EVALUATION REPORT THE IMCC SAN LUCAS … REVISED FINAL COPY 300404.pdfTHE IMCC SAN LUCAS PRIMARY...

IMCC

EVALUATION REPORT

THE IMCC SAN LUCAS PRIMARY HEALTH CARE PROJECT

CHUQUISACA

BOLIVIA

FINAL REPORT

May 2004

IMCC San Lucas Primary Health Care Project Evaluation Report

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Table of Contents LIST OF ABBREVIATIONS ........................................................................................ 5 EXECUTIVE SUMMARY IN SPANISH / Resumen Ejecutivo ................................ 6

1. Introducción y antecedentes...................................................................................... 8 2. Aspectos nuevos de la política de salud de relevancia al proyecto .......................... 9 3. El municipio de San Lucas y la población rural ....................................................... 9 4. La metodología de la evaluación ............................................................................ 10 5. El impacto del proyecto .......................................................................................... 10 6. Sostenibilidad.......................................................................................................... 19 7. Aspectos institucionales.......................................................................................... 21 8. Monitoreo y evaluación del proyecto ..................................................................... 26 9. Conclusíon .............................................................................................................. 27

EXECUTIVE SUMMARY .......................................................................................... 28 Sustainability of the IMCC model............................................................................... 41 1 introduction ................................................................................................................ 42

1.1 Project background ............................................................................................... 42 1.3 Methodology......................................................................................................... 42

2 Project background ................................................................................................... 45 2.1 Objectives ............................................................................................................. 45 2.2 Activities............................................................................................................... 46 2.3 Strategy ................................................................................................................. 46

3. Project Description and implementation................................................................ 50 3.1 Investments in health infrastructure, including investments in health equipment 54 3.2 Research into health and illness concepts and into health seeking behaviour...... 54 3.3 Institutional set-up and the project implementation arrangements ....................... 55

4. Possibility of achieving objectives with the current strategies ............................. 58 4.1 Special considerations........................................................................................... 67

5. Relevance of the project ........................................................................................... 69 5.1 Relevance of the project organisation: the IMCC model ..................................... 71

6. Project sustainability ................................................................................................ 73 6.1. Training, primary health care management, and human resources management 73 Inti Pallay.................................................................................................................... 75 6.2. Infrastructure and equipment investment ............................................................ 75 6.3. Research and baseline work................................................................................. 76 6.4. Institutional aspects and implementation arrangements ...................................... 77

7. Conclusions and recommendations......................................................................... 80 7.1 Training and strengthening of PHC management and health resources management ................................................................................................................ 81 7.2 Infrastructure and equipment donations ............................................................... 84 7.3 Research and baselines studies ............................................................................. 85 7.4 Institutional, implementation, and monitoring aspects......................................... 86


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Annexes Annex 1. Terms of Reference. Annex 2. List of persons met. Annex 3. Workshop with hospital and IMCC staff on the project. Annex 4. Mini workshop with auxiliary nurses. Annex 5. Mini workshop with ACSs. Annex 6. Focus Group Discussion with women and men villagers, Canchas

Blancas. Annex 7. Detailed summary of IMCC infrastructure and equipment investments

with HAM counterpart funds, 2002-2003. Annex 8. Programme of the Evaluation Mission. Annex 9. Declaration of Alma-Ata, 1978. Annex 10. List of documents consulted. Annex 11. Operations Manual of the EPC (Manual de Funciones del EPC)


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LIST OF ABBREVIATIONS ACS (s) Agente (s) Comunitario (s) de Salud / Community Health Worker ADRA (NGO) Agencia Adventista de Desarrollo y Recursos Asistenciales /

Adventist Agency for Development and Human Resources AIEPI Atención Integral de Enfermedades Prevalentes de la Infancia /

Integrated Services for Childhood Diseases ARI (s) Acute Respiratory Infection (s) ‘ CAI Comités de Análisis de la Información / Information-Analysis

Committees CAP Conocimientos Actitudes y Prácticas / Knowledge, Attitudes and

Practices CEMA Centro de Educación Para Mujeres y Adultos / Educational Centre For

Women and Adults CCSUTC Confederación Sindical Única de Trabajadores Campesinos de Bolivia /

Sole Union Confederation of Peasant Workers of Bolivia Danida Danish International Development Assistance DILOS Directorio Local de Salud / Local health Directory EDAs Enfermedades Diarreicas / Diarrhoeal Diseases EIB Educación Intercultural Bilingüe / Bilingual Intercultural Education EPC Equipo de Planificación y Capacitaciones / Planning and Training Team EBRP Estrategia Boliviana de la Reducción de la Pobreza (2004 – 2007)

/ Bolivian Poverty Reduction Strategy (2004 – 2007) FGD (s) Focus group discussion(s) HAM Honorable Alcaldía de San Lucas / Municipality of San Lucas IEC Information, Education and Communication IMCC Comité Internacional de Cooperación Médica / International Medical

Cooperation Committee IRAs Infecciones Respiratorias Agudas / Acute Respiratory Diseases KAP Knowledge Attitudes and Practices LFA Matriz del Marco Lógico / Logical Framework Matrix LPP Ley de Participación Popular y de Descentralización / The Law of

Popular Participation and Decentralisation MMI Mortalidad Materno-Infantil / Maternal Infant Mortality NGO Non Government Organisation O.C.I.ACS- MSL Organización Campesina Integral de Agentes Comunitarios de Salud del

Municipio de San Lucas / Integrated Peasant Organisation of the ACS of San Lucas Municipality

OMS Organización Mundial de la Salud / World Health Organisation PASACH Danida-financed Agricultural Sector Programme PHC Primary Health Care PIVs Promotores de Investigaciones de Vectores POA Plan Operacional Anual / Annual Municipal Plan of Operations SEDES Servicio Departamental de Salud / Departmental Health Services SUMI Programa de Salud Universal Materno Infantil / Universal Maternal

Infant Health Programme


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EXECUTIVE SUMMARY IN SPANISH / RESUMEN EJECUTIVO EVALUACIÓN DEL PROYECTO IMCC SAN LUCAS DE SALUD PRIMARIA 24/03/2004 Resumen: versión muy breve en español Impactos del proyecto IMCC de salud primaria Durante los tres primeros años de la primera fase, mediante las actividades de capacitación, educación, e inversiones en infraestructura, el proyecto IMCC ha logrado su meta principal de mejorar la salud de la población rural de San Lucas, especialmente la de la mujer y de los menores de cinco años. Además el proyecto ha podido:

Fortalecer el conocimiento y mejorar las prácticas del grupo meta, es decir de la población rural, con relación a la enfermedad y a la salud

Mejorar y aumentar la oferta de salud del municipio de San Lucas Fortalecer la organización de la población rural en el campo de la salud y fomentar

una mayor comprensión de los conceptos de salud que tiene la población rural, con el fin de mejorar la colaboración entre los voluntarios de las comunidades, los Agentes Comunitarios de Salud (ACSs), el municipio, el hospital y otras instituciones.

Impacto sobre la mujer y menor de cinco años Con respecto al objetivo general de mejorar la salud de la población rural de San Lucas, especialmente la de la mujer y de los menores de cinco años, ha habido en el área del proyecto impactos importantes, a saber: • Un leve mejoramiento de la cobertura de vacunaciones • Con respecto a las IRAs, hay menos casos de neumonía • Con respecto a las enfermedades diarreicas (EDAs), hay una leve reducción de los

casos registrados • Hay un mejor control y seguimiento de la madre en San Lucas. Se debe este

mejoramiento a la mejor preparación de los ACSs • Ha habido un aumento del parto institucional. Los partos institucionales en los

puestos sanitarios se han aumentado de 33% en 2002 a 41% en 2003 • El parto en domicilio ha disminuido porque se ha incrementado el parto en servicio • La tasa de mortalidad materna ha bajado del 1999, cuando existía siete por año. Para

el año 2003 hubo 4 casos registrados. Para el año 2004, hasta la fecha (marzo 24 2004) sólo existe un caso registrado.

• La tasa de mortalidad infantil ha bajado de 112 /100,000 a 92 /100,000 en 2003 Impacto del proyecto sobre el conocimiento, actitudes y prácticas (CAP) sobre la salud y la enfermedad A pesar de la vigencia de conceptos e ideas tradicionales andinos sobre la salud y la enfermedad, se puede constatar la influencia del proyecto y la existencia de una nueva comprensión de las causas de la enfermedad. Se ha podido constatar mediante entrevistas y grupos focales con mujeres en las zonas del proyecto una comprensión de


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la necesidad de mejorar la higiene del hogar y la nutrición de los niños. Además se ha registrado un fuerte interés en las charlas de los ACSs, y una demanda para los servicios de este recurso humano de salud capacitado por el proyecto con respecto al manejo del parto limpio en el campo. Impacto del proyecto sobre el conocimiento de personal de salud El personal de salud entrevistado a todos niveles se expresa satisfecho de la capacitación recibida, la valora, y tiene ideas y preocupaciones para capacitación adicional. En especial hay que señalar que ambos auxiliares y ACS entrevistados ven de suma importancia la capacitación en el manejo del parto limpio para los ACSs, y en el manejo de medicinas y el estudio farmacológico para entender mejor el uso de medicinas y antibióticos. Impacto del proyecto sobre infraestructura Es de subrayar que el hecho de que el IMCC prioriza inversiones en infraestructura de salud en el campo, es decir, afuera del pueblo de San Lucas, obliga a la HAM a hacer inversiones en las zonas rurales que previamente se han visto excluidas de este tipo de inversión. El IMCC ha financiado la construcción de puestos sanitarios y la refacción y mejoramiento del hospital y de puestos sanitarios. Las inversiones incluyen: baños, duchas, viviendas para personal auxiliar de salud, equipamiento técnico, salas de parto, acémilas, moto, ecógrafo, sistemas de agua potable para escuelas y puestos sanitarios. El IMCC en los años 2002, y 2003, ha cumplido con el objetivo del documento de proyecto de utilizar la mayor parte (70% logrado de la meta de 80% en los tres primeros años del proyecto) del presupuesto para inversiones infraestructurales y dotación de equipamiento en las zonas rurales, para beneficiar a los habitantes rurales. La HAM por su parte ha tenido que responder con su contraparte en los POAs para las áreas rurales. Grado de logro de los objetivos Por lo general, el proyecto ha podido lograr sus objetivos dentro del cronograma de actividades, a pesar de que ocasionalmente ha habido varias demoras. Sostenibilidad Las actividades de capacitación desarrolladas por el personal de salud del hospital de San Lucas, por los auxiliares, y por de los ACSs, están incorporadas en el Plan Operacional de Actividades (POA) de la municipalidad. Esto abre la posibilidad de que dichas actividades sean sostenibles en el futuro. La HAM está asumiendo el costo de los cursos de capacitación que se llevan a cabo en la provincia. Monitoreo y evaluación del proyecto Los sistemas de monitoreo y evaluación del proyecto son satisfactorios, y permiten el control de calidad de las actividades, asimismo permiten el control cualitativo y cuantitativo de la capacitación y de las inversiones en infraestructura y equipamiento. Conclusión En vista de los logros palpables y considerables del proyecto IMCC en sólo 3 años, se recomienda que el proyecto continúe por los menos una fase adicional de 5 años.


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Resumen: versión amplia en español 1. Introducción y antecedentes El proyecto IMCC de salud primaria, con financiamiento de Danida, viene ejecutándose desde el mes de julio del año 2001 en el municipio de San Lucas, en la Provincia de Nor Cinti, en el departamento de Chuquisaca. San Lucas es uno de los municipios más pobres de Chuquisaca, y Chuquisaca es uno de los departamentos con la más elevada índice de pobreza de Bolivia. Las índices de mortalidad materno-infantil (MMI) son extremadamente altas en el municipio. En la zona de los valles, las cuales son las zonas más aisladas del municipio de San Lucas, hay que caminar por ejemplo desde las comunidades más lejanas hasta 25 leguas (125 kms) a pie, es decir un viaje de dos días enteros, para llegar a los centros médicos más cercanos. El objetivo global del proyecto IMCC de salud primaria es el de mejorar la salud de la población rural de San Lucas, especialmente la de la mujer y de los menores de cinco años. Los objetivos inmediatos del proyecto son: 1. Fortalecer el conocimiento y mejorar las prácticas del grupo meta, es decir de la

población rural, con relación a la enfermedad y a la salud 2. Mejorar y aumentar la oferta de salud del municipio de San Lucas 3. Fortalecer la organización de la población rural en el campo de la salud y fomentar

una mayor comprensión de los conceptos de salud que tiene la población rural, con el fin de mejorar la colaboración entre los voluntarios de las comunidades, los Agentes Comunitarios de Salud (ACSs), el municipio, el hospital y otras instituciones.

Las actividades principales del proyecto IMCC se pueden dividirse en tres áreas: • Capacitación de ACSs, auxiliares de enfermería, del personal del hospital del San

Lucas, de grupos de mujeres (Inti Pallay) y de los comunitarios mediante sus organizaciones sindicales de base

• Inversiones en la infraestructura de salud, con inversiones menores en equipamiento de salud

• Investigaciones de los conceptos de salud y de la enfermedad y sobre los patrones de conducta relacionados con la salud.

