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Evaluation database

Evaluation report

2013 Liberia: End of program effectiveness of ACSI in Gbarpolu county



Author: ADEAS, Ministry of Health

Executive summary

"With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System". Within this system, an external independent company reviews and rates all evaluation reports. Please ensure that you check the quality of this evaluation report, whether it is “Outstanding, Best Practice”, “Highly Satisfactory”, “Mostly Satisfactory” or “Unsatisfactory” before using it. You will find the link to the quality rating below, labelled as ‘Part 2’ of the report."

Background:

In December 2011, the Ministry of Health and Social Welfare published the Revised National Community Health Services Strategy and Plan 2011 – 2015.  The document is aimed at reducing the number of maternal deaths by 10% and reducing the number of under-five deaths by 15%.  However, challenges ranging from poor road condition; lack of skilled health workers, poor referral system and limited resources for Liberia’s health sector are major causes for maternal and child mortality as well as malaria, diarrheal and ARI. These conditions are similar for other parts of Liberia, in particular the South Eastern counties.
Recognizing these challenges, ChildFund with funding from UNICEF Liberia implemented the Accelerated Child Survival Initiative (ACSI) project in Gbarpolu County in 2010.  The project was aimed at increasing access to health services, most especially for pregnant women and children under five on an equitable basis. The core intervention was focused on reducing maternal and child mortality rates; improving access to health care services for Children under 5; enhancing the capacity for the prevention of common childhood illnesses and new born death; upgrading skills for the effective management of childhood illnesses; and enhancing the capacity of Gbarpolu County Health for efficient management of the ACSI project.

Purpose/Objective:

The final evaluation for the ACSI Project was commisioned by UNICEF Liberia to access the relevance, effectiveness, efficiency, and impact of the project.

Methodology:

The research tools used to evaluate the project includeda literature review,pilot testing, the administering of questionnaires; several structured and semi structured interviews; Focus Group Discussions (FGDs);Key Informant Interviews (KII); informal conversations, and direct observations. AnSPSS database was designed; data cleaned and analyzed.
The final evaluation covered eighteen communities in the six political districts of Gbarpolu County. The 18 communities constitute 19% of the total number of communities targeted (95). Communities were selected through Systematic Random Sampling (SRS), while households were selected through simple random sampling.A sample size of four hundred ninety-five (495) respondents was distributed among the eighteen communities. Households were selected randomly for interview. The number of communities selected in each district along with the actual sample size was disaggregated by sex. Since the project major targets were pregnant women and children, 93% of respondents were females.

Findings and Conclusions:

• Access to Health Care:  the project was successful in providing health care to under-fives in all communities visited.  The dedicated services and commitment of the community health structures like the gCHVs, TTMs and HHPs greatly contributed to achieving this objective, unlike the CHCs who were inactive in most of the communities.
• Training and Setting up of community structures:  With the exception of the training of gCHVs in the area of Child Nutrition and Growth, all trainings under the project were conducted.  The successful training of the community health structures led to the exceptional performance of gCHVs, HHPs and TTMs during the implementation of the project.
• Capacity building of Clinical Staff:  The training of clinical staff under the project was a good initiative. However, the distances some beneficiaries have to travel to access health centers could easily undermine this effort.  In some cases where the cost of transportation is higher than the cost of drugs administered at these health facilities, respondents are likely to purchase drugs from community based drug vendors instead of going to the health centers.
• Up-grading the capacity of County Health Team: The capacity of the CHT was not sufficiently built during the project.  This has undermined the sustainability of the project to a large extent.
• Impact of the Project:  on the overall, the project greatly impacted the lives of the beneficiaries.  Children and pregnant women in all communities visited had access to health care. Health education was an important component of the project that recorded major impact.  Community members had an appreciation for the ITNs and made use of them.  Many HHs also knew how to treat diarrhea by orange juice and salt in the absence of ORS.

Recommendations:

Government of Liberia
1. GOL to improve road networks throughout the country and increase the number of health facilities in the county  to improve access to health centers
2. Salaries and incentives of the CHT should be increased to attract more health workers to take up assignment in the rural areas.
3. GOL to continue the program by increasing the budgetary allotment for community health services
4. For proper coordination between the CHT, communities and IPs, and each stakeholders is encouraged to maintain accurate records

MOH/County Health Team
1. Ministry of Health and Social Welfare should be actively involved in the implementation of all health projects.
2. CHT should be more involved with health interventions of both local and international partners
3. The criteria set up in selecting members of the CHCs should be re-visited to remove the dependency syndrome which leads to de-motivation of community structure administrators. Town Chiefs of various communities, should form part of the CHC.
5. There should be timely supply of drugs to gCHVs
6. GCHVs and TTMs motivation should not only be left to the community, but the government should take initiative in enhancing the motivation package put together for the gCHVs and TTMs by Partners. Government should include this initiative in the budget especially for gCHVs and TTMs.
7. Maternal waiting centers should be constructed near every health center in the county to accommodate pregnant women who are in delivery pain, but come from far places to allow them to remain near the health center until delivery.
8. More logistical support should be given to gCHVs and TTMs in addition to periodic training
9. To address the issue of capacity building at county level, , GOL to institute a periodic nationwide training for health administrators since attrition of health personnel is still a major problem.

Lessons Learned:

ChildFund
1. Training of CHT should be implemented three times during the project cycle (at the beginning, at the midpoint and at the end).  This will enable the CHT to be prepared for sustainability of the project and at the same time fill in the gap of any staff change.
2. If the project is to be replicated to other counties, the CHT should actively get involved with the project from its inception.
3. GCHVs and TTMs motivation should not only be left to the community, but the government and implementing partners should also take initiatives in enhancing the motivational packages  for gCHVs ,TTMs and HHPs
4. Method of supervision should be changed from vaccinator to nurse aid. Vaccinators are not necessarily health personnel to supervise the community structures. Vaccinators were not trained to supervise the gCHVs.
5. There should be a specific budget line for MOHSW Team at central and county level for motivation, M&E and supervision.
6. Future projects should take into consideration preventive health care for malaria by administering anti-malarial drugs since access to health centers are far and costly.

UNICEF
1. UNICEF should disburse funds for projects on time to enhance efficiency and effectiveness
2. The reason for the poor performance of CHCs was attributed to lack of incentives. Motivational packages could  boost the morale of the CHC and make them active
3. UNICEF should access the terrain before procuring equipment for use.  The motorbike ambulances did not effectively serve the intended purpose since it was not appropriate for the road.
4. The uses of the motorbike ambulances were not clearly defined.  Whether to take patients from the community to the health centers or whether from the referral center to the hospital.  This led to misunderstanding among stakeholders.  In future the use of similar equipment for project implementation should be clearly defined.



Full report in PDF

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Report information

Year:
2013

Country:
Liberia

Region:
WCARO

Theme:
Health

Type:
Evaluation

Partners:
Ministry of Health

Language:
English

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