of USAID/Guatemala in releasing John Massey for these activities. In Honduras, the special interest and support of the A.I.D. health and human resource staffers -- Tom Park, Barry Smith, Anita Siegel, and Juan Castillo, as well as Orlando Hernandez, the Mission evaluation officer -- were particularly appreciated by the project team. The administrative demands of this project required particularly complex management. In Honduras, we benefited from the excellent International Executive Secretarial Services of Miriam Barjum and Suyapa Reina. In Washington, D.C., University Research Corporation (URC) staff, especially Julie Stagliano, Madeleine Carmichael, Connie Costta, and Josefina Vega, often went beyond the call of duty to facilitate the logistics of this project. We also appreciate the assistance of CDIE staff, particularly Sandra Malone Gilmer, who executed the multiplicity of contracting arrangements, and Pat Brown and Pamela McDade, who provided the word processing support. Finally, the conceptual insight, encouragement, and experience of our Advisory Panel -- Abraham Horwitz, former Director of the Pan American Health Organization; Karl Kendall, Johns Hopkins University; Stewart Blumenfeld, URC; and Wayne Stinson, URC -- greatly enhanced this project. PREFACE Why are the activities and benefits of some health development assistance programs sustained while others are not? Which contextual factors seem most important for sustainability? Which project characteristics? Do some types of health programs seem inherently unsustainable? How should sustainability be defined and measured? What guidance can we offer policymakers and project and program designers and managers? What type of research is called for in this area? In 1986, the Center for Development Information and Evaluation (CDIE) initiated a group of studies with special emphasis on assessing the sustainability of health project and program activities and benefits after A.I.D. funding ends. The decision to conduct these studies followed a prior set of evaluations carried out by A.I.D. in the early 1980s to try to understand more about the impact (the actual effects) of its projects and programs in the health sector. The impact evaluations show clearly that many of those activities had difficulty continuing after outside assistance was terminated. Sustainability has become an important development issue in health (as well as in other sectors) for both lender/donor countries and borrower/recipient countries. The studies undertaken by CDIE in this area have taken several forms, including literature reviews, syntheses of existing A.I.D. evaluation reports, field studies of single completed health projects, and field studies taking a broad, sectoral, historical perspective. It is into this last category that the present study of Honduras falls. The Honduras study is the first in a planned worldwide series of historical studies. Since this report was written, CDIE has continued to analyze, research, and refine both the concept of sustainability and the approaches used to explore it. A number of CDIE studies have been completed that shed more light on the area. Other reports are still in progress. In addition, a significant body of related work by other offices in A.I.D., as well as other institutions and lenders/donors, has begun to accumulate which addresses this subject and adds to the issues and the discussion set forth in the Honduras study. This report does not attempt to reflect these recent works, which will be incorporated in a subsequent synthesis report now under discussion in CDIE. The reader is asked to bear in mind, therefore, that we are presenting this report as an important first study and set of findings in one country in the larger effort now in progress, not as the final word on the important issue of sustainability. SUMMARY This report is the first in a series of comparative historical evaluations of the sustainability of U.S.-supported health projects.{1} The central question is: What factors of project design and implementation account for the sustainability of project outputs and benefits after U.S. funding has terminated? To answer this question, a group of consultants and Agency for International Development (A.I.D.) staff developed a new methodology and applied it to a historical field review of all U.S. Government-supported health projects in Honduras since the 1940s. A.I.D. and its predecessor agencies have funded 17 health projects since the 1940s. These included five projects supported through the Inter-American Cooperative Public Health Service (SCISP), a separate U.S.-run agency that built water systems and health service facilities and carried out antimalaria campaigns from 1942 to 1964. In the 1960s, A.I.D. supported rural water supply programs of the National Water and Sanitation Service (SANAA), efforts to eradicate malaria through the National Service for Malaria Eradication (SNEM), and an ill-fated family planning project. In the 1970s, under the Honduran
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