Abstract
Final evaluation of the activities implemented by John Snow, Inc. under the REACH II project to support the Accelerated Cooperation for Child Survival (ACCS) Project (2790082). ACCS is designed to improve the primary health care (PHC) system in four governorates in Yemen: Hajjah, Mareb, Sa'adah, and Hodeidah. The evaluation covers the period 1989-9/93. REACH supported the ACCS project in five areas: manpower and training, commodities and equipment, Expanded Program of Immunization (EPI) cold chain system and equipment maintenance, PHC management, and cost recovery. Results are as follows. REACH was largely effective only in training PHC workers (PHCWs); 259 new PHCWs (165 males and 94 females) have greatly enhanced the Ministry of Public Health's (MOPH) capability to provide health care to rural, underserved population, especially women and children. REACH did not perform management or clinical training and only superficially performed trainer training, even though these types of training, particularly of females, is crucial to strengthening the PHC system. Because PHCW training used an outdated 1986 curriculum (the 1989 revised curriculum and approved by REACH consultants was not ready in time), graduates lacked some skills required by their job descriptions. A new curriculum for female PHCWs has been completed but not yet produced. REACH developed a standard list of commodities and equipment for the PHC Units and the health training centers, appropriate to the tasks and capabilities of the personnel who were to use them. REACH was not responsible for ordering and procuring the commodities and equipment. REACH consultants played a key role in developing the National Model EPI/PHC Operations Plan, which contributed to the development of cold chain systems in the four project governorates and of an equipment repair and maintenance workshop and program. REACH was also involved in follow-up work in the four governorates. There was no apparent change in PHC management as a result of REACH activities. REACH consultancies were elementary inputs rather than sustained activities with closure. Health cost recommendations produced by the REACH consultant in early 1992 were incomplete and inconclusive; they focused on cost containment and improved financial management, rather than cost recovery through the use of clinic fees. The project demonstrated the importance of having a national counterpart for long-term personnel and of having a proactive management oversight mechanism, especially if project management by the contractor is weak. The project also demonstrated that buy-ins do not facilitate the long-term counterpart relationship essential for developing shared ownership, sustainability, and transfer of technology. Other lessons include the following. (1) The process followed by the MOPH in developing the National EPI Plan should be emulated when strengthening the PHC system as a whole. (2) In the current political climate, a task force seems to be the most effective mechanism for fostering collaboration within the MOPH and donor collaboration. (3) Strengthening the management and decisionmaking capacities of institutions at all levels is essential for sustainability, as is government commitment to senior-level policies such as decentralization and financial support of PHC. (4) When key MOPH players do not feel they are active project partners, they are less likely to commit to the project. (5) The implementation and sustainability of a project are adversely affected when the MOPH and governorates are not involved in its design. (6) The difference between willingness to pay and ability to pay must be carefully weighed before signing grant agreements with the Yemen Government. When there are no mechanisms for ensuring commitments, the Mission must either not expect sustainability or actively help the host government develop alternative health care financing mechanisms.