IMCC es una ONG danesa sin fines de lucro, de religión o de política. Los voluntarios daneses, los cuales son mayoritariamente estudiantes de medicina, de salud pública, o de enfermería, y entre los cuales figuran también médicos, enfermeras, ingenieros civiles, economistas, y quiroprácticos titulados, vienen a Bolivia, después de una etapa de preparación de 9 a 15 meses, para un período de 14 meses. Antes de acudir a San Lucas, reciben cursos en lengua española, medicina tropical, y otros temas de relevancia para la realidad rural de Bolivia. Además de los cursos recibidos en Dinamarca, los voluntarios han recibido cursos de capacitación en Bolivia en los siguientes temas:


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• AIEPI comunitario • Medicina tradicional • Taller de comunidades saludables • Educación de promotores Aparte de los voluntarios daneses, hay una trabajadora social, oriunda de San Lucas, la cual es bilingüe en quechua y español, y quien trabaja a pleno tiempo y que reside en San Lucas. Además del trabajo de la formación y capacitación de grupos femeninos Inti Pallay, la trabajadora social ha sido estrechamente involucrada en la gerencia y ejecución de actividades de capacitación y fortalecimiento institucional del proyecto IMCC. Quedan 21 meses antes de terminar la primera fase del proyecto. Según los reglamentos de Danida, ente que financia IMCC, el proyecto tiene que ser evaluado antes de que se concluya la primera fase de cinco años, y antes de que se pueda proseguir a solicitar una nueva fase. El objetivo de toda asistencia danesa a los países en vías de desarrollo es el de la reducción de la pobreza. Por eso, el proyecto IMCC de salud primaria, que trabaja en una de las zonas más pobres de Bolivia, y que trabaja con la población más pobre y aislada del municipio de San Lucas, se enmarca plenamente dentro de la política danesa del desarrollo. 2. Aspectos nuevos de la política de salud de relevancia al proyecto A partir de abril del 2004, SEDES va a iniciar el “nuevo modelo de atención prenatal”, bajo el cual se capacitará a los ACS y a los parteros a manejar el parto limpio. En el AIEPI, el ACS es el nexo del programa en la comunidad. Según la política de salud de Bolivia, el papel de los y las ACSs es de prevenir, no de curar, la enfermedad, de mejorar el nivel nutricional de los menores de cinco años, de dar charlas sobre la higiene, el control del embarazo, y otros temas que se enmarcan dentro de la estrategia de la salud primaria. El Ministerio de Salud y Provisión Social, respondiendo a los objetivos de la Estrategia Boliviana de la Reducción de la Pobreza (2004 – 2007), (EBRP), ha creado dos programas muy importantes que enfocan la reducción de la pobreza: el Programa de Salud Universal Materno Infantil (SUMI) y el Programa de Atención Integral de Enfermedades Prevalentes de la Infancia (AIEPI). Estos dos programas tienen como fin el de mejorar la salud de la población pobre de Bolivia. En especial, se enfoca a la mujer embarazada y al menor de cinco años, éstos siendo los que más sufren altas índices de mortalidad. SUMI y AIEPI, dentro del marco de la EBRP, tienen que bajar las aún altas índices de mortalidad materno-infantil (MMI). 3. El municipio de San Lucas y la población rural La población de la zona del proyecto IMCC de salud primaria en la mayoría es quechua-hablante. A pesar de que se ha establecido el programa de Educación Intercultural Bilingüe (EIB) en el municipio, la tasa de deserción escolar, especialmente femenina, sigue siendo muy alta y, por ende, la tasa de analfabetismo también sigue siendo alta. En la zona del proyecto IMCC de salud primaria, la medicina tradicional se basa en una dualidad entre el ser humano y la Pachamama (Madre de la Tierra) y el mundo de los


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ancestros y de los espíritus, y que también se basa en un balance entre el calor y el frío del cuerpo humano. Los conceptos que sustentan la medicina tradicional del municipio de San Lucas también admiten nosologías y tratamientos místicos o mágico-religiosos. Varios individuos, tales como el “campo médico”, o médico del campo (en quechua el jampiri), el partero, y los promotores de salud son importantísimos en la realidad vivida en el campo. Los jampiris o curanderos tienen conocimientos que han heredado de sus ancestros de los jampis, o plantas medicinales. El uso de las medicinas tradicionales dentro de la farmacopea tradicional se basa en el concepto de reestablecer un balance físico y psicológico en el individuo. Entre las nosologías tradicionales más importantes en la zona del proyecto IMCC figuran la del mancharisqa, o asustado; la Gloria, o enfermedad de Gloria o Rayo; la q’echalera chirimanta, o diarrea por frío, y la q’echalera q’oñimanta o diarrea por calor; y varios otros. La Organización Mundial de la Salud (OMS) reconoce el susto o mancharisqa como una enfermedad tradicional. El susto figura en la clasificación internacional de las enfermedades. Algunos de los estudios epidemiológicos del susto1 muestran que la presencia del susto en una población determinada indica que los habitantes sufren de enfermedades muy graves, tales como el cáncer. Los asustados sufren de más enfermedades orgánicas que las personas que no son asustadas. La población del municipio de San Lucas vive en la mayoría de la agricultura. Las áreas de cabecera de valle se caracterizan por el cultivo de cebada, maíz y trigo. En las zonas más altas del municipio, se cultiva la papa. En estas zonas, la cría de oveja, llama y chivos es importante. La producción de lana ovejera y de llama es sumamente importante. El tejido tradicional andino de lliqllas, awayus, y fullos también es muy importante. El patrimonio cultural quechua del tejido juega un papel clave en las comunidades quechuas del municipio. Las enfermedades prevenibles más importantes en el municipio de San Lucas que afectan al grupo meta del proyecto incluyen el mal de Chagas, la tuberculosis, las enfermedades diarreicas (EDAs), las Infecciones Respiratorias Agudas (IRAs), la desnutrición crónica, y el bocio. 4. La metodología de la evaluación El punto de partida de la evaluación ha sido a través de una evaluación participativa, es decir una apreciación, mediante actividades tales como entrevistas, mini talleres de análisis de la realidad y grupos focales, del impacto percibido del proyecto. El objetivo de una evaluación participativa es el de fomentar la propiedad de las conclusiones, hallazgos, y recomendaciones hechos. El énfasis en muchas de las actividades ha sido, por lo tanto, en que los mismos participantes de las actividades trabajaran en grupos y que ellos mismos presentaran sus conclusiones y recomendaciones para mejorar el proyecto. La lógica de una evaluación participativa es que este documento será disponible y entregado a los actores del proyecto. 5. El impacto del proyecto Todos los actores entrevistados en esta evaluación participativa, a saber: SEDES, el municipio de San Lucas, el personal de salud, los ACSs, y los habitantes de las comunidades del área del proyecto, se expresan satisfechos de la contribución

1 Rubel et al, 1984. Susto: a folk illness. University of California Press, Berkeley.


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importante en el campo de la salud que el IMCC ha brindado en los tres años desde el inicio del proyecto. 5.1 Impacto epidemiológico2 Con respecto al objetivo general de mejorar la salud de la población rural de San Lucas, especialmente la de la mujer y de los menores de cinco años, ha habido en el área del proyecto impactos importantes, a saber: • Un leve mejoramiento de la cobertura de vacunaciones • Con respecto a las IRAs, hay menos casos de neumonía • Con respecto a las enfermedades diarreicas (EDAs), hay una leve reducción de los

casos registrados • Hay un mejor control y seguimiento de la madre en San Lucas. Se debe este

mejoramiento a la mejor preparación de los ACSs • Ha habido un aumento del parto institucional. Los partos institucionales en los

puestos sanitarios se han aumentado de 33% en 2002 a 41% en 2003 • El parto en domicilio ha disminuido porque se ha incrementado el parto en servicio • La tasa de mortalidad materna ha bajado del 1999, cuando existía siete por año. Para

el año 2003 hubo 4 casos registrados. Para el año 2004, hasta la fecha (marzo 24 2004) sólo existe un caso registrado.

• La tasa de mortalidad infantil ha bajado de 112 /100,000 a 92 /100,000 en 2003 5.2 Impacto del proyecto sobre el conocimiento, actitudes y prácticas (CAP) sobre la salud y la enfermedad Impacto del proyecto sobre el conocimiento del personal de salud del hospital de San Lucas El personal de salud del hospital resaltó el problema de no hacer buen uso de la oferta de financiamiento IMCC dentro de cada gestión para la capacitación del recurso humano de salud. Este problema se debe a problemas de gerencia del hospital, a la interferencia política en los asuntos técnicos del hospital y a la alta rotación del personal (por ejemplo, 5 médicos jefes en el año 2003). Recomendación: Se recomienda que cada mes durante el EPC que se incluya en el orden del día la oferta de capitación (se ha informado al equipo evaluador que esto ya se está haciendo). También se recomienda que el director del hospital elabore un plan de recursos humanos para capacitación del personal y que esto se presente al IMCC durante las reuniones del EPC cada mes. Todo el personal de salud ha recibido capacitación en 11 temas en total: • Ecografía (para médicos) • Gerencia del recurso humano hospitalario • Calidad de atención • SUMI • AIEPI clínico • TB • Cursos de repetición • Emergencias obstétricas.

2 La fuente de los datos epidemiológicos en el acápite 5.1 es SEDES.


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El personal de salud entrevistado a todos niveles se expresa satisfecho de la capacitación recibida, la valora, y tiene ideas y preocupaciones para capacitación adicional. En especial hay que señalar que ambos auxiliares y ACS entrevistados ven de suma importancia la capacitación en el manejo del parto limpio para los ACSs, y en el manejo de medicinas y el estudio farmacológico para entender mejor el uso de medicinas y antibióticos. Sin embargo, hay que subrayar que la política de salud del gobierno boliviano no es de capacitar a ACS en el tratamiento de enfermedades, sino en la prevención de la enfermedad y en avisar sobre partos riesgosos. La capacitación financiada por el IMCC ha mejorado la oferta de servicios de salud a la mujer embarazada en el municipio de San Lucas. La capacitación financiada por el IMCC también incluye becas para ACSs que desean estudiar enfermería auxiliar. Hasta la fecha (abril del 2004) dos ACSs han recibido becas para estudiar en el colegio CENPRUR en Ocuri. El personal de salud del hospital y los auxiliares también han sido capacitados en emergencias obstétricas. Dicho personal del hospital, habiendo sido capacitado, posteriormente ha reciclado a los auxiliares de los puestos sanitarios. Esta capacitación probablemente ha contribuido a la reducción de la mortalidad materna en la zona del proyecto. Sin embargo, ambos ACSs y auxiliares quienes se capacitan con la ayuda del proyecto resaltan la necesidad, arriba mencionada, de que los ACS sean capacitados lo más rápido posible en la atención a los partos. Esto especialmente es necesario en las tres zonas de valle, debido a las grandes distancias que hay que transcurrir para llegar al centro médico más cercano (dos días de caminar). Es importante mencionar que se han registrado a unos cinco casos en esta evaluación de ACSs que han seguramente salvado la vida de mujeres con partos difíciles porque han contactado el hospital por radio. Además algunos de los ACS, por interés o por capacitación previa recibida, ya están ofreciendo servicios de partero en sus comunidades. Este hecho hace aún más importante la capacitación y reciclaje en el parto limpio de los ACSs, para hacer más posible una buena coordinación y harmonización de las prácticas. Finalmente, sobre el trabajo realizado por los ACSs, se subraya el hecho de que este recurso humano en muchos servicios de salud cuida los puestos mientras los auxiliares y otros funcionarios de salud están presentando informes en San Lucas, están de vacación, o mientras están atendiendo emergencias en el campo. Por eso, se subraya la necesidad de capacitar a los ACSs en el reconocimiento de medicinas si es que las tiene que recetar bajo el control e instrucción por parte de un médico por medio de la radio en caso de una emergencia. Los ACSs reconocen la necesidad de ser capacitados en el manejo del parto limpio, y han pedido que el proyecto se les capacite acerca de este tema. Además, ambos ACSs y habitantes de las comunidades del campo subrayan el papel de unos cuantos parteros tradicionales y el papel potencial para los ACS que podrían reemplazar o complementar a los parteros. Recomendación: En vista de la vigencia entrante del “nuevo modelo de atención prenatal”, bajo el cual se capacitará a los ACS y a los parteros a manejar el parto limpio, se recomienda que los ACS sean capacitados por personal de salud de hospital y


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auxiliar con fondos del IMCC lo más antes posible. Se recomienda que ambos el hospital e IMCC hagan conocer a SEDES la necesidad de capacitar en temas de parto a los ACSs, especialmente a los que trabajan en las zonas del valle. Además, se recomienda que los parteros tradicionales sean ofrecidos cursos de capacitación sobre el parto limpio. Recomendación: SEDES debería de considerar la posibilidad de que Hospital de San Lucas e IMCC capaciten en el reconocimiento y el manejo de medicinas bajo supervisión médica en los puestos sanitarios en casos de emergencia (en el caso de que estén ausentes o el personal médico o auxiliar). Los ACS carecen de materiales y equipamiento para ofrecer el servicio del parto limpio (el parto institucional e intercultural incluye la posibilidad del parto domiciliario bajo condiciones higiénicas y culturablemente aceptables). El personal de salud del hospital resaltó la falta de acercamiento entre el sistema hipocrático de medicina y la medicina andina de la zona rural.

Recomendación: Se recomienda que el personal de salud del hospital y los auxiliares se reúnan para identificar problemas relacionados a la atención intercultural y atención integral de salud. El producto de dicha reunión será una priorización de problemas y la elaboración de un proyecto de capacitación del personal de salud para solucionar los problemas. Una primera etapa sería la de estudiar el Estudio Antropológico que se ha realizado en el año 2003. El IMCC se ha comprometido a hacer algunos módulos para capacitación en medicina intercultural, utilizando como material de enseñanza, los resultados de dicho Estudio Antropológico. Se prevé una metodología práctica “hands on”, mediante el cual se prevé observar a médicos y auxiliares mientras que consulten a pacientes en el campo. Impacto del proyecto sobre el conocimiento de los auxiliares Los auxiliares entrevistados resaltaron la falta de mayor coordinación entre hospital, IMCC, y auxiliares para los cursos de capitación para auxiliares y para ACSs. Recomendación: Se recomienda que se programe fijamente las fechas de cursos en estrecha coordinación. Los auxiliares entrevistados resaltaron el idioma inadecuado para cursos de capitación para ACSs: algunos de los capacitadores no hablan corrientemente el quechua, con el resultado de que los ACS no captan el contenido de los cursos. Recomendación: Se recomienda que se utilicen capacitadores del hospital que hablan y que escriben corrientemente el quechua. Los auxiliares valoran altamente la capacitación que han recibido en AIEPI y SUMI, especialmente en vista de que ésta ha sido una capacitación muy práctica y muy relevante a sus necesidades. Los aspectos prácticos de la capacitación han posibilitado que los auxiliares capaciten en su turno a los ACS utilizando métodos sencillos y prácticos. Impacto del proyecto sobre el conocimiento de los ACSs Los ACSs han recibido capacitación con fondos del IMCC en los siguientes temas:


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• Primeros auxilios (2002) • Reconocimiento de partos difíciles (2004) • AIEPI y medidas preventivas (2002-2004), como hacer charlas • SUMI (2003) Esta capacitación es valorada altamente por los mismos ACSs, por los habitantes de las comunidades donde trabajan, y por los auxiliares, con los cuales trabajan los ACS. Tal es el sentimiento de responsabilidad de algunos ACSs que, al ausentarse el personal médico o auxiliar del puesto de salud, algunos ACSs atienden a los pacientes en el puesto y, con la ayuda del personal de salud de San Lucas por radio, administran medicinas y curan a pacientes que acuden a los puestos. Aunque no se prevé que los ACSs curen la enfermedad, en la práctica, algunos de ellos ya recetan medicinas y antibióticos inyectables / orales en el campo. Esto se debe a varios factores:

• Algunos de los ACSs ya sabían manejar medicinas y recetar, debido a

capacitaciones bajo programas anteriores de salud (por ejemplo, Esperanza Bolivia) • Otros ACSs por motivo propio o por ser autodidactos han aprendido algunos

aspectos • Las creencias tradicionales andinas sobre la medicina y sobre el cuerpo. Los

pacientes del campo demandan estos servicios, y a veces traen penicilinas y otras inyectable que ellos mismos han comprado de terceros para que el ACS se les coloque una inyección; si el ACS se niega a ayudar, el paciente irá a otro lugar, tal vez menos higiénico, para hacerse colocar su inyección.

