Services and products delivered

Research hypothesis n°3

The beneficiaries received the goods and the services provided within the schedule, thus confirming the relevance of the identified problems and the alignment of the project with the health priorities of the Mozambique government.

a. Framework of reference

The project included several and different areas of intervention, from the support to health services of the Sofala province, to training (“continuous” for the existing personnel, “basic” for the new personnel), to the technical support of the government bodies in the DPS of Sofala, to the implementation of specific activities such as the treatment of urinary-vaginal fistulae.

Therefore there are several project beneficiaries, as summarized in the table below:

Category of

beneficiary Type of beneficiary

Direct beneficiaries

managers of DPS, in particular those responsible for training and human resources activities (Human Resources Directorate and Training Directorate)

teachers and managers at the Nhamatanda Training Center and at the Institute of Health Sciences of Beira

human resources in the province health system women affected by urinary-vaginal fistulae Indirect beneficiaries population of the Sofala province

In the absence of project and monitoring data aimed to measure the results of the training activities and of the activities in support to the DPS, the evaluation mission had to necessarily focus on the identification of the type of benefit received.

with reference to the managers of DPS

The following table and comments recap the main remarks about the first group of direct beneficiaries, that is the managers of the DPS of Sofala (in particular the officials in charge of the Human Resources Directorate and the Training Directorate):

Beneficiaries Benefit Comments

managers of DPS

• technical assistance in the implementation of integrated supervisions to the health facilities

• technical assistance in the programming and managing of continuous training courses and of ‘on the job’ training courses

• contribution to the running costs and managing costs of health facilities at province level

• availability of higher qualified human resources in the training centers and in the province health facilities (see following table)

• within the scope of the activities in support to the DPS of Sofala, the project aimed to strengthen the role of supervision of the health system provided by the managers of the Human Resources Directorate and Training Directorate

The on-site analysis managed to identify what follows in relation to the goods / services delivered to the managers of the DPS of Sofala and for the functioning of its Departments:

→ Thanks to the technical support of the expatriate staff, around ten integrated supervisions were carried out in some health facilities of the province (health centers and rural hospitals in particular), with the aim to evaluate the functioning of the health facilities and of identifying any weaknesses (in particular in the area

47 of human resources, regarding availability of materials, functioning of infrastructures and quality of some clinical sectors such as the mother-child one).

These supervision and research activities allowed for planning the following procurement of materials and of health supplies for some health facilities of the province and they were very appreciated by the DPS officials.

Even the competences provided by the project manager to the maternal -child sector (his specialization) were particularly appreciated.

→ Still thanks to the support of the expatriate staff, the DPS benefited from technical assistance in the planning and management of continuous training courses and of 'on the job’ training courses (a training course on the continuous training was organized for the DPS personnel in charge).

As for the previous case, if the lack of data prevented the evaluation team from fully understanding the provided benefit, the appreciation on the usefulness and the quality of the provided support expressed both by the director and by the officials of the Training Directorate of Sofala DPS was however significant.

It was particularly highlighted how the support provided enabled the functioning of fruitful collaboration mechanisms in the drafting of the Strategic Training Plan for the Sofala province and of the Operational Plans for Training.

→ Lastly, the Sofala DPS office could benefit of a contribution to the running costs of the health services at province level, in particular of the purchase of office equipment and material (computer, printers, photocopiers, stationary), of the purchase of fuel for the vehicles of the DPS offices, hospitals and districts, and of the purchase of various consumables, equipment (syringes, suture strings, gloves, masks, surgical tools, sphygmomanometers, metal cabinets, surgical beds, autoclave for sterilization etc.) and drugs and medicines for health facilities.

Even in this case, if on one side it was not possible to acquire detailed information on the quantity and exact type of the materials /contributions supplied by the project, in order to estimate the relative contribution of the project (compared to the government supplies) or / and its contribution in absolute terms, on the other side it must be mentioned that the key informants interviewed during the evaluation exercise confirmed that the project contribution prevented the interruption of the health service, while waiting for government supplies.

With reference to teachers and managers at the Nhamatanda Training Center and at the Institute of Health Sciences of Beira

The following table summarizes the main remarks related to the second group of direct beneficiaries, which are the teachers and managers at the Nhamatanda Training Center and at the Institute of Health Sciences of Beira:

Beneficiaries Benefit Comments

Teachers of CF and ICS-B (36)

• refresh courses and training of pedagogical methodologies and didactics

• support and technical assistance in the planning and managing of courses and in their proper outline

• the Nhamatanda Training Center and the Institute of Health Sciences of Beira are two governmental centers for the training and re-qualification of health personnel

• the project provided support to these two centers because the need analysis pointed out common problems, such as: lack of didactic material, limited pedagogical capacities of the teachers, lack of resources to cover training / requalification expenses of government health personnel

The evaluation exercise pointed out that:

→ the directors of the Nhamatanda Training Center and the Institute of Health Sciences of Beira expressed appreciation for the support on the training and update on pedagogical methodologies delivered to 36 teachers in the training centers through the following activities:

• support and technical assistance provided by the project manager to the teachers of the training centers in the planning and managing of courses and in the proper outline of practical internships;

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• support of two supervisors, whose costs were covered by the project, with the specific task of strengthening the pedagogical component of the beneficiary teachers.

