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PRIMARY HEALTH CARE PROJECT Fifth Year External Evaluation

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PRIMARY HEALTH CARE PROJECT Fifth Year External Evaluation PRIMARY HEALTH CARE PROJECT Fifth Year External Evaluation (PIO 669-0165-3-60047) Submitted to: United States Agency for International Development Monrovia, Liberia Submitted by: University Research Corporation 5530 Wisconsin Avenue Chevy Chase, Maryland 20815 IQC Contract No. PDC-1406-I-00-7113-00 December 1987 LIBERIA PRIMARY HEALTH CARE PROJECT Fifth Year External EvaluatiGn December 1987 TABLE OF CONTENTS Paae Acknowledgements i Team Composition ii Acronyms I ,Introduction 1.A Purpose of Evaluation 1 i-E Evalua.tion Methodology 1 2.0 Execut iye Summary 3 3.0 Findings 7 4.0 SER PHC Fro.iect 4.A Village Developrnent Committees 12 4.D Village Heaith Worker T"lrai ;i: and Effectiveness 16 4.C The Reolvr1, Dn-u_] Fund 21 4.) Supervisicn 29 4.E The Referral Ss:eem 6 4.F Decentralizotioi 40 4.G Financial Viability of Che VHW 54 Frogram 4.H General 61 5.0 Recommendations 72 6.0 Annexes 6.A Persons tnterviewed 6,B Scope of Wcrk b.C Documents Consulted 6.D Survey Questionnaire TABLES ACKNOWLEDMEMENTS The team would like to express its appreciation for the adminis­ and trative and logistics support provided by the SER PHC Project the staff of USAID/Monrovia, and the openness and candor with The which the SER PHC Project was discussed with the team. evaluation was further assisted by the extensive efforts of the MHSW, CHS in Grand Gedeh and Sinoe, MEDEX and USAID to provide all relevant documentation. TEAM COMPOSITION Harry Feirman, Ph.D, Team Leader Health Management Specialist University Research Corporation David Collins, F.C.A., M.A. Financial Aralyst Regina Cooper, M.D., MPH County Health Officer, MHSW Maryland County, Liberia ii ACRONYOMS CCCD Combatting Childhood Communicable Diseases CFO County Finance Officer CHD Community Health Department CHO County Health Officer CHS County Health Service CHSA County Health Services Administrator CHT Count Health Team CLM Central Level Manacement CLO County Logistics Officer CM Certified Midwife CPO County Personnel Officer CS Clinic Supervisor EPI Expanded Program of Immunization GOL Government of Liberia HAC Health Advisory Committe HC Health Center HI Health Inspector HIS Health Information System HP Health Post LPN Licensed Practical Nurse LTA Long Term Technical Assistant MCH Maternal and Chld Health iii MHSW Ministry of Health and Social Welfare MIT Management Implementation Team ,MLHW Mid-Level Health Worker NDS National Drug Service ORS Oral Rehydration Solution PA Physician Assistant PCV Peace Corps Volunteer PHC Primary Health Care PHP Public Health Physician PP Project Paper RDF Revolving Drug Fund RN Registered Nurse SER PHC Southeastern Region Primary Health Care SPP Supplementary Project Paper TA Techrical Assistance TBA Traditional Birth Attendent USAID United States Agency for International Development (Liberia) VDC Village Development Committee VHT Village Health Team VHW Village Health, Worker iv 1.0 INTRODUCTION I.A Purpose of the Evaluation This evaluation of the Agency for International Development/Min­ istry of Health and Social Welfare Primary Health Care Project (No.669-0165) is the first external assessment of the project following the March 1986 mid-term evaluation. As a result of the mid-term evaluation a series of modifications in the project design and implementation strategy were introduced in order to more sharply focus on village level outputs, The purpose of this evaluation is to conduct an in-depth assessment of the village health worker program and county-level management support systems in the two project counties (Grand Gedeh and Sinoe). The specific areas of focus for the evaluation are: Village Development Committees Village Health Worker Training and Effectiveness - The Revolving Drug Fund - Supervision - The Referral System - Decentralization - Financial Viability of the VHW Program - General (attainability of project goals and priority activities) 1.B Evaluation Methodology The evaluation was conducted by a multidisciplinary team of three consultants with extensive experience in primary health care design, implementation and evaluation (including financial analysis, alternative methods of health care financing, health management and administration, community health work, health worker training and performance evaluation and community part­ icipation in health programs). The evaluation scope of work was divided up among the consultants, but the final product is the result of their cumulative efforts. The findings and recom­ mendations reflect the consensus of the entire team. I The evaluation was guided. by a set of specific questions devel­ oped by USAID/Liberia which were included in the evaluation scope of work (see Annex 6.B). The evaluation is based in