Recomendación: En vista de que algunos ACS ya están recetando y manejando medicinas biomédicas, sería aconsejable que recibieran capacitación en los peligros de recetar incorrectamente las medicinas y drogas. Se recomienda mediante este informe que SEDES y Red Camargo consideren esta problemática, y que hagan conocer al hospital e IMCC sus consideraciones lo más antes posible. Los ACSs, conscientes de la importancia y vigencia de la medicina andina de la zona del proyecto, piden cursos de capacitación en la colección, clasificación, manejo, y uso correctos de las medicinas del campo (jampis). Los mismos ACSs mencionan el hecho de que, siendo muy pobres los habitantes de las comunidades rurales, las medicinas biomédicas que no son gratuitas bajo programas tales como SUMI, o Seguro Básico, están fuera del alcance de los comunitarios. Por ende, sería aconsejable, según los ACSs, estudiar cómo utilizar las medicinas del campo para curar o prevenir la enfermedad. Las mujeres en los grupos focales también expresaron – por motivos culturales, prácticos y económicos - el deseo de que los ACS aprendan sobre la medicina tradicional de los jampis, para poder instruirles a ellas cómo prevenir y curar las ERAs e IRAS y otras enfermedades prevenibles. Recomendación: Se recomienda que personal de salud y de IMCC estudien otros proyectos de salud primaria que tienen un componente de medicina tradicional, para ver cuáles posibilidades habrá para incluir este elemento en el proyecto. Un proyecto que los ACS, auxiliares, otro personal médico y mujeres comunitarias podrían visitar es el de la ONG danesa-boliviana Diálogos, bajo la dirección del Dr. Miguel Isolá.


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Impacto del proyecto sobre el conocimiento de mujeres y hombres en las zonas rurales El Estudio de Línea de Base La trabajadora social del proyecto IMCC conjuntamente con una consultora quien la apoyó hizo el estudio de línea de base (un sondeo de 328 encuestas en 328 hogares). En total se utilizó aproximadamente ocho meses del tiempo de la trabajadora social en hacer el estudio de línea de base, a saber: • Abril 2003 Diseño de cuestionario / traducción • Mayo 2003 Encuestas (2 semanas) • Junio-agosto 2003 aplicación de encuestas (2 meses) • Septiembre 2003: revisión, codificación • Octubre a noviembre 2003 (seis semanas): diseño de base de datos • Diciembre 2003: borrador del estudio • Enero 2004: Entrega final Ocho meses representa un gasto inaceptable del recurso financiero y de tiempo de la trabajadora social del proyecto. ONGs como OXFAM Gran Bretaña y CARE Bolivia han establecido pautas para hacer líneas de base en mucho menos tiempo. El proyecto IMCC podría seguir este tipo de pautas directrices. Además se debería hacer el estudio de línea de base en un mes, porque ocho meses representa demasiado tiempo en la vida de un proyecto de 5 años. El objetivo de una línea de base es hacer un estudio rápido y representativo que sea útil a los fines de monitoreo del proyecto. Recomendación: Se recomienda que en el futuro para la repetición del estudio de base se contrate a una empresa consultora que con un equipo de unos 10 encuestadores podría ejecutar todo el estudio en 4 semanas. 4 días para capacitación de los 5 equipos de encuestadores y traslado al lugar de la encuesta; 10 días para prueba piloto y ejecución de las encuestas inclusive traslado y logística, y 6 días para análisis de datos y generación de recuadros, y 8 días para elaboración de un informe breve. Claro está que el presupuesto para el estudio de línea de base en la nueva fase tendrá que ser aumentado para reflejar el uso de más consultores, pero convendría gastar más dinero y hacer el estudio rápidamente y librar al recurso humano de la trabajadora social que tiene actividades más importantes en el proyecto. En la opinión del equipo evaluador, sería mejor que la trabajadora social utilice más de su tiempo en la supervisón y capacitación de los grupos de mujeres Inti Pallay, actividad que está retrasada, y en actividades de coordinación y monitoreo de los ACSs. Se prevé en el documento del proyecto que los habitantes de la zona rural – especialmente las mujeres y padres de menores de cinco años – tendrán como resultado de las actividades educativas del proyecto mediante auxiliares y ACS un mejor conocimiento de las causas y de la prevención de las enfermedades prevalentes en la zona. Para poder medir el impacto sobre el CAP de salud / enfermedad del grupo meta, se llevó a cabo, como arriba mencionado, un estudio de línea de base en el año 2002. Los resultados de dicho estudio muestran que:


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• Un alto porcentaje (75%) de la población encuestada no realiza prácticas de prevención de las EDAs, y que el 55% de la población encuestada atienda al menor en la casa y 35% recurre al puesto sanitario

• Que 75% identifican como causas de la desnutrición a los “malos olores”, cuya connotación tiene carácter mágico

• En general la percepción sobre las causas de las enfermedades tiene una connotación mágico-cultural (susto y otros), o no sabe (24% para EDA, 7% en IRA, 61% para Chagas, Bocio 87% y desnutrición 89%).

Cabe decir que la consultora que ejecutó el estudio de línea de base nunca entregó los datos crudos en forma electrónica al IMCC. Recomendación: Se recomienda que el IMCC San Lucas obtenga los datos crudos en forma electrónica de las preguntas que se van a hacer en abril / mayo 2004, y que en el futuro el IMCC obtenga todos los datos electrónicos antes de pagar la empresa consultora para sus servicios. Al poseer el IMCC los datos crudos de la línea de base podría generar estadística sobre temas de interés y para poder mejor monitorear el proyecto. Se va a volver a repetir la línea de base dentro de unos 21 meses. Hasta que se vuelva a repetirla, no se puede hacer conclusiones exactas sobre posibles cambios en el CAP de salud y de la enfermedad de los habitantes de la zona rural. Sin embargo, los grupos focales y entrevistas con comunitarios que han sido llevados a cabo durante esta evaluación corroboran la persistencia de dichas creencias y percepciones tradicionales sobre la enfermedad y la salud. Esto se debe probablemente al hecho de que las creencias sobre salud y enfermedad en la zona del proyecto forman parte de un conjunto de creencias mágicas-religiosas del pensamiento andino quechua. Al llevar a cabo el estudio de línea de base, no se incluyó una serie de preguntas sobre el CAP en cuanto al parto y al embarazo. Ambos el personal de hospital y el IMCC opinan que es urgente que se lleve a cabo un estudio que incluya las preguntas faltantes. A no hacer esto, será muy difícil medir el impacto del proyecto precisamente en cuanto a su objetivo principal: el de mejorar la salud de la mujer y niños menores de cinco años y el de medir cambios de percepciones y preferencias en cuanto al parto, el embarazo, y preferencias para el parto. Recomendación: Se recomienda que se contrate a un (os) consultor (es) para llevar a cabo estas preguntas, bajo la supervisión de IMCC, lo más rápido posible y antes del fin del mes de abril del 2004, y que se utilicen la misma metodología y universo que se utilizaron en el estudio original (muestreo aleatorio). Al volver a repetir el estudio de línea de base en el 2005, se podrá por ende mostrar el impacto del proyecto en la área importante de CAP de parto y embarazo. El Estudio Cualitativo Antropológico Para mejor entender las creencias tradicionales acerca del cuerpo, la salud, y la enfermedad de los habitantes rurales, se llevó a cabo un estudio antropológico. El estudio fue financido por fondos externos al proyecto. Estos fondos eran muy mínimos, con el resultado de que no se podía pagar un honorario a la consultora antropológica. Esto resultó en que al IMCC le era muy difícil presionar a la consultora cuando tardó en terminar el informe.


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Como mencionado ariba, la consultora danesa tardó seis meses en completar dicho estudio. A pesar de este retraso considerable, y pese al hecho de que el lenguaje, la ortografía y la gramática del informe antropológico son de calidad inferior (el informe está lleno de errores gramaticales y ortográficos), el estudio contiene muchos datos interesantes y de importancia para el proyecto. En su condición actual no es recomendable entregar una copia de dicho informe ni a SEDES ni al hospital de San Lucas. Hay que editar y corregir el informe antes de entregarlo a estos entes. El reto ahora es saber cómo utilizar este informe que tanto ha tardado. El tercer objetivo del documento del proyecto tiene como objetivo: el de “fomentar una mayor comprensión de los conceptos de salud que tiene la población rural, con el fin de mejorar la colaboración entre los voluntarios de las comunidades, los Agentes Comunitarios de Salud (ACSs), el municipio, el hospital y otras instituciones”. Se prevé por lo tanto utilizar el informe antropológico como fuente de datos los cuales pueden asistir el personal de salud de los diferentes niveles en apreciar y respetar mejor las percepciones sobre salud y enfermedad de los habitantes rurales de San Lucas. Recomendación: Se recomienda que un antropólogo médico del área andina o persona calificada que entienda la realidad andina acerca de la enfermedad y la salud asista el personal IMCC y de hospital en diseñar algunos folletines y materiales educativos utilizando fragmentos de dicho informe antropológico. Es necesario emplear a un antropólogo medico profesional porque los voluntarios IMCC no tienen la capacidad técnica de diseñar elos mismos los folletines y materiales educativos. Dichos folletines y materiales educativos podrían ser utilizados en cursos de capacitación sobre los conceptos de salud y de la enfermedad y sobre los patrones de conducta relacionados con la salud de la población rural. (En el informe principal en inglés se presentan algunas ideas para el contenido de curso para la capacitación antropológica-médica). 5.3 Impacto del proyecto sobre infraestructura de salud Los auxiliares y ACSs y habitantes del campo entrevistados resaltaron la falta de accesibilidad a los lugares lejanos en la zona de los valles. A pesar de las inversiones en infraestructura, ACSs, habitantes de áreas rurales, y auxiliares aún subrayan la falta de vías de comunicación (radios y caminos) en algunas de las comunidades lejanas, y la falta de infraestructura de salud en la zona de los valles. Los auxiliares entrevistados resaltaron la falta de una mayor coordinación entre hospital, HAM, IMCC en la planificación y ejecución de las obras. La falta de coordinación entre los entes involucrados en la planificación y ejecución de obras de infraestructura ha dado pie a retrasos, gastos de tiempo y de dinero. Por el momento se desconoce si SEDES prevé la dotación de nuevos ítems para más personal auxiliar de salud para posibles nuevos puestos sanitarios en la zona de los valles. Por esto, no se recomienda aquí que el IMCC y la HAM presupuesten todavía para construcción de más puestos de salud en la zona de los valles. Recomendación: Se recomienda, sin embargo, que se haga conocer a SEDES mediante este informe el problema del extremo aislamiento de la población rural de los valles (unos 10,000 mil personas) y que este aislamiento es un riesgo a su salud.


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Es de subrayar que el hecho de que el IMCC prioriza inversiones en infraestructura de salud en el campo, es decir, afuera del pueblo de San Lucas, obliga a la HAM a hacer inversiones en las zonas rurales que previamente se han visto excluidas de este tipo de inversión. El IMCC ha financiado la construcción de 1 puesto sanitario (2 puestos sanitarios nuevos están financiados por el IMCC y HAM en el POA del año 2004) y la refacción y mejoramiento del hospital y de 6 puestos adicionales (incluye baños, duchas, viviendas para personal auxiliar de salud, equipamiento técnico, sala de parto, acémilas, moto, ecógrafo, sistema de agua potable para escuela y puesto sanitario de La Palca (cerca de 800 habitantes). Este sistema de agua beneficiará a alrededor de 80 alumnos de la escuela de la Palca. En este momento (marzo del 2004) en Uruchini se está construyendo un sistema de agua potable para el puesto sanitario. El IMCC en los años 2002, y 2003, ha cumplido con el objetivo del documento de proyecto de utilizar la mayor parte (70% logrado de la meta de 80% en los tres primeros años del proyecto) del presupuesto para inversiones infraestructurales y dotación de equipamiento en las zonas rurales, para beneficiar a los habitantes rurales. La HAM por su parte ha tenido que responder con su contraparte en los POAs para las áreas rurales. Se espera lograr la meta de 80% de inversiones gastadas en áreas rurales a lo largo del período de cinco años de la primera fase. En algunos casos la calidad de la construcción financiada por IMCC con contraparte de la HAM no es aceptable. Por ejemplo, la ducha y el sistema de desagüe en el puesto sanitario de Canchas Blancas no han sido construido correctamente. En dos casos adiconales (Uruchini y La Palca), se construyeron duchas y baño sin que se hubiera verificado la presencia de un sistema de aprovisionamiento de agua para los nuevos sistemas. El IMCC está en el proceso de solucionar este problema en colaboración con la HAM. Recomendación: El IMCC y la HAM deberían de asegurar mediante supervisión de obras y supervisión de personal que los ingenieros de la HAM sean de una calidad suficiente para garantizar la buena calidad de las obras financiados por el IMCC. Asimismo la HAM debería de asegurar una supervisón adecuada de las obras para evitar problemas de calidad. Resultados positivos inesperados del proyecto IMCC En una comunidad donde no hubo agua potable el IMCC con la HAM han instalado un sistema de agua potable que beneficia ahora al puesto sanitario y la escuela con un gran número de alumnos. Este resultado no esperado (no está previsto en el documento del proyecto que se haga construcción de sistemas de agua) debería de ser repetido en varias comunidades donde la población está sufriendo las consecuencias de fuentes inseguras de agua potable y la falta de y servicios sanitarios. Recomendación: Se recomienda que el IMCC incremente el presupuesto anual para sistemas de agua potable, posiblemente con la construcción de algunas letrinas en lugares claves (escuelas, puestos sanitarios) o servicios sanitarios sencillos. Asimismo se recomienda que el IMCC siga ofreciendo cursos de capacitación (utilizando los ACSs) sobre temas de salud y prevención de la enfermedad que incluyan diagnósticos


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participativos sobre la situación de salud, agua potable, y servicios sanitarios en cada comunidad. 6. Sostenibilidad Las actividades de capacitación desarrolladas por el personal de salud del hospital de San Lucas, por los auxiliares, y por de los ACSs, están incorporadas en el Plan Operacional de Actividades (POA) de la municipalidad. Esto abre la posibilidad de que dichas actividades sean sostenibles en el futuro. Sin embargo, con respecto a la construcción de obras de infraestructura hay retrasos de más de un año debidos en parte a demoras por parte de la HAM en hacer licitaciones, presupuestos, y en hacer diseños técnicos. Estos retrasos necesitan que el IMCC tiene que devolver dinero a Danida que está presupuestado pero no utilizado en una determinada gestión. Recomendación: Se recomienda que se exija a la HAM para que desembolse en su debido tiempo lo asignado para obras de construcción y mantener en el POA el monto de la contraparte. ACSs Hay un alto y alarmante porcentaje de abandono de los ACS que varia entre el 30% hasta el 55%. En Canchas Blancas, por ejemplo, de 21 ACSs originalmente capacitados por el IMCC, 11 (55%) son todavía activos, y 10 (45%) han abandonado su trabajo como ACS en la comunidad. En Huañumilla, de 18 ACS capacitados, 10 son activos y 8 han abandonado el trabajo de ACS. En Buena Vista, de 18 ACS capacitados, 12 son activos y 6 han abandonado el trabajo de ACS. Los motivos de abandono son varios: • En el caso de jóvenes mujeres, a veces se migran por motivos de trabajo o

matrimonio a otras zonas del país, o son demasiado jóvenes para asumir la responsabilidad de ser un ACS.

