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Project Evaluation Summaries
Prepared by the Policy, Planning and Evaluation Unit (PPEU)

Cormoros

I. Basic Project Data

Project Number: COI/86/C01
Project Title: Health Centre at Mitsoudje
UN Cooperating Agency: OPS
Govt. Executing Agency: Ministry of Public Health
and Population
Sector: Health (1000)
Sub-Sector: Comprehensive Health Services (1010)
UNCDF Budget: US$     1,227,340
UNDP Budget: 201,000
Gov't. Budget: 223,208
Total Budget: 1,651,548
Actual Total Expenditures
at Evaluation: 		N/A
Date Project Approved: Jan 1988
Date Project Began: 1988
Date Project Evaluated: Jan 1993
Type of Evaluation: Mid-term


II. Background

The Federal Islamic Republic of Comoros had both a high infant mortality rate (94 in 1000) and a low life expectancy (55 years) among its population of 600,000. The lack of adequate health services was a critical part of this problem. In all of Comoros, there wore only 3 hospitals and 11 health centers, which wore served by 18 Comorian doctors and 27 expatriates. The city of Mitsoudje, for example, which has a population of 18,000, of which 7,000 are women or children under the age of five, had neither a health clinic nor a maternity ward, but only five first-aid stations which were unable to operate effectively without proper guidance and supervision from a health center. The lack of qualified health personnel and meager budget support ware additional constraints to the country's provision of adequate health care. To redress this problem, government policy over the past 10 years has focused on improving primary health care. The current project addresses the health care needs of the district of Hambou, of which Mitsoudje is the capital.


III. The Project

In order to provide basic health services to the district of Hambou (18,000 inhabitants in the capital of Mitsoudje and 12,000 in the surrounding areas) the project objectives were as follows:

  • to construct a 20-bed health center with maternity ward, an inpatient clinic with 12 beds, and an outpatient clinic; and to construct housing for technical assistance personnel and a village pharmacy;

  • to provide basic medical equipment as well as adequate personnel to run the center;

  • to implement a self-help management and financial scheme with the participation and support of the local population, including the establishment of a Support Association, a Support Fund, and a Management Committee;

  • to provide training of medical personnel and representatives of community groups;

  • to collect and analyze baseline date.

Through the development of a joint-management scheme (government/local residents) and financial procedures based on covering costs through user fees, this project was also to serve as a pilot for possible replication elsewhere in Comoros. The role of UNCDF was to cover the cost of construction, to provide medical equipment, furniture, transportation equipment, raw material for pharmacy construction, startup capital for the pharmacy and the Support Fund, and the means to follow up implementation of the pilot scheme by a French NGO.


IV. Purpose of the Evaluation

The purpose of the Evaluation Mission was to examine the progress of the project and to evaluate the results achieved with regard to anticipated results and objectives. The mission was to analyze (i) project conception, formulation and execution; (ii) the use, effectiveness and impact of the achieved results; and (iii) the long-term viability of the project. The mission was also to provide recommendations for the continuation of the project.


V. Findings of the Evaluation Mission

Assessment of results achieved

The Mission reported that the project had how very successful in meeting its objectives. The health center was constructed as envisaged in the project document and was found to be well equipped. The management was very effective, especially in achieving the financial model of covering recurrent costs through user few. The pharmacy was functioning well, with the support of the community, although its location was not close enough to the health center, which resulted in a lack of coordination between the two.

The goal of meeting the medical needs of the population was considered 100% effective and the goal of financial accessibility of services was satisfied. The center was financially inaccessible for only 3% of the population.

Personnel training was executed in collaboration with L'Ecole Nationale de Sante (the National School of Health) and the French NGO, ASI. The mission suggested that the training could be augmented and better utilized through an evaluation of training needs and the preparation of a training plan.

The management and financing of the health center both proved to be successful, which is particularly important given that the innovative scheme was being considered for replication. The plan was based on the following:

  • Financial participation of both local population and government
        Projected Actual
      Government 58% 35%
      Population
      (pharmacy and user fees) 34% 65%
      International Aid    
  • Separate management of government funds and user fan

  • Joint management of public and private resources

In the end, the difference between projected and actual outcome with regard to financing resulted from the efficiency of the fees system. Indeed, it proved so efficient that investment and amortization capacity was developed from the health center's and the pharmacy's own funds. This supported the assumption that the financial and management model was replicable in other areas of Comoros. Moreover, the participation of the population in the center's management was also found to be highly successful, and the health center staff worked well in association with the population and community groups as envisaged in the project document.

A few problems wore noted. The mission found that it was difficult to ensure a high enough profit margin to guarantee cost recovery for supplies and management fees because of the low discount rate provided by the supplier and preset selling prices. At the time of the report, there was financial equilibrium even though the cost recovery rate could not be determined due to lack of information on value of the supply stock.

Assessment of project design

The project design was considered both appropriate and original. In particular, the plan to divide management costs between public and private funds, as detailed above, was a sound one. The method of fee collection as outlined in the project document was also found to be coherent, resulting in a recovery level of 81% of operating costs.


VI. Recommendations

The evaluation mission mode the following recommendations:

  • Complete basic improvements in the Center's infrastructure.

  • Implement a maintenance plan for the sanitation system and include maintenance costs in the budget of the health center.

  • Strengthen the health center staff by nominating a nurse as deputy to the Chief Doctor.

  • Implement an ongoing training program.

  • Implement a pilot project committee which would include the co-management committee, regional- level representatives and representatives from the Ministry of Public Health.

  • Better integrate the project into the health activities of the district as a whole, with assistance from Association Sante International (ASI). Establish a multi-year, district-wide, health development plan and an annual plan of the health center budget and activities.

  • Extend the technical assistance mandate of the project.

  • Introduce supervision and implementation (at district level) costs into the normative budget of the health center.

VII. Policy Implications and Lessons Learned

Most importantly, this project highlighted the efficacy of the particular management and financial models based on cost sharing and community participation. However, the project also highlighted the importance of integrating the services provided by the health center with health care activities in the rest of the district. Because of an absence of this type of integration , the impact of the health center was limited to nearby areas. This question of district-wide integration of the health center has important implications for the replicability of this project in other areas of the country.


VIII. Evaluation Team

The mission team was led by an independent consultant provided by IMC (based in Cologne) and assisted by Dr. Aboubacar Oumadi, Director of la Direction de Lutte contre les Endemies du MSPP, and Mr. Abdallah Adinane, architect from la Direction Generale de I'Urbanisme.