part on a review of project documentation maintained by USAID, the SER PHC ect -pooffices in Monrovia, Zwedru and Greenville (the latter sites being coiunty headquarters for Grand Gedeh and Sinoe), the opera-tive divisions and working groups Of the central level Ministry of Health, county health services and MEDEX. The team reviewed project files, documents, the PP and SPP, implementation letters, periodic activity and supervision reports, financial records and reports, SER PHC operations manfllals, cOnsItant's reports and other background documents (including the mid-term evaluation, Liberian Demographic and Health Survey etc.). A second major source of information was lengthy inte-views with the central and county SER PHC Project staff; AID staff (includ­ ing Human Resources Division Staff); technical advisors (including employees of MEDEX, Peace Corps Volunteers attached to the County Health Service in Sinoe, and the CCCD advisor); and Ministry of Health personnel involved directly and indirectly in project activities (including staff of the National Drug Service). The team visited the two project counties and made an extensive series of site visits to health centers (4), health posts (5) and VHW communities (10). To gather comparable data a standard survey instrument was developed and used in eliciting data from the villages and health facilities visited (see Annex, 6.D). A list of persons interviewed is included as Annex 6.A. A complete draft of the evaluation report was submitted to the SER FHC E.ecutive Committee. The draft was reviewed and discussed in a meeting of the Executive Committee and Evaluation Team with commenits being submitted to the Team. The focus of the evaluation, determined by USAID, is project implementation. Since the major focus of village activities have been underway for such a brief period, the evaluatioin i2 prim­ arilv one of process, not impact. This report focus on the seven pro ject assessment areas: village development committees, village health worker training and effectiveness, the revolving dr-iq fuids, supervision, decentralization and financial viability oF thu YHW program. Finally, the teati suggests priority areas for acticn (the eighth assessment area) and specific re.ccmmendations for strengthening SER PHC Project and consolidating its aclhieve­ mentE. 2 2.0 EXECUTIVE SUMMARY The purpose of the evaluation (USAID/MHSW Primary Health Care Project No. 669-0165) was to conduct an assessment of the village health worker program and cocunty-level management support systems in the two project coLtnt ies (Grand Gedeh and Sinoe) . The evaluation is based on a review of project documentation maintained by USAID., the SER FHC project. MHSW and Medex. A seconj majoF source of data was a series of in-depth interviews iti IER PHC, UAID, MSHW and count'/ health wervi me staff, tchni al advisers (including MEDEX person:el), Village. Health or. Vi 19 .iqe Developmer't (c mm:.tkte m mbers and persons in the . o c: c ml itiffleLll.es A, s,tandard s.rvy,' i :tument was empolo,ed to a ,er-cc mparative da ta from 1h 111Sane an d health F.1ciJities v siin, ince th . iajcr foc,_m: of /i13 l atO. ,'tie2 have been u.ndirq,,' for br tef per io,d, Whoh: 'Ai'. "or ti pI 1 m:r O n O f ,on2su, no-t impact. Vi. - '.. D.e.: 'l_-p t- .. ...o..._.. _te,.a- -- VD s re c t-, 1 i shed and fn t :nie in 62 communites. work in wi th KsTneir JHJ in c,-hv' iin healkh prcmotion and hZalth e:duzotion ec.vire- to their co'mn_-i o . in the 352 ,cmmuni a wh, ,ch have rec, Vd dr'ucy-, the y.a ,ODear to be invclved in the n-nagmc ' n the' r-ve v in i. f'.nd (RDF"; h ,'vver, che Level .F i ,c1 'e,'n , i mi ted Fii,- .raioig r aid suppr rt cf thc, V C w. iI be neec:ed p a- i .lari y in regards tc n:-1 toi ,-. and mair!ain inq the ri cL-=av",' rucord-keeping for the KDF, 1]ne Heal th Worke_ rs - The VHWs are capable cf providing the •yp:e5 of treatment for which they have beEn trained. However Wei- knowledge and skills need to be reilnfo!ced in the areas of personnel preventive services and communicable disease control. The 'VHWs have been emperiencing difficulti e i..s completing the vario,..us VHW reporting forms and need further support in this arTa, The deve1opment of the FTDA compcnernt of the VHT has not M:ucn adequately addressed. Tht.qh only 11.4 of the 204 targeted c:,mmunit.es wi l].be mobilized and fun:tion1ng by Auq..i'st 1938 it appears that the 90 coverage tar'e will be achieved as the health centers and health posts sere as primary care units for a greater populat:on thrni was cr 1 g 1i all thought. Though it is too e-:, 1y to me asur e the eff1cbiveness of the VHWs. they appear to Le e',panding overall systems coverage by treating a large proportion of the persons who had not previously been treated by the MHSW system. Reol vi ,Druq_ Funds - Most of the 53 established RDFs appear to be functioning.
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