• Por pobreza y por la falta de fuentes de ingresos (los ACS no son pagados y no pueden cobrar sus servicios), algunos ACS se migran definitiva o temporáneamente a otras zonas del país

• Por motivos de los estudios de los hijos las familias de algunos ACS migran a ciudades como Tarija, Sucre, o Santa Cruz

• Por fallecimiento. Por ejemplo, el ACS de la comunidad de Qapira (Canchas Blancas), Don Catalina Ruiz, falleció trágicamente en el camino yendo a su casa después de un curso del IMCC.

En solamente unos tres o cuatro casos registrados por esta evaluación, los ACSs han sido reemplazados. Sin embargo, en la mayoría de los casos registrados en la evaluación, casi ninguno de los ACS que han dejado de trabajar ha sido reemplazado. Recomendación: Ni el hospital ni el IMCC pueden asumir la responsabilidad de avisar SEDES si un ACS se deja de trabajar. Es el deber del sindicato, y de los líderes de la comunidad de donde proviene el ACS, de avisar al auxiliar del puesto al que pertenecía el ACS. Asimismo el sindicato debería de elegir a un nuevo ACS en reemplazo, y tal vez mediante el O.C.I.ACS-MSL (cuando se habrá recibido su personería jurídica y cuando las tres mesas estarán funcionando).


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El IMCC al salir al campo siempre revisa conjuntamente con los auxiliares la lista de ACSs para hacer un control de monitoreo muy sencillo de sí los ACS siguen activos o no. En época de lluvias, no es posible salir al campo, y pueden pasar varios meses antes de que se vuelva a hacer un control de monitoreo en los puestos sanitarios sobre los ACSs. Por eso se sugiere que el IMCC pida a los auxiliares, al presentarse éstos en San Lucas en el hospital, revisen las listas de nombres de ACSs con el hospital e IMCC. Sin embargo, no es la responsabilidad del IMCC ni de identificar o seleccionar a los y las reemplazantes, sino de las organizaciones comunitarias conjuntamente con el personal auxiliar de salud. Todos los ACSs entrevistados alegan que el hecho de no ser asalariados, ni recibir viáticos, es un factor determinante en el abandono. Sí fueran asalariados, o si recibieran un pequeño salario, dicen, podrían seguir como ACSs. Sin embargo, no es la política de salud del gobierno boliviano de pagar a los ACSs. Lo que sería psicológicamente muy importante sería más el reconocimiento de la labor del ACS y esto se podría lograrse mediante más capacitación y más profesionalización de los ACSs. Recomendación: Esto se podría asegurarse posiblemente por la siguiente manera: • Acreditación con firma de SEDES, Red de Camargo y Hospital de que el ACS

puede trabajar en el campo de la salud. Todos los ACSs capacitados hasta la fecha (marzo del 2004) tienen una acredititación y carnet de identidad. Nuevos ACSs necesitarán estas acreditaciones cuando han recibido capacitación

• Tramitación de la Personería Jurídica de la organización que representa a los ACS, O.C.I.ACS-MSL

Recomendación: Se recomienda que la problemática del abandono del trabajo de ACS y los problemas económicos de los ACSs se analicen más profundamente en un taller con todos en el período de abril 2004 hasta octubre del 2004. En este período IMCC prevé visitar todos los puestos sanitarios. Botiquín de primeros auxilios Al evaluar el proyecto, el equipo de evaluación constató que los ACSs entrevistados carecen de materiales que les fueron originalmente dotados al completar el curso en primeros auxilios. Los ACS explicaron que en el campo, o los pacientes pagan en productos como huevos (que son muy difíciles de vender) o no pagan por varios motivos (pobreza, escasez de dinero en el campo). Esto resulta en que los ACS no pueden comprar vendas, gasa, jabón, etc. Para mantener sus botiquines en orden, los ACS sí son permitidos de cobrar para los materiales usados (1 BOB por artículo, que no cubre el costo real de reemplazo), pero alegan que los comunitarios no quieren pagar porque piensan que los ACS son asalariados. Recomendación: Se recomienda que la problemática del no reemplazo de materiales en los botiquines de los ACSs se analice más profundamente con las comunidades durante las giras del IMCC y personal de salud previstas para el período de abril 2004 hasta octubre del 2004. Sostenibilidad de la infraestructura nueva Para que se mantengan los nuevos puestos sanitarios, sistemas de agua potable, puestos refaccionados / reparados, baños y duchas, paneles solares y baterías, y otros


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equipamientos médicos en buen orden y en un buen estado de funcionamiento en el futuro será necesario lo siguiente: Recomendación: Se recomienda que la HAM con la ayuda del proyecto, y conjuntamente con los otros actores relevantes (hospital, auxiliares, ACSs, líderes de comunidades), lo más antes posible establezca un sistema de mantenimiento preventivo. (Esto es un requerimiento de Danida para donaciones de este tipo.) La contraparte de los gastos previstos para mantenimiento debe de ser incluida en los POAS anuales. 7. Aspectos institucionales Coordinación entre el IMCC y las organizaciones e individuos involucrados en el proyecto SEDES y el IMCC A pesar de que hay una buena coordinación entre el IMCC y SEDES con respecto a la planificación de las actividades, en la percepción de personal clave de SEDES la alta rotación de los voluntarios daneses a veces dificulta la coordinación entre ambas entidades. Cabe decir que también ha habido una rotación bastante alta del personal de SEDES y de Red Camargo! Planificación de cursos Ambos el personal de salud del hospital, auxiliares e IMCC señalaron un problema de falta de coordinación de los planes del proyecto. A pesar de que el proyecto siempre hacer llegar a SEDES cada mes su plan de actividades, en varias ocasiones, SEDES con unos cuantos días de aviso llega para hacer supervisiones en San Lucas o requiere la presencia inmediata de personal clave que estaba destinada para hacer un curso del proyecto. El resultado ha sido la cancelación y postergación de varios cursos, gastos económicos y gastos de tiempo de personal IMCC / hospital. Recomendación: Se recomienda que SEDES e IMCC establezcan un canal seguro de comunicación e intercambio de planes de actividades para evitar este tipo de problema en el futuro. Hospital e IMCC Los cambios frecuentes de personal de salud, especialmente del personal médico, amenazan la sostenibilidad y el buen seguimiento del trabajo en salud primaria en San Lucas. La ley del servicio civil establece que personal de salud en diferentes niveles son empleados del estado y que tienen que ser empleados por mérito, no por afiliación política. Recomendación: Se recomienda que el IMCC pida a la HAM y a SEDES que se estabilice el personal de salud en el hospital y los puestos sanitarios, con la institucionalización de los cargos por méritos y no por afiliación política. OCIACS-MSL OCIACS-MSL se fundó en junio del 2003. Por eso, sólo recién esta organización muy nueva está tramitando su personería jurídica. Al recibir ésta podrá ser incluida en el POA. Esto hará más posible (pero no lo asegurará) la sostenibilidad de algunos aspectos de la coordinación y del monitoreo del trabajo de los ACSs en el futuro cuando el IMCC se retire de la provincia. Sin embargo se juzga que OCIACS-MSL es todavía una


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organización muy débil y que necesita mucha ayuda para funcionar independientemente. Recomendación: Se recomienda por ende que el IMCC lleve a cabo fortalecimiento institucional de OCIACS-MSL, tal vez empelando a capacitadotes de ACLO o de IPTK. Otras instituciones e IMCC Mediante el Equipo de Planificación y Capacitación (EPC), se prevé que el trabajo del proyecto IMCC se coordine bien cada mes. Sin embargo, en la percepción de personal de salud del hospital, los planes que resultan de las reuniones mensuales, entre IMCC y la jefatura del municipio, no siempre son respetados por SEDES, que muchas veces impone sus propios planes. Esto perjudica la buena coordinación de los cursos de capacitación. Esperanza Bolivia y ADRA Aunque estas dos ONGS han trabajado anteriormente en el sector de salud primaria, en este momento no están trabajando mucho con capacitación ni de ACSs ni de parteros. Tampoco en este momento están realizando seguimiento o supervisión de estos recursos humanos que apoyaban anteriormente. Efectivamente los recursos humanos en salud que han sido capacitados por Esperanza y ADRA han sido abandonados, aunque se supone que personal de salud del hospital en las zonas donde están siga trabajando con los que han quedado activos. Esperanza Bolivia y ADRA aparentemente no han mantenido sistemas de monitoreo ni han producido informes de evaluación, con el resultado de que se desconoce el impacto del trabajo en salud con ACSs y parteros. Sin embargo, Esperanza y ADRA sí siguen trabajando con promotores de investigaciones de vectores (PIVs), bajo el programa de Chagas. Varios de los PIVs también son ACS. ADRA en el 2004 prevé iniciar un proyecto de capacitación de ACSs en AIEPI en zonas de San Lucas donde no trabaja el IMCC. Esperanza Bolivia, ADRA e IMCC se reúnen normalmente cada mes con el hospital y con el resto de los miembros del arriba mencionado EPC. Un médico de ADRA está insertado en el hospital de San Lucas con el objetivo de hacer fortalecimiento institucional del hospital. Recomendación: Se recomienda que el hospital hace llegar a SEDES los planes de las actividades a más tardar el día 24 de cada mes, y que SEDES tome en cuenta y respete las actividades (tal como está previsto en el convenio entre SEDES e IMCC). (Esta recomendación ya ha sido implementada, pero sigue siendo un problema). Los ACS subrayan la falta de coordinación con ellos por parte del personal de salud y autoridades para las visitas domiciliares (AIEPI comunitario). Esto dificulta mucho y a veces estorba el buen trabajo de los ACSs. Recomendación: Se recomienda que el proyecto analice maneras de mejorar la coordinación en el campo, entre el puesto / centro médico y el ACS, posiblemente la compra de más radios, o tal vez mediante mejores sistemas de monitoreo y aviso de actividades por parte de los auxiliares.


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Aspectos de género Con respecto a la selección y elección de los Agentes Comunitarios de Salud (ACSs), la vasta mayoría de los cuales son hombres, no se ha incluido a la mujer de manera adecuada en el proyecto. Las organizaciones de las bases eligieron los ACSs antes de que el IMCC iniciara su trabajo en San Lucas. Recomendación: Se recomienda que el proyecto exija que se elija a nuevas mujeres para ser ACS para reestablecer la equidad de género en el proyecto y para reemplazar los ACSs que han abandonado el trabajo, o quienes han fallecido. Será necesario – mediante el trabajo del IMCC con Inti Pallay - analizar qué tipo de mujer habrá que elegir. El proyecto debería también incluir a promotoras de salud que ya están trabajando gratuitamente pero las cuales no han sido elegidas por las bases, que son dominadas por los hombres. Por ejemplo, en la comunidad de Pulquina, Doña Eulogia, una mujer casada y con hijos, nunca fue elegida por la base. Sin embargo, ella quiso ser promotora, asistió a los cursos del IMCC, y ahora ella es un recurso muy importante del sistema de salud en esta comunidad. El proyecto IMCC está haciendo esfuerzos valiosos en el campo de la equidad de género mediante el trabajo realizado por la trabajadora social del proyecto. Mediante la organización de mujeres Inti Pallay, que ya tiene personería jurídica, se está trabajando con dos grupos de mujeres en dos zonas del proyecto con el fin de empoderar a la mujer campesina y con el fin de que tenga un rol protagónico en su familia, comunidad, y municipio. La pregunta: ¿serán sostenibles los grupos de mujeres Inti Pallay? no se la puede contestar todavía. Es demasiado temprano en vista de que la trabajadora social está trabajando con solamente dos grupos3. El trabajo de formar a grupos femeninos parece que empezó sólo a fines del año 2003, unos cuantos meses antes de esta evaluación. Capacitación de miembros de las bases El tercer objetivo inmediato del proyecto es el de “fortalecer la organización de la población rural en el campo de la salud y fomentar una mayor comprensión de los conceptos de salud que tiene la población rural”. Este componente incluye actividades y capacitación brindadas por el proyecto mediante la Centralía de Campesinos de San Lucas. Aunque el monto de 12, 000 BOB por año donado a la Centralía de Campesinos de San Lucas (con sede en Putaca) sólo reprenda un 5% del presupuesto del IMCC para actividades de capacitación, el hecho de que el proyecto apoya a una organización que está intentando mejorar los niveles de conocimiento de los habitante rurales de San Lucas es importante. Este objetivo del proyecto IMCC se enmarca plenamente dentro del objetivo de la OMS de educar a los habitantes pobres de los países del mundo, tal como está expresado en la Declaración de la OMS en Alma Ata en 1978, a saber: “Incluir por lo menos educación sobre problemas de salud prevalentes y los métodos de prevenir y controlarlos (párrafo 3)”. Entre los temas de los cursos de capacitación financiados por el IMCC que han tenido lugar en el Centro de Capacitación de la Centralía de Campesinos figuran los siguientes: • Ley de SUMI • Temas de salud

3 Hay varios grupos de mujeres Inti Pallay en la provincia y otras organizaciones trabajan con ellos. El IMCC trabaja con sólo dos de los grupos.