→ Together with the training support, it must also be mentioned the contribution provided by the support personnel of the project for the analysis of the training and organizational needs of the institutes.

Therefore, even though it was not possible to provide documented evidence, it is reasonable to believe that the technical and training support provided to the 36 teachers of the two training institutes had at least contributed to the increase of availability of qualified human resources.

with reference to human resources in the province health system

The following table and comments summarized the main remarks related to the third group of direct beneficiaries, human resources in the province health system:

Beneficiaries Benefit Comments

human resources in the province health system (at least 157)

• better quality of training

• availability of didactic equipment and consumables

• availability of better training infrastructures

• access to training activities

• one of the acknowledged problems of the Mozambican health system is the lack of human resources, for number and qualification

• training is considered an important incentive element for health human resources

Thanks to the project, the Mozambican health personnel benefited from:

→ training courses.

In particular, through the project funds, the following courses were delivered, for a total number of 157 beneficiaries (new health workers):

• two training courses for maternal -child nurses and basic level nurses (one in Beira and one in Nhamatanda);

• two training courses for generic basic level nurses (one in Beira and one in Nhamatanda);

• one training course for lab technicians in Beira;

• one training course for preventive medicine agents in Beira.

• training courses in addition to those directly financed by DPS, and in particular courses which involved:

10 maternal-child nurses trained on basic obstetrical support 10 nurses trained on H1N1 and H5 N1 flu

30 technicians of preventive medicine on environmental hygiene

10 border health staff trained on the problem of disease-spreading and epidemics

• “on the job” training for the treatment of urinary-vaginal fistulae as tutorial support of a supervisor / trainer in the workplace.

→ better quality of training thanks to the pedagogical support provided to the teachers of the two centers (see previous section) and to the support provided to the students by the project in the internship places;

→ availability of adequate didactic equipment (computer, photocopier, printers, furniture and health equipment among which phonendoscopes, sphygmomanometers, etc.), consumables and stationery for training activities (toner, paper, pens, etc.) and higher availability of books for libraries, due to the purchase of new books;

→ availability of better training infrastructures, due to small renovation works in the training rooms both at the Institute of Health Sciences on Beira and the Nhamatanda Training Center (particularly relevant the rehabilitation of the water supply in the students dormitories and in the institutes, both in Beira and in Nhamatanda, and the renovation of the IT room at the Beira institute);

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→ at the Nhamatanda center availability of accommodation for the temporary residence of the teachers coming from other centers. The two houses built were visited during the on-site mission and they looked well-kept and functional.

Even in this last case, if on one side the lack of relevant data does not allow for a specific measurement of either how much the goods and services delivered by the project contributed to the achievement of the objectives, or how was the level of reception of the benefits of the Mozambican health personnel, it is however possible to state that the project contribution seems to have been appreciated and therefore it seems substantial in terms of number of people trained, as well as relevant regarding the strategic objective of contributing to the MISAU Accelerated Training Plan.

with reference to women affected by urinary-vaginal fistulae

The following table summarized the main remarks related to the fourth and last group of direct beneficiaries, women affected by urinary-vaginal fistulae:

Beneficiaries Benefit Comments

women affected by urinary-vaginal fistulae

• availability of personnel specifically qualified for the treatment of urinary-vaginal fistulae

• strengthening of the referral system for the treatment of this pathology

• the pathology occurs especially following prolonged blocked labour and obstetrical hindrances during the delivery. It is a highly invalidating pathology, both on a physical and social level

• in absolute terms, it is not a high prevalence pathology, although precise data are not available

• it is often a non-declared pathology due to the connected stigma

The initiative carried on the experience of a similar project implemented by an Italian NGO which was particularly appreciated also at ministerial level because of its relevance, as to include the treatment of urinary-vaginal fistulae in the national protocols.

The project aimed to strengthen the referral system for the treatment of fistulae (identification of the women in the community affected by the pathology) and the improved assistance after the surgical treatment (training of specialized medical personnel in the treatment of the pathology and supply of surgical material and equipment). In particular, thanks to the project it is believed that the women affected by urinary-vaginal fistulae benefited (and will benefit) from:

→ 11 medical doctors and surgical technicians in the hospitals of Nhamatanda, Buzi, Muxunque, Marromeo and Chipunga, Beira trained on the treatment of urinary-vaginal fistulae (implementation of five on-the-job training courses as tutorial training).

