Abstract
Final evaluation of the RICHES 2000 project (10/96-9/00), designed to improve child survival by emphasizing maternal health services in eight communes of Western Grand'Anse, Haiti. The project was implemented by CARE. The project area included a total population of 212,352 and a direct target population of 53,088 women. Children and men also benefitted indirectly from project interventions. The project approach was based on the institutional strengthening of health centers to improve the delivery and management of quality services for maternal health, family planning (FP), and HIV/AIDS and sexually transmitted diseases (STDs). The project also trained health center personnel in crosscutting strategies for community mobilization and behavior change communications related to the technical interventions. RICHES 2000 made very good to excellent progress in achieving its objectives. The project surpassed all objectives for the FP and institutional strengthening components, achieved or nearly achieved all of its objectives for maternal health, and made impressive progress for the HIV/AIDS-STD component. A major strength of RICHES 2000 was in balancing health center-based activities to improve quality and services with community-based activities to increase knowledge and demand. This was particularly impressive in the area of FP, where contraceptive prevalence rose from 14% to 33%. Also, the emphasis on direct maternal health services contributed indirectly to (or did not limit) improvements in health services for children. The project was weak in monitoring project objectives and in developing an information system. In addition, inconsistencies between the detailed implementation plan (DIP) and knowledge, practice, and coverage (KPC) survey methodologies made it difficult to assess achievement of project objectives. Lessons learned include the following: (1) The management of an institutional strengthening project is quite different, more difficult, and slower than a project to develop direct service delivery at the community level, but offers greater possibilities for the continuation of services after the end of the project. (2) A project based on institutional partnerships requires a careful, flexible implementation process, continuous two-way dialogue, and clear roles that are respected by each partner. (3) In an institutional strengthening project, the decentralization of planning plays an important role in creating local ownership. (4) Every sustainability strategy should systematically include a structured phase-out plan that is known by all the partners. (5) The effectiveness of an institutional strengthening project is enhanced when it builds on existing community mobilization and behavior change communication strategies. (6) In an institutional strengthening project it is important to balance health center-based activities to improve quality and services with community-based activities to increase knowledge and demand. (7) A project that focuses on maternal health services can indirectly maintain or improve health services for children. (8) Behavior change communication through youth, mothers' , and fathers' clubs is effective because of the multiplication effect in disseminating information and the reduced cost in adding new messages. (9) The level of knowledge required to achieve a significant change in behavior varies by type of intervention. (10) By responding to client demand for clinic-based methods it is possible to increase the utilization of FP services without depending on a well-developed community-based distribution network. (11) Care for STDs and AIDS requires a functioning referral system. (12) Cost recovery objectives and activities should be included in every project in order to encourage sustainability.