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• Nuevas leyes • Derechos de los campesinos Los consultores contratados por el IMCC para dar cursos de capacitación no presentan informes sobre el contenido de los cursos, ni dejan materiales, libros, folletines o revistas. Esto resulta en que se desconoce lo que se ha enseñado en los cursos, y en que no se deja una memoria o resultado concreto que serviría de guía o archivo para un campesino que tal vez quisiera consultar un libro u otro documento que se refiere a un curso determinado. El Centro de Capacitación de la Centralía está desordenado, los dormitorios están en desorden, la cocina muy sucia. Falta asear y ordenar el Centro. No existe un archivo o biblioteca o centro de documentación. Estos problemas son debidos a una falta de buena gerencia y están fuera del alcance del proyecto IMCC. Sin embargo, el IMCC debería de imponer algunas condiciones sobre el uso de dinero público danés, a saber: Recomendación: Se recomienda que: (a) Los consultores4 que ya dieron cursos de capacitación escriban informes breves

sobre lo que han enseñado y que éstos se presentan al IMCC lo más antes posible para entregar al Centro de Capacitación de la Centralía. Dicho centro debería de archivar los informes y futuras memorias de cursos para constituirse en un pequeño recurso didáctico y bibliográfico para el Centro;

(b) Consultores de cursos en el futuro deberían de recibir Términos de Referencia y firmar un contrato en donde se especifiquen la necesidad de producir una memoria de curso y un informe breve de lo enseñado;

(c) Se debería de contratar a consultoras de género de vez en cuando para no olvidar el aspecto género y los problemas de la mujer en el campo;

(d) El IMCC debería de obligar al Centro archivar en forma ordenada las memorias de los cursos;

(e) Un miembro del IMCC debería de estar presente en la inauguración o durante la clausura de cada curso de capacitación en el Centro. Esto permitiría que el IMCC podría describir en sus informes de monitoreo (Informes Semestrales) qué cursos y temas se han enseñado cada año.

(f) Que se contraten a consultores que tengan experiencia en enseñar a analfabetos, y que los consultores utilicen medios mnemotécnicos apropiados para analfabetos.

El problema del analfabetismo El IMCC brinda varios cursos de capacitación: • Para miembros de las bases • Para mujeres en el campo / en los grupos Inti Pallay • Para mujeres que asisten cursos en el Centro de Capacitación de la Centralía • Capacitación para ACS y comunitarios / comunitarias interesados en trabajar como

ACS en la comunidad En todos estos ámbitos el problema del analfabetismo se ha mencionado. Por ejemplo, mujeres en los grupos focales durante esta evaluación han dicho que aunque les gustan mucho las charlas y cursillos dados por su ACS en la comunidad, que muchas veces no

4 Jacob Paredes; Fernando Albarado; Trifón Ramón; y Lucio Chino.


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entienden lo dicho y, por ser analfabetas, no pueden hacer anotaciones, con el resultado que olvidan muy rápido lo que aprendieron. Recomendación: Se recomienda que el IMCC, mediante el medio de los cursos de grupos de mujeres Inti Pallay que son organizados por la trabajadora social, busque organizaciones solidarias como una ONG que podría brindar cursos de por lo menos dos años de alfabetización adulta a las mujeres que son miembros de los grupos. Igualmente durante las entrevistas con los ACS y con los miembros del Centro de Capacitación de la Centralía, surgió el problema del analfabetismo. Algunos ACS dijeron que no siempre entienden a los médicos o enfermeras que llegan del hospital para enseñarles (el problema es más que el personal educador no sabe hablar o escribir bien el quechua). Claro está que se utilizan medios como el socio drama para capacitación de los ACS, pero se destaca el problema de que los ACS dicen que su bajo nivel educacional se les dificulta el buen entendimiento y memorización de los contenidos de los cursos. Recomendación: Se recomienda que el IMCC financie uno o dos becas5 por año para ACSs que sólo tienen grados mínimos de escolarización (tercero, cuarto, quinto, sexto, séptimo) y los cuales expresan el deseo de continuar sus estudios. Si los ACS podrían completar sus estudios hasta lograr el séptimo grado, podrían funcionar mejor como ACSs y algunos de ellos podrían solicitar una beca para estudiar para ser auxiliar. Los ACSs pueden hacer sus estudios en CEMA (Centro de Educación Para Mujeres y Adultos) a una hora y media de distancia de San Lucas. Finalmente, los miembros del Centro de Capacitación de la Centralía hacen hincapié en el hecho de que hombres y, especialmente, mujeres del campo no pueden leer y escribir, entonces no pueden hacer anotaciones sobre los contenidos de los cursos financiados por IMCC. Recomendación: Continuar la capacitación financiada por el IMCC pero de manera más rigurosa (informes y memoria institucional y dotación de materiales sencillos didácticos) y más apropiada (uso de socio drama, comprar y dotación de grabaciones, uso de charlas y explicaciones de leyes en cassette) para analfabetos. El IMCC no puede sólo resolver el problema general del analfabetismo. Sin embargo la presencia de unas 65 escuelas EIB en San Lucas ofrece una sincronía potencial entre el trabajo de capacitación financiado por el IMCC y las escuelas EIB, especialmente en el campo de la salud. Recomendación: Se recomienda que el IMCC en una nueva fase trabaje con maestros dentro del marco de EIB. Sería importante si los auxiliares y ACSs podrían dar charlas en la aula sobre aspectos de la prevención de la enfermedad. Además el IMCC podría trabajar con los maestros y los alumnos en la identificación participativa (y mediante el foro de la junta escolar que reúne a los padres de familia) de problemas que amenazan la salud en la comunidad (falta de agua potable; falta de sistemas de mini riego; falta de letrinas, etc.), problemas que el IMCC conjuntamente con la HAM podrían tal vez solucionar con la plena participación de la comunidad, de los maestros y de los alumnos.

5 Costo estimado aproximadamente entre 800 BOB a 1600 BOB por persona por año.


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Un ejemplo de una comunidad en crisis en estos días (marzo del 2004) – y donde se presenta la necesidad para una sincronía de actividades IMCC-escuela-comunidad-ACS-HAM-hospital - es la comunidad de Pulquina. Al llegar el equipo de evaluación, no se encontró agua potable en esta comunidad de unas 70 familias, y hay actualmente una epidemia de diarrea en la comunidad. Además la escuela carece de letrinas, agua para tomar, para aseo y para lavarse las manos. Los niños en esta comunidad sufren de sarcoptosis, IRAs graves y EDAs. En este tipo de comunidad el IMCC podría trabajar con el ACS y con el maestro en hacer un plan de emergencia para proveer agua potable y atacar la epidemia de diarrea. A largo plazo se debería de construir con contraparte de HAM sistemas de agua potable y letrinas en la escuela, y enseñar a los adultos sobre la necesidad de construir una letrina en cada vivienda. Para poder trabajar con maestros y alumnos de las escuelas en la nueva fase recomendada, se prevé un aumento presupuestario para más personal. El proyecto necesitaría los servicios de una trabajadora social adicional y de una educadoras de niños. El personal adicional sería responsable de capacitar a maestros para que éstos estén mejor capacitados para enseñar a los alumnos sobre temas de salud y prevención de la enfermedad. Para que esta recomendación sea factible, el IMCC en esta fase debería de tomar contacto con representantes del Ministerio de Educación (el Servicio Departamental de Educación y los encargados de educación de la HAM) para discutir estas ideas y para elaborar un convenio entre IMCC y Educación en borrador para inclusión en la nueva fase recomendada. Capacitación para ayllus Ha sido muy difícil, si no imposible, para el IMCC tener una relación adecuada con los representantes de los ayllus. Pese a varias invitaciones y tentativas por parte del IMCC de ofrecer cursos de capitación en liderazgo y otros temas de fortalecimiento institucional, parece que los representantes de los ayllus rechacen contacto alguno con ONGs extranjeras como el IMCC. Recomendación: Se recomienda que el IMCC siga invitando a representantes de los cuatro ayllus de San Lucas a reunirse con ellos, pero que el monto de dinero para actividades con ayllus podría ser utilizado para financiar becas para ACSs, o parteros, o para financiar capacitación y alfabetización de mujeres y hombres adultos mediante el Centro de Capacitación de la Centralía o mediante Inti Pallay. 8. Monitoreo y evaluación del proyecto El proyecto tiene varios sistemas de monitoreo. Sin embargo, los sistemas no permiten en su mayoría un análisis cualitativo de las actividades que son registradas de forma numérica o en términos monetarios. Por ejemplo, existen los nombres de todos los ACS capacitados desde el inicio del proyecto, y existe también una indicación de si el / la ACS siga activo / a. Sin embargo, los voluntarios no suelen actualizar dicho sistema más de una vez al año o menos. Al salir a campo, el equipo de evaluación llevó la lista de nombres de ACS de los puestos sanitarios visitados y comprobó, como mencionado arriba, que entre 30% y 50% de los ACS han dejado de trabajar en las tres zonas visitadas. Un proyecto de salud primaria de este tipo tiene que darse cuenta de este tipo de problema de inmediato si no demasiado tiempo puede transcurrir y el grupo meta de las comunidades puede sentirse abandonado por el proyecto.


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Además será necesario añadir rubros en la base de datos en Excell del sistema de monitoreo del IMCC para mostrar si el ACS ha sido reemplazado por las bases. Con respecto a los Informes Semestrales, se informa sobre actividades y gastos presupuestarios, y se menciona el número de reuniones y los temas abordados en dichas reuniones. Algunos aspectos del sistema cualitativo de monitoreo sí son buenos. Por ejemplo, en el Informe Semestral del 2002 (Primer Semestre6) se lee que con 4 días de anticipación el SEDES sacó a los dos auxiliares de enfermería quienes iban a participar en los cursos del IMCC para capacitarse en AIEPI. Con el resultado que el IMCC se vio obligado a suspender y posponer el curso. Recomendación: Se recomienda además que problemas serios como problemas de coordinación entre IMCC y SEDES se presenten en la forma de un breve resumen ejecutivo en la primera página de cada Informe Semestral para provocar una discusión, y, se espera, la resolución rápida de los problemas que amenazan el buen funcionamiento y sostenibilidad del proyecto. 9. Conclusíon Aspectos de la reducción de la pobreza y el combate de la exclusión El proyecto IMCC está trabajando en áreas sumamente aisladas, áreas que todavía carecen de infraestructura vial y servicios básicos. El IMCC ha financiado la construcción de infraestructura de salud an áreas rurales, muy aisladas. El proyecto capacita a Agentes Comunitarios de Salud y está empezando a capacitar a grupos de mujeres en el municipio de San Lucas. La población que predomina en la área de influencia del proyecto es indígena de habla quechua. Esta población ha sido y sigue siendo excluida de los beneficios y servicios básicos de salud y educación que otras áreas del país disfrutan en mayor grado. El hecho de que el proyecto IMCC trabaja precisamente con esta población que está geográficamente aislada y excluida es un elemento muy positivo e importante en la lucha contra la pobreza y exclusión de la población rural del municipio de San Lucas. La estrategia del IMCC adhiere completamente a la estrategia boliviana de la lucha contra la pobreza y la exclusión, tal como está descrita en la Estrategia Boliviana de la Reducción de la Pobreza (2004 – 2007), EBRP7. Además se enmarca dentro de la política de salud primaria expuesta por la OMS en la Declaración de Alma Ata, especialmente en lo que se refiere a la provisión de servicios básicos de salud primaria a todos los ciudadanos de cada país por medio de trabajadores comunitarios de salud, auxiliares y personal de salud, y otros miembros de la comunidad. En vista de los logros palpables y considerables del proyecto IMCC en sólo 3 años, se recomienda que el proyecto continúe por los menos una fase adicional de 5 años.

6 “Informe Semestral del 2002” (Primer Semestre, página 22 / 27). 7 Republic of Bolivia. Revised Bolivian Poverty Reduction Strategy, 2004 – 2007.