It was also reported that, during the training courses, around 100 women were operated in the selected peripheral hospitals and 50 more were sent for treatment to the Central Hospital of Beira.

→ availability of surgical material and equipment supplies (surgical tools, autoclave for the sterilization of tools, etc.) and consumables (suture strings, surgical gloves, etc.) for the treatment of the pathology.

b. Evidence:

N. 10. The evaluation exercise pointed out that not all the benefits expected from the project, and described in the plan, were measured and / or described in the progress reports. In some cases the identification of merely activity indicators did not allow for the measurement and the description of benefits ‘owned’

by the beneficiaries thanks to the project (e.g. the improvement of the teaching skills of the teachers in the training centers); in other cases no indicators was used (e.g. the improvement of the health status of women suffering of urinary-vaginal fistulae and surgically operated).

Therefore, an accurate analysis of the benefits received by the beneficiaries due to the project was incomplete and partial and it was exclusively based on the perceptions of the various stakeholders as collected during the evaluation exercise.

50 The analysis of goods and services produced and delivered by the project confirmed its supplementary-complementary nature (see also evidence n.4) compared to the ad hoc and urgent needs of the health system of the Sofala province, as well as the request the DPS of Sofala submitted in accordance with the objectives identified in the national plans. The initiative AID 8835 perfectly integrated in the health system, by contributing to its overall functioning and respecting the principle of strengthening the national health systems, also supported by the international agencies.

The analysis of the goods and services produced by the project has also confirmed the alignment of the project strategy with the health priorities identified by the Mozambican government for the qualitative and quantitative improvement of human resources in the health system, and in particular with the objectives described in the Plano de Aceleração da Formação de Tecnicos de Saúde 2006-2009. Indeed the sectors involved by the project intervention fall within the objectives of the Plan, which includes the support to the training institutes (training, support to teachers and to institutes equipment) and to the health facilities hosting the internship programs.

N. 11. The analysis of the goods and services produced by the project confirms that the project goals fall within the strategic objectives of the Italian Cooperation in Mozambique. The initiative is perfectly integrated within the framework of cooperation agreements signed by the Italian government and the Mozambican one, which is in line with the principles inspiring the health policy of the Italian Cooperation (“Global health: guidelines of the Italian cooperation” – 2009). Nevertheless, it must be mentioned that the objectives of the health cooperation policy are not well specified as far as geographical areas and sectors are concerned.

The project component related to technical assistance basically complemented the transfer of resources to fund the activities planned by the Mozambican authorities, and favoured their coordinated implementation. There was no evidence of any contribution of the Italian assistance in the assessment of the needs that should have been met by the plan, and of its adequacy compared to the needs of the health system and of the health human resources in particular.

N. 12. The training of the DPS personnel of Sofala, together with the contribution to the running and management costs of the health facilities at provincial level, should have contributed to the improvement of the quality of the delivered services. It is certainly reasonable to consider that the technical assistance and the support provided by the project contributed to improve the capacities of the DPS officials, for example, in the implementation of the integrated supervisions, but it is not possible to quantify and to compute the improvement and therefore the increased capacity of analysis and response of the Directorate to the health needs of the province.

The technical and training support provided to the 36 teachers involved in the two training institutes likely allowed the increase of availability of qualified human resources and, therefore, the possibility of the training centers to deliver better services (with an obvious impact on the beneficiaries of the courses). On the other hand, it is not clear whether the DPS of Sofala and the two training centers have the capacity to ensure the financial resources to pay for the teachers and the supervisors paid by the project.

The same conclusions can be drawn with reference to the training delivered to 157 medical doctors, technicians and nurses employed by the national Mozambican health system, with regard to whom it is likely to suppose that the received training may have increased their skills and, consequently, their ability to deliver quality services. Furthermore, it can be presumed that the trained personnel will keep working within the health system and that it will use its (improved) skills for the implementation of the appointed tasks.

N. 13. The specific training delivered to 11 surgeons and surgical technicians in the hospitals of Nhamatanda, Buzi, Muxunque, Marromeo and Chipunga, Beira on the treatment of urinary-vaginal fistulae, in addition to the supply of surgical material and tools, certainly contributed both to the access to treatment, and to the treatment itself, of a highly invalidating pathology, both from a physical and a social point of view, which is often not mentioned because of the associated negative stigma.

The treatment of urinary-vaginal fistulae was stabilized as a model that is now included in the national treatment protocols, also due to the project contribution.

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