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EXECUTIVE SUMMARY Introduction The International Medical Cooperation Committee (IMCC) primary health care (PHC) project, financed by Danida, has been implemented since July 2001 in the municipality of San Lucas, in the Province of Nor Cinti, in the Department of Chuquisaca. San Lucas is one of the poorest municipalities in Chuquisaca department which has some of the highest poverty levels in Bolivia. The maternal-infant mortality rates (MMI) are extremely high in the municipality. In the most isolated areas of the municipality, in the zone of the valleys, it is sometimes necessary to travel on foot up to 125 km e.g. from the most distant communities, i.e., a journey of two whole days, to arrive at the nearest medical centres. The overall development objective of the IMCC PHC project is to improve the health of the rural population of San Lucas, especially of women and of children under five years of age. This report presents the evaluation of the IMCC San Lucas PHC project. David Moore, social anthropologist, an independent consultant hired by PEMConsult, evaluated the project. He was assisted in Bolivia by Juan José Fernández Murillo, M.D., Chief Medical Officer of San Lucas hospital, and by Marlene Miranda Valverde, the social worker of the IMCC project who acted as a resource person during some field trips and as a focus group organiser and assistant. The evaluation took place between the 10th and the 28th March 2004. Before leaving San Lucas, the evaluation team presented in the hospital in an open forum an extended Executive Summary in Spanish (presented in this report following the Executive Summary in English) to project stakeholders. Structure of the report This chapter is the Executive Summary. Following this are: Chapter 1, Introduction Chapter 2, Project background Chapter 3, Project description and implementation Chapter 4, Possibility of achieving objectives with the current strategy Chapter 5, Relevance of the project Chapter 6, Project sustainability Chapter 7, Conclusions and recommendations Degree of attainment of project objectives Project impact Knowledge of health staff Primary health staff at hospital levels and below – including the auxiliary nurses and the village health workers, known as Agentes Comunitarios de Salud (ACSs) - have received training in PHC principles and have also received instruction in the use of new equipment donated by the project. In particular, all levels of health staff in the province have received instruction in the government PHC programmes: Atención Integral de Enfermedades Prevalentes de la Infancia (Integrated Services for Childhood Diseases, AIEPI) and the Programa de Salud Universal Materno Infantil (Universal Maternal


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Infant Health Programme, SUMI). In addition, the ACSs have been trained in first aid. The quite considerable amount of training for health staff has resulted in them being able to provide a better health service to the client population, the mainly Quechua speaking men and women villagers of San Lucas municipality. The training financed by IMCC also includes grants for ACSs who wish to study auxiliary nursing. To date (April 2004) two ACSs have received IMCC grants to permit them to study in CENPRUR college in Ocuri. Health staff have not yet received instruction in intercultural medicine. The anthropological report findings will be used to design this sub-component of the training for health staff that is meant to change the Knowledge, Attitudes, and Practices (KAP) of health staff towards rural Andeans, and to encourage the former to respect the traditions and beliefs of the latter. Knowledge of men and women villagers The baseline KAP study shows a very high proportion of mystical attribution of disease among the village men and women respondents in the survey. When the baseline is repeated after five years, there may be some registered change in KAP of health and illness, but it may still be too early to register significant changes. It is likely that attitudes will not change very quickly. One reason for this is the continuing high illiteracy rates. Another reason is that health staff—especially those from the area or from similar Andean areas – also share certain key beliefs about hot / cold balance and certain mystical notions concerning causality and conditions such as debilidad (weakness or malnutrition) and susto (fright illness caused by loss of the soul from the body). Despite the presence of some 65 Intercultural Educational Schools (EIB) in the municipality of San Lucas, adult illiteracy and a high drop out rate of girls and boys from school continues to contribute to a lack of awareness of measures to prevent disease. Working in the communities are the Agente (s) Comunitario (s) de Salud (Community Health Worker, or ACSs) who, during home visits and in community meetings, teach women about improved nutrition, the need to attend prenatal health checks, and who look for signs of illness or danger of death in infants and pregnant women. The women appreciate the teaching that the ACSs provide in the community, but they say that they do not always understand the pictures shown to them or the words that the ACSs say to them. It will be a long process to get the health messages across, and it will, ultimately, only have its highest potential impact when illiteracy levels fall substantially in the general population. Knowledge of women in the Inti Pallay women’s groups Inti Pallay has obtained its juridical personality and funds for its sustainable running are currently included in each year’s Annual Municipal Plan of Operations (POA). Some training for women has begun, mainly in organisation. IMCC works with two groups of Inti Pallay women. Actual training on health or other topics that the women choose has not begun yet. Progress with the Inti Pallay women’s groups is too slow and the IMCC social worker should spend more time and energy on this aspect of the project.


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Knowledge of men and women trained in the Centralía Peasant Training Centre It is difficult to ascertain the impact of the training given at the Peasant Training Centre because little or no written record has been left of what topics were covered, how they were taught, and how successful the course participants were in understanding the topics covered. Interviewed participants who attended courses said that they did not always understand, or could not always remember, what was taught since they are illiterate. In the future the project will require consultants to leave written reports, to be accountable for what they do, and to use more appropriate mnemonic techniques. Impact of the infrastructure and equipment donations IMCC donations have been mainly in the rural areas. 70% of total infrastructure donations so far have been outside San Lucas town. This means that the poverty reduction objective of the project is being maximized: most infrastructure investment is benefiting the hitherto excluded and under-served rural population. It is likely that the end of Phase 1 will achieve the goal of 80% of infrastructure investments being in the rural areas. The infrastructure donations include renovating existing health posts, building new ones, and installation of showers, toilets, and drinking water systems. In one village (soon to be two villages, March 2004), the drinking water systems are also benefiting school children and teachers: this is an unexpected positive result of the project. Donations of medical and dental equipment for the hospital and health posts have also had a positive impact on the ability of the health services to offer an improved health service in the municipality. In particular, ultrasound equipment and improvements in the operating theatre now allow medical and nursing staff to offer improved services to pregnant women and help achieve the project and national policy goals of reducing the Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR). Despite one or two white elephants – i.e., constructing water supply systems where there is no source of water – in the main the infrastructure component has been well thought out, and fairly well designed. In one of the cases where there was no water, a water source has now been found for the installed system. There have been some delays in doing the construction: the HAM has been slow in making technical designs and drawings, budgets, and tenders. But budgetary disbursements have been on time. In one or two instances the construction work has been of low quality, but steps are currently being taken to put right the mistakes. Impact and implementation of the research component Baseline The baseline is designed to show the before and after project situation. When repeated after five years, it is hoped that positive impact on KAP of health and illness behaviour and beliefs among the rural target population will be shown. Both baseline and anthropological reports were considerably delayed. The baseline was delayed partly because the social worker hired by IMCC to do baseline work, turned out


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not to be qualified to do this. The external consultant who was then hired to help the project social worker complete the survey did not deliver on time. In addition to the delay, some important questions on maternal preferences and beliefs about birth and labour were omitted. The project volunteers and hospital staff now agree that these questions need to be included. It is a very positive step that a project of this type is building up a monitoring and evaluation (M&E) system of before and after impact. Anthropological report The anthropological report was delayed for at least six months. The report that the international consultant has delivered is substandard – although it does have a lot of useful information in it - and cannot be used in its present form without a lot of revisions and editing. The Spanish in which the report is written is at times unintelligible; several sections are characterized by quotations of ethnographic statements with little or no analysis; there are several rather wild and uncorroborated statements; and there are quotations of literary or historical reference works that are not relevant to the field work data or the needs of the project. There are also several sections in the report where it is not clear what the source of the statement is (reference work; field data; or the report author’s opinion). IMCC staff in San Lucas are not qualified to apply the findings of the anthropological report. Sufficient funds need to be budgeted for in the future to use this knowledge for strengthening the project’s intercultural component. The need for money to work on the anthropological report is urgent, however, since the first phase requires the anthropological report findings to be used for designing intercultural health training modules and strategies, and this work is already delayed by about a year. Possibility of achieving project objectives with the current strategy Training of health staff The approach to training and strengthening of human resources personnel in health and PHC services has been demonstrated to be working. Staff report learning new ideas, being happy with the new practical approach to learning, and having more job satisfaction. In particular, the auxiliaries and the ACSs are able to work together in a more coordinated way in carrying out their respective functions under the community and clinical AIEPI and SUMI programmes. Threats to the transfer of technology approach mainly concern the staff changes that affect medical staff more than nurses and ACSs. Not all the ACSs say they are happy with the training: it should be conducted in Quechua so they would understand it better. Some of the ACSs complain of lack of coordination in the planning of training courses. This means that sometimes ACSs, who say they do not get sufficient warning about supervision visits or courses (they often live at great distances form the health posts and are sometimes out of radio contact), are unable to meet project staff or attend events. Hospital and IMCC staff complain of a lack of coordination in planning the training as well. These problems are due to internal problems in the Equipo de Planificación y


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Capacitaciones (the Planning and Training Team, EPC) and to the fact that the Servicio Departamental de Salud (Departmental Health Services, SEDES) reportedly does not always respect project activity dates and itineraries, and imposes its own itinerary on the project. This means that staff, which the project has been counting on, are suddenly requisitioned to SEDES activities. These problems can be solved by improved management, and by SEDES managing its time better, and are not killer assumptions in themselves. Training of men and women through the Centralía and women’s groups Unless the training be made more high quality and more appropriate for illiterate people, it is not likely that this sub-component will lead to significant improvements in the trainees’ knowledge of rights, laws, health and other topics. It will also be necessary to improve general literacy levels to complement and cement the training given. It is likely that training through Inti Pally will have a benefit. So far IMCC has worked with two women’s groups in institutional strengthening and organisation. The training has been considerably delayed however, and the project should increase the tempo of this work. As with the training in the Centralía, it will also be necessary to improve general literacy levels to complement and cement the training given. Training and knowledge transfer alone to the women’s groups without significant institutional strengthening of Inti Pallay will probably not be sustainable or sustained after the project stops. The project document is not clear about what the purpose of the project strategy and project support is vis-à-vis the Inti Pallay groups: Is it to strengthen an organisation (that is also being supported by other NGOs) that was created some years before the IMCC project began? Is it to provide a forum for further training in health and Mother and Child Health (MCH) matters, and to inspire more women to become female ACSs? The project needs to be clear on these questions and to define a strategy; in this way it would also be easier to monitor the impact of the Inti Pallay work. It would appear that the most useful strategy toward the Inti Pallay women’s groups would be to offer high quality adult literacy classes to women over the next two years and to evaluate its effect just before the end of the project Phase 1. Infrastructure and equipment donations The project M&E systems show that it is possible to improve PHC delivery by making investments in health infrastructure. The investments mainly improve retention of front line health staff, make their working environment more professional and safer, and provide better health services. In particular, MCH services have been improved by donations of labour beds, labour wards and ultrasound equipment. These donations will be wasted however if preventive maintenances systems are not set up and if the HAM through its POA does not as of this year (2004) begin putting aside monies for Operation and Maintenance (O&M) of buildings and equipment. There is a small amount of money in the POA for O&M of equipment, especially for the hospital vehicles. Recently the ultrasound equipment donated by IMCC was repaired with money from the POA. It appears that there is no money in the POA for O&M of buildings. DILOS has the power to authorise money for O&M. In the convenio (agreement) between IMCC and HAM it is stated that “O&M of investments carried out must be paid for by the HAM, and should be budgeted for in the annual POA budget”.


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It is clear that the hospital management should periodically remind DILOS of the HAM’s obligations towards O&M whenever equipment breaks down or buildings need repairs. Promotion of intercultural health The current strategy to promote intercultural health among biomedical health staff is not likely to work, unless: • The project can recoup the delay (about one year) in the anthropological work • The anthropological report can be thoroughly edited and corrected • A professional medical anthropologist can be hired and can apply the report’s

findings to making teaching modules and working out an internal staff training programme in the hospital and health posts to promote intercultural health

• Some money can be obtained under the current budget to do this Baseline The baseline, which was carried out over eight months from April to December 2002, and finalized in January 2003 – much too long a period in the life of a five year project - is still deficient and needs some MCH and reproductive health questions added to it. But it provides an important tool for before and after M&E. As soon as the baseline has been improved, when repeated it will be possible to measure questions that are key to assessing the degree of attainment of the development objective: to improve the health of women and under five year olds. Project organisation and implementation arrangements The project organisation is very “flat” and very fluid. There are no project managers, administrators, or professional staff, except one Bolivian social worker who takes orders from one of the volunteers in the out-group who is designated to be responsible for the social worker. The disadvantages of this set-up are that there are problems of continuity: there is an ever changing stream of Danish medical students, some of whom do not learn to speak very fluent or understandable Spanish, and some of whom have new ways of doing things (this is the perception of the Bolivian staff interviewed). Because the home group are studying or working full time, time they take to respond to reports from Bolivia (“fagbreve” and semester reports) can be up to six weeks. If there are urgent problems that need advice from Denmark, this is too long for a project with a relatively short time span. When new students come to Bolivia, the out group have to spend time (reportedly a maximum of 14 days) collecting them, introducing them to SEDES and other stakeholders, and arranging for practicalities to be sorted out (driving licenses, visas, etc). The out-group is responsible primarily for: Daily management Overall decision-making competence, except for cases where the out-group would not be able to have a say (salary, sickness) Budget management Liaise with the Danish embassy in La Paz about the project


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The home group’s primary functions are to: Select new volunteers Teach new volunteer recruits about the project (a function praised by earlier IMCC evaluations) Do occasional fund-raising for the project Identify an anthropologist consultant Make arrangements to locate and contract evaluation teams Liaise with Danida and Danish institutions about evaluations and project infomation The “IMCC model” is relatively expensive and time-consuming: approximately 57% of the total project budget goes on training, language training, air travel, allowances and re-establishment allowances. (This sum also includes the cost for two external evaluations). This is some two and a half times bigger than the budget for construction, or that for training and countryside supervision visits, as shown in the following table of the budget:

IMCC San Lucas PHC Project Total 5 year budget 2001-2006 in thousands of DKK8 Item Amount and % of total budget Amount % Investments 960,000 12.9 Running costs 950,000 12.8 Rural countryside visits / activities 975,000 13.2 Danish personnel, recruitment, administration in Denmark, evaluation

4,278,500 57.7

Information on the project in Denmark 250,000 3.4 Total (excluding unforeseen expenses) 7,413,500 100 Source: Danish Project Document, p. 28.

International aid effectiveness standards, applied by NGOs such as MS, IBIS Denmark, OXFAM and Action Aid, establish that a project that uses more than half of its budget on salaries, logistics, and administration is under achieving in terms of its potential poverty reduction effect. One model to improve the effectiveness of project implementation and reduce administration costs of training the volunteer students could be to have a small, permanent, professional staff in place in San Lucas (at least one of whom would be a permanent project manager), helped by one or two (instead of two or three) medical student volunteers who would come out to Bolivia for a minimum of two years. This model would save a lot of money. It would be quite feasible to finance a small staff of professionals from some of the money saved by reducing the number of volunteers. Perhaps equally important as the improvements in cost-effectiveness by using this model, much more continuity in the project implementation and relationships with counterpart Bolivian staff would be achieved.

8 The budget as presented here excludes unforeseeable expenses.


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A sample budget could look like this: Staff Monthly

salary (DKK) Yearly salary (DKK)

Number of months on project

Total cost (in DKK)

International Project Manager 30,000 360,000 60 1,800,000 International medical anthropologist

26,000 312,000 18 468,000

1 Bolivian social worker/institutional strengthener

1,200 14,400 60 72,000

1 Bolivian educator 1,400 16,800 48 67,200 10 IMCC students 1,250 15,000 24 300,000 Flights * 260,000 Re-establishment for students 600,000 Two evaluations 300,000 Subtotal 3,867,200 10% unexpected costs / inflation 386,720 Grand total 4,253,920 * Flights: Project manager gets 2 return flights @ 20,000 DKK = 40,000 DKK Medical anthropologist gets 1 return ticket @ 20,000 DKK = 20,000 DKK 10 IMCC students get one return flight each @ 20,000 DKK = 200,000 DKK This draft budget does not include costs of language training and driving lessons, which would be paid for by the students themselves, but it allows for the presence of two IMCC students at all times in the life of the 5 year project. The draft budget also allows for the employment of professional staff, including an extra member of staff (1 educator). If IMCC consider using a similar model (such as the one proposed above) in the future, when requesting funding for a possible new phase they would be advised to increase the overall budget by about 1 million DKK so that the amounts for infrastructure and training could be increased. In this way the percentage taken up by salaries, evaluations, and travel could be reduced as a percentage of the overall project budget. It is likely that it would be more possible to achieve the project objectives by converting the project into a mainly professional enterprise, staffed by one long-term international doctor / public health specialist, one international medical anthropologist, and one or two Bolivian community development workers / institutional strengthening specialists. It would be possible to finance over five years this type of staff cadre and keep well within the approximately four million DKK or so currently spent on personnel. Institutional set-up The project has shown quite a lot of creativity in keeping abreast of the changes in Bolivian institutions. Since the project started, some institutions have folded; others have metamorphosed into new ones. The project is working with the key stakeholders and showing initiative in its relations with them. The institutions with which the project work are very weak, in particular: OCIACS DILOS EPC OCIACS and DILOS are still very new. Despite their weakness, it is beyond the capacity of IMCC – with its current staff - to strengthen directly these Bolivian


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institutions. OCIACS and EPC are essentially creations of the project, i.e., they are at risk of folding when the project activities stop. Monitoring and evaluation (M&E) Despite its problems, the baseline is useful and promises to give good before and after impact M&E data. But it should be carried out more quickly next time, and not take up the valuable time of the project staff: it is a means to an end, not an end in itself. The anthropological report is potentially good, and if improved and used well, will enable the project to achieve the objective of designing intercultural health sub-activities. The medical anthropologist, that the evaluation team recommends be hired, could also work out some M&E indicators to reflect intercultural KAP of health staff. The semester reports are good, and provide a lot of useful and qualitative data. Many M&E systems do not include such qualitative data. The “fagbreve” are less good, in the evaluation team’s opinion. Depending on how many “fagbreve” are written each year (between 6 and 8) they take approximately a total of between 18 and 24 days in a project year (assuming that 48 weeks are in a working year) per volunteer. That is approximately between 3 and 4 weeks of project time per volunteer in a given year. Nevertheless, the out-group find the “fagbreve” important project managment tools, because they are forced to describe in writing what the basis for the decisions they are taking is, what they are doing and why: I.e. the out-group can make known their experiences to the home group. Reading the “fagbreve” is reportedly very useful to the volunteers at home, especially for the new recruits who can be introduced to the workings of the project before they actually come to Bolivia. The out-group feels that the “fagbreve” are especially important because IMCC does not have a permanent staff. In the process of writing the “fagbreve”, the out-group members update each other on different aspects of the project. The “fagbreve” are, in a way, a form of reporting to a “virtual” project manager (who admittedly does not have more “power” than the out-group!). In this case the “project manager” is the home group which includes volunteers who have completed their tour of duty in Bolivia and who now advise the home group and out group and help introduce the new volunteers who will be sent out. It would be more effective to have one full time, international project manager in Bolivia who could make decisions and enable the project to speed up in critical areas where progress has been slow. The “fagbreve”, if they are to continue, should be shortened and professionalized. It is not really professional, in the evaluation team’s opinion, to include a “gossip column” in a health project, despite the fact that project time is not used to write the gossip. Nevertheless, the out-group maintains that the gossip is important and gives a feel for the project and can give the new volunteers an idea of what life is like in San Lucas and is good entertainment. Other potentially excellent M&E systems exist in the project. E.g. the Excel spread sheet on the names, and location of the ACSs. The spreadsheet should be however kept more updated and a gender column should be added to it so that the project can monitor gender balance among ACSs.


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A very useful M&E feature is the post training course mini evaluations, and the short questionnaires fielded to ACSs about patient referrals and sickness cases they have seen in each three-month period. After each training course, the qualitative and quantitative M&E data about ACSs and their work are collected and collated for the overall IMCC M&E system. These data and all other M&E data are reportedly being built into a single M&E report to be produced twice a year. (This system was first introduced in 2003, so M&E results will appear in future semester reports). Infrastructure (quality, problems, repairs status) needs to be monitored, so that the project can evaluate its infrastructure status easily. IMCC is in the process of setting up an M&E system, which will also cover the IMCC investments. Every six months health personnel will be asked to report on equipment and infrastructure donations, to see whether there have been problems and to assess how much the equipment / infrastructure are used. The system is already working, as evidenced by the fact that the ultrasound equipment was found recently to need repair and is currently under repair in Santa Cruz. Relevance of the project The justification for the project was based on the following six key issues: 1. Lack of knowledge among the rural population about basic health 2. Health infrastructure characterised by poor quality building and insufficient

resources 3. Health staff are poorly trained and do not always understand the rural population’s

problems and needs 4. Training of volunteer community health workers (originally called “Responsables

Populares de Salud” (Popular Health Workers), now called ACSs) is insufficient 5. Women are only minimally involved in local development, including health 6. The peasants’ poor organisation weakens their potential influence on the area’s

development. These six key problems are being addressed by the project and are still major problems in the project area. The following section summarises briefly the main points of relevance being addressed by the project: Lack of knowledge among the rural population about basic health The KAP baseline study provides considerable evidence of mystical attribution and magico-religious and humoral notions of disease causality and treatment. It is relevant that the project teaches about germ theory notions of disease causality and about the dangers of malnutrition. But because of the particular and unique set of beliefs and the extreme scarcity of resources such as land and water in the project area, it will be very difficult for the rural poor to apply the new knowledge they receive. Additionally, unless the project teaching includes elements of an intercultural rapprochement between biomedicine and Andean medicine, the teaching to village women may not be acted upon. Infrastructure and equipment investments Health infrastructure at the beginning of the project was indeed poor. That situation is changing now, with the following investments completed or nearly completed:


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• The construction of one new health post in 2003 in Malleri (70% financed by HAM, 30% by IMCC);

• Two new health posts in Ocuri and Collpa in 2004 (70% financed by HAM, 30% by IMCC);

• In 2003, with completion due in early 2004, the health posts in Ajchilla and Canchas Blancas have been further improved;

• In 2002 six bathrooms were constructed in six health posts (La Palca, Payacota, Chinimayu, Uruchini, Canchas Blancas, and Ajchilla);

It was discovered that there was no water in La Palca and Uruchini. Therefore HAM and IMCC in 2003 decided to put in water in these two communities. In March 2004, the water system was completed in La Palca (and water was also provided to the school in La Palca), and the one in Uruchini is reportedly soon (April 2004) to be completed. Knowledge and PHC skills of health staff Health staff at the beginning of the project were poorly trained and did not always understand the rural population’s problems and needs. The improved training for health staff has been shown to be relevant for all levels of staff that have benefited, because, importantly, it follows national PHC and international WHO guidelines, and fits within and reinforces current programmes, mainly AIEPI and SUMI. SEDES believs the prject contribution to improving the quality of human resources is very relevant to its national programmes and important in improving health delivery in the project area. Training of health promoters (ACSs) The training of the ACSs has been highly relevant because: • It offers low-cost, appropriate technology training for the first aid role of the health

worker • It reinforces the ACSs’ central role in the community AIEPI programme • It has trained to promote women in development, and this respects and reinforces the

gender equity laws of Bolivia • The ACS is, apart from the curandero and partero – many of whom are dying out –

the only human resource in health in many very remote villages, and thus it is a relevant poverty-alleviation strategy to train the ACS. This follows WHO poverty-reach principles for PHC programmes

The position of women Women have been, and continue to be, marginalized. By targeting MMR and the subjugation of women, the project is highly relevant for the struggle to reach gender equity and reduce gender inequalities in health. Organisation of the peasants Due to a variety of factors, the peasant’s organisations have been weakened. By offering them training and education in topics that can promote democratic inclusion is highly relevant for the National Poverty Reduction strategy. Implementation arrangements The TOR, and its annexed additional questions for further analysis, ask the evaluation team to consider the organisation of the project, specifically the “IMCC model”. These questions have been addressed above, section 2 (project organisation and implementation arrangements).


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Sustainability of the project M&E A good M&E system will enable the project to know if activities, infrastructure, and transferred knowledge for example are sustainable. For this reason, the TOR and additional questions for further analysis ask the evaluation team to consider M&E of project activities. M&E questions were addressed above, as part of an appreciation of their quality and effectiveness. So far conclusions on sustainability of various aspects of the project are preliminary, but several conclusions can be made, viz: Training of health staff Project training for health staff is within the national health guidelines within the national programmes AIEPI and SUMI. Therefore, the training activities are sustainable in the sense that the current health staff are able to carry on the training and supervision since the training and supervision activities are theoretically included in the existing national PHC programmes. A positive sign of sustainability of training for health promoters is the fact that some health training courses for ACSs are now conducted entirely by hospital staff without IMCC intervention. However, as regards effective and merit-based staff promotion and staff delegation, the political system is probably the greatest threat to successful, cost-effective, and merit-based management and execution of public health functions in the province. The village health workers (ACSs) There are serious problems of sustainability with the health worker system. From an original total of some 126 health workers, who are called Agentes Comuniatrios de Salud, or Community Health Workers, a certain percentage has stopped working, for a variety of reasons. In the three communities which the evaluation team visited, between 30% and 55% of the ACSs have stopped working. Some communities now only have one ACS, some have none. However, on a positive note, the fact that the project trains volunteer ACSs who, despite not being paid and despite some 20% of them dropping out, still continue to work in their communities is a very positive sign. It is on this aspect that the project must continue to expend a great deal of energy. The ACSs who are encountering problems must not be abandoned. They need more support and more training, and a solution needs to be found to the non-replacement for those stopping work. The first aid kits of the ACSs A problem of sustainability concerns the fact that the ACSs are encountering difficulties in getting patients to pay the very minimum charges (1 BOB = USD 0.13) for first aid services. The result is that essential first aid kit supplies, such as bandages and Vaseline and oxigenated water are running out in the kits inspected by the evaluation team. IMCC and hospital staff will analyse these problems at the first opportunity. In order to increase the chance of sustainability, the project will study the possibilities of using appropriate technology and local knowledge: i.e. the use of plant and tree products that could be used to replace some of the shop-bought supplies.


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Training and knowledge retention of village women (women’s groups) At the moment this activity is very much dependent on the project. The activities only started at the end of 2003, so it is too early to evaluate their sustainability or not. Training and knowledge retention of village men and women (training provided via the Peasant Union Centralía) Unless IMCC encourages more practical and accountable teaching methods, it is likely that the knowledge imparted in the training sessions will not be sustainable in the long run. It will be forgotten, or the message will be confused since no documents are handed over for future reference. However, the strategy of training villagers in leadership and public information about rights, laws, new strategies, and responsibilities (with a focus on health) will likely lead to an improved organisational capacity of the rural population concerning prevention of illness and improving health, as long as the quality of the training is good and designed for the audience of mainly illiterate Quechua speakers, and as long as the consultants change their working practices and leave a much more tangible record of the training. Infrastructure and equipment New or reconditioned infrastructure needs to be maintained. IMCC and the hospital management need to insist on the municipality honouring its commitments, as specified in the convenio (agreement) between IMCC and HAM, and make money available each year in the POA for O&M and preventive maintenance. The modality to do this is the DILOS. Equipment donations and drinking water supply schemes As long as the municipality ensures that the POA includes funds for regular maintenance (including stocking spare parts) for health equipment donations and water supply schemes, the equipment should be sustainable for as long as it can be reasonably expected to last, or as long as its technological level remains up to date. Research and baseline work It is important that the project get a small pilot intercultural mini-project to function. By hiring a medical anthropologist consultant, on a needs basis, to design intercultural modules, the health staff can be trained in intercultural ideas. This could increase the possibility of sustainability of the intercultural component. Institutional aspects and implementation arrangements DILOS DILOS (municipal health committee) was created by the law of SUMI and legally constituted in the second half of 2003. DILOS will be sustained as long as its existence is required under the above-mentioned law. To date there have been seven meetings of DILOS, which is the highest health authority in the municipality. IMCC has been able, with DILOS’ influence, to push through its investments in infrastructure. Additionally, DILOS has been able to obtain the HAM’s compliance and fulfilment of its budgetary counterpart obligations under the POA. EPC The EPC is an interdisciplinary team composed of health personnel and representatives of the organisations in San Lucas. The EPC is supposed to meet each month, but this


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does not always happen if the chief hospital staff are being changed. To avoid these delays, the project will insist on a system of delegation: if there is no chief doctor in a given month, then the EPC must meet anyway with a stand-in with authority to plan the courses. The project will request SEDES to delegate another two other members of the hospital staff as soon as possible to be used whenever there is a lack of a chief doctor. OCIACS: The organisation of the ACS This is still a weak organisation, and does not yet have its juridical personality. It is an organisation set up by the project and thus liable to fail when the project withdraws. This report recommends extensive capacity strengthening for the O.C.I.ACS-MSL to make it a more dynamic and proactive organisation capable of monitoring and representing the ACSs. Sustainability of the IMCC model Inasmuch as Danida is committed to supporting Bolivia in the long term, and as long as IMCC respects Danida poverty-reduction objectives, it is likely that the model of sending out IMCC volunteers will continue sustainably.


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1 INTRODUCTION This report presents the evaluation of the IMCC San Lucas Primary Health Care (PHC) project. David Moore, social anthropologist, an independent consultant hired by PEMconsult, evaluated the project. He was assisted in Bolivia by Juan José Fernández Murillo, M.D., Chief Medical Officer of San Lucas hospital, and by Marlene Miranda Valverde, the social worker of the IMCC project who acted as a resource person during some field trips and as a focus group organiser and assistant. Before leaving San Lucas, the evaluation team presented in the hospital in an open forum an extended Executive Summary in Spanish to hospital and IMCC staff, to a member of the NGO, ADRA, and to three members of the municipal council of San Lucas. 1.1 Project background The IMCC Primary Health Care (PHC) project, financed by Danida, has been implemented since July 2001 in the municipality of San Lucas, in the Province of Nor Cinti, in the Departament of Chuquisaca. San Lucas is one of the poorest municipalities in Chuquisaca department, which has some of the highest poverty levels in Bolivia. The maternal-infant mortality rates (MMI) are extremely high in the municipality. In the most isolated areas of the municipality, in the zone of the valleys, it is sometimes necessary to travel on foot up to 125 km for example from the most distant communities, i.e., a journey of two whole days, to arrive at the nearest medical centres. The overall development objective of the IMCC PHC project is to improve the health of the rural population of San Lucas, especially of women and of children under five years of age. 1.2 Objective of the evaluation The purpose of the evaluation is to elucidate the following issues: 1. The possibility for achieving the objectives and targets with the current strategy 2. The relevance of the project, both as regards the target group and the local partners 3. Project sustainability – especially as regards the training and knowledge-retention of

the ASCs The evaluation should lead to recommendations as to whether a new phase should be applied for, and which strategies, project activities and, possibly, new project activities or strategies should be recommended taking account of Danida’s NGO strategies. The evaluation is also to provide overall recommendations concerning strategy re-adjustments for the remainder of the current project phase. Attached to the TOR for the evaluation are a series of questions that IMCC also requested the evaluation team to consider. Where possible the evaluation team tried to cover these questions. 1.3 Methodology The methodology applied was as far as possible participatory. By this is meant that the evaluators attempted to elicit the perceptions of the project beneficiaries in their own words, instead of asking direct questions all the time and instead of setting the agenda.


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The evaluators attempted in the Focus Group Discussions (FGDs) to get the participants to focus on one or two themes and to discuss these themes freely in relation to the subject of inquiry. This method was only partially successful due mainly to the extreme reticence of villagers, especially women, in the FGDs. Nevertheless, the methodology did uncover practices, beliefs and attitudes in different stakeholder groups the knowledge of which has been very useful in evaluating perceptions of impact of the project. The outcomes of the mini workshops and FGDs with health staff and village women and men have been written up and are reproduced in the annexes in the original Spanish so that IMCC volunteers and hospital staff in San Lucas can use them for future monitoring and evaluation work of stakeholder perceptions. Extensive use was made of mini workshops, FGDs, and of the technique of “giving the stick9” to the persons being interviewed. The main methods and activities used are: • Interviews with key personal from SEDES, Sucre • Mini workshop with personal from San Lucas hospital and with IMCC personnel • Mini workshop with seven auxiliary nurses in Palacio Tambo • Four focus groups with men and women from communities from Buena Vista,

Canchas Blancas, Huaiñumilla / Pulquina (a total of 81 women and 34 men) • General village meetings with the above mentioned men and women • A focus group with six concejales from the municipality of San Lucas • A short interview with a representative of the organisation that represents the ACS

(O.C.I.ACS-MSL or Integrated Peasant Organisation of the Community Health Workers (CHWs) of the municipality of San Lucas

• A meeting with representatives of the NGOs Esperanza Bolivia and ADRA • A logical framework matrix adjustment exercise with personnel of IMCC in San

Lucas • A Mini workshop and focus group with eight ACSs from the area of the valleys in

Canchas Blancas • A focus group with representatives of (5 men, 1 woman) from the Peasant Union of

San Lucas (HQ in Pututaca), from the Only Union Confederation of Peasant Workers of Bolivia (CCSUTC).

Focus group discussions (FGDs) The results of the FGD were written up on large sheets of paper (even though not all participants could read or write) and served as a focal point for the discussions. Other data collection exercises In addition to interviews, village meetings, and FGDs, a Venn10 diagram was applied in one village to assess perceptions of relative importance of formal and informal health

9 The process of the “villager takes the stick” refers to a reversal of roles, whereby the subjects of the inquiry (the villagers or ACSs) are asked to identify problems and possible solutions to them, and to present them to the evaluation fieldwork team. This approach is meant to encourage a more active approach in evaluation, as opposed to a passive role of answering a prepared questionnaire. Cf. R. Chambers, “Participatory Rural Appraisal (PRA): Challenges, Potentials and Paradigms." World Development 22 (10), 1994. Chambers, Robert. 10 Institutional maps are sometimes called Venn or chapati diagrams. Venn diagrams are visual representations of the different groups and organizations within a community and their relationships and importance for decision-making. Participants are asked to use circles - either drawn on paper, or cut out


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service personnel and infrastructure. The following photograph shows a village woman presenting her perceptions on this matter. Finally, where possible, health personnel interactions with patients were also observed to assess the interplay between biomedical and Andean medical ideas. Time constraints meant however that the main focus was on the village meetings, interviews and FGD exercises rather than on observing patient health staff interactions.

and placed on the ground - to depict the different groups. The relative importance of a group is shown by the relative size of the circle representing it - the larger the circle, the more important the group. The extent to which the different groups interact with each other is shown by the degree of overlap shown in the diagram - the greater the overlap, the more interaction and collaboration between the groups.


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2 PROJECT BACKGROUND IMCC, a not-for-profit Danish NGO, has no religious or political objectives and is made up entirely of volunteers except for one or two paid Bolivian staff members in the San Lucas and Azurduy PHC projects. The Danish volunteers, who are mainly students of medicine and public health, but among whom also figure qualified doctors, nurses, civil engineers, economists and chiropractors, come to Bolivia for a period of 14 months after a preparatory stage of nine to 15 months. Before travelling to San Lucas, they attend courses in Spanish language, tropical medicine, and other subjects of relevance to the reality of rural Bolivia. In addition to these courses in Denmark and other countries, some of the volunteers receive training courses in Bolivia in the following subjects: • Community AIEPI • Traditional medicine • Workshop on healthy communities • Training health promoters In addition to the Danish volunteers, there is a social worker, a native of San Lucas, who is bilingual in Quechua and Spanish, and who works full time on the project in San Lucas. The social worker was originally employed to carry out baseline survey work, but it became apparent that she was not qualified to do large-scale survey and data work. The social worker is qualified and experienced in setting up, training and institutionally strengthening rural grass-roots groups. The social worker’s main task is to set up and support OCIACS, and to organise and train in health and leadership issues women’s groups, known as Inti Pallay. In addition to the work of forming and training Inti Pallay women’s groups, the social worker has been involved in managing and executing the following activities of the IMCC project: • Field work and joint writing of the baseline study • Field work and joint writing of the anthropology study • O.C.I.ACS-MSL: Institutional strengthening and future workshop with the three boards • Information, education and communication (IEC) on safe motherhood • Training activities in courses for women’s groups, courses for ACSs, and training

for villagers. 21 months remain before the completion of the first phase of the project. According to the regulations of Danida which finances IMCC with Danish tax payers’ money, the project must be evaluated before the first five year phase ends, and before IMCC is permitted to seek financing for a second phase. 2.1 Objectives The objective of all Danish development assistance to developing countries is to reduce poverty. For this reason it should be noted that the IMCC PHC project, which operates in one of the poorest zones of Bolivia, and which works with the poorest and most isolated population in the municipality of San Lucas, is in harmony with Danish development policy.


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2.1.1 Objectives of the project The overall development objective of the IMCC PHC project is to improve the health of the rural population of San Lucas, especially of women and of children under five years of age. The immediate objectives of the project are: 1. Improve the knowledge and practices of the target group, i.e., of the rural

population, in relation to illness and health 2. Improve and expand the health services of the municipality of San Lucas 3. Strengthen the organisation of the rural population in the field of health and

encourage an improved understanding of the concepts of health held by the rural population, with the aim of improving the collaboration among the community volunteers, the Agentes Comunitarios de Salud (ACSs) (Community Health Workers), the municipality, the hospital and other institutions.

2.2 Activities The main activities of the IMCC project can be divided into three areas: • Training of ACSs, auxiliary nurses, of hospital personnel, of women’s groups (Inti

Pallay) and of villagers via their peasant union base organisations • Investments in health infrastructure, including investments in health equipment • Research into health and illness concepts and into health seeking behaviour. 2.3 Strategy The strategy rests on three main inter-related principles: • Training of health staff and village men and women and transfer of knowledge

following PHC precepts • Infrastructure investments to allow front line health personnel to live and work in

the rural areas • Action research into Andean concepts of health and illness and health seeking

behaviour which is to help promote intercultural health services and teach biomedical health personnel to break down the “rural / urban “ divide.

Time frame The project will run for five years in Phase 1 from 2001 to 2006. Special studies The project social worker and an external consultant have carried out a baseline survey. In addition, a Danish social anthropologist carried out an anthropological study with assistance from the project social worker. Project administration IMCC volunteers in Denmark who have worked on the project in Bolivia form part of the “home project group”. This group is also responsible for selecting, interviewing and training new volunteers who will go to Bolivia to work on the project. The home group is not responsible for actual day-to-day administration of the project. This is the task of the “out-group”, the group of two to four volunteers who are in San Lucas. The home group has also done fund raising in Denmark for the anthropological report.


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The out-group takes care of the day-to-day administration, planning and executing training courses, and preparing monitoring reports (called “informes semestrales”, or semester reports). On a rotating basis out-group members do the project accounts following Danida budgeting principles. Project Planning Overall planning follows the logical framework matrix (LFA), which specifies the main activities and expected outputs. The evaluation team has assisted the out-group revise and bring up to date the LFA during this evaluation. Project Monitoring The out-group send “fagbreve” or project newsletters back to the home group every one or two months. These deal with issues on which the out-group feels they may need advice on from the home group, or which are issues that need flagging for discussion. As mentioned above the out-group also writes monitoring reports called “informes semestrales”, or semester reports. These reports are quite useful. They reportedly take about one to two weeks to write. Nevertheless the fact that the semester reports contain a lot of qualitative information outweighs the possible disadvantage of time spent writing them. A useful feature of the semester reports is their short executive summaries and summary of recommendations. An annoying aspect – for the evaluator at least! – is the fact that the table of contents of the semester reports is not uniform. Thus, for example, in the First and Second Semester Reports for 2002, p. 14 (section 3.7), and p. 9, (section 3.2.2) there is information about the location and amount of community CAIs (CAIs comunales), whereas in Semester Report for July 2003, there is no information. In the other Semester Report for 2003, the information on CAIs is that IMCC participated in the departmental CAI and evaluation of SUMI, CAI of the Red Camargo and the municipal CAI. But again in the latter documents there is no information about the community CAI which is seen as crucial in building up sustainability of the ACS programme. The reason why nothing has been written about the CAIs in some of the semester reports is that some of the most recently planned CAIs have been cancelled. Recommendation: It is recommended that the table of contents be standardized so that crucial elements such as Community CAI are included. From the point of view of the evaluator and assessing sustainability aspects, it would be useful to know why there is no information about the CAI in a particular report. In 2003 and 2004 IMCC out-group has started to design a “Deltagerorienteret monitoreringssytem” or participant oriented monitoring system. One problem for the project is that there is no money for a monitoring system as such. However, there is money for the baseline before and after study. These two studies will provide a lot of monitoring data.


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As far as monitoring processes, such as impact of training on knowledge / changing of attitudes of health staff and ACSs, the out group have so far come up with the following indicators: • Improved knowledge of the ACS´s about health. • Increased respect among heath personnel for Andean health and illness concepts Other indicators which have been used in the semester reports11, or in other M&E systems being developed by the project are: • Number of health talks on average given by each ACS in a three month period • Number of patients referred to health posts • Number of patients seen by each ACS in each three month period. It would be important to improve these indicators, by adding: • Gender of patient • Age of patient • Nature of the referral (suspected illness type) • Outcome. The outcome could be added by the auxiliary telling the ACS what the outcome was. This would give the ACS more job satisfaction and provide useful moniring indicators for gravity and illness type for the project M&E system. By using some of the indicators from the LFA logframe, a series of indicators have so far been isolated. Short question sheets have also been designed, for example one is ready for use with the ACSs. The best way to monitor the project is to use the indicators in the updated Log frame matrix and to measure progress against these indicators. As regards the monitoring of the ACSs, the IMCC or hospital staff, when visiting health posts, reportedly take the list of names of ACSs belonging to the health post catchment area and check it through with the auxiliary nurse, an ACS, or community leader. This is a simple and effective tool for monitoring sustainability of perhaps the most important aspect of the project: the health promoter sub component. ACSs In the semester report for the second semester of 200312, there is mention of an attempt to initiate a supervision system for the ACSs. The report (in its annex 7) sets out a three-page supervision sheet. These qualitative and quantitative data, which are collected after every training course, are now entered onto a simple database for generation of some basic data on the work and problems of the ACSs. This system looks quite promising and useful. The data are reported on in the semester reports.

11 For example, IMCC-San Lucas. “Informe semestral. Primer semestre 2003”, p0 12-13. 12 IMCC-San Lucas. “Informe semestral. Segundo semestre 2003”, p. 29 and Anexo 7.


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Monitoring of before and after situation: the baseline The baseline, which was carried out over eight months from April to December 2002, and finalised in January 2003, is designed to show the before project situation. When repeated after five years, it is hoped that positive impact on Knowledge Attitudes and Practices (KAP) of health and illness behaviour and beliefs will be shown. Project budget The budget for the five-year project is a total of DKK 7.8 million. Per year the project costs break down thus: IMCC PHC project five year budget: Item 2001 2002 2003 2004 2005 2006 Total

budget Investments 648,000 18,000 223,500 32,000 18,500 0 924,645 Voluneers in Bolivia

700,179 650,552 577,000 644,250 843,450 0 3,567,899

Local staff 10,000 35,000 56,225 45,870 54,030 0 179,845 Activities & running costs

292,500 322,500 553,810 426,790 413,175 2,500 1,604,271

Local admin 5,000 10,000 12,960 6,000 6,000 0 36,470 Project info in DK

10,000 210,000 230,000 230,000 10,000 10,000 250,000

Evaluation 0 0 0 180,000 40,000 0 220,000 Other expenses (Grants)

0 6,000 5,000 13,054 10,000 0 25,000

Unforseen expenses

38,650 77,300 99,030 300,000 398,298 0 698,298

Admin in DK 55,000 110,000 59,667 60,000 63,000 30,000 276,885 Totals 1,759,329 1,439,352 1,817,192 1,937,964 1,856,453 42,500 7,783,313


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3. PROJECT DESCRIPTION AND IMPLEMENTATION This chapter describes briefly the three project components and the implementation of the main activities, divided up into the following three main headings: • Training • Infrastructure and equipment support • Research. Following the brief overview of the three main activities in the project, there is a section describing the institutional set-up and the project implementation arrangements. Training of health promoters (ACSs) and courses Before the project began, some 130 ACSs were elected in a total of 61 communities served by 10 health posts and San Lucas hospital. This is part explains the preponderance of male ACSs. The project wanted at least one woman ACS to be elected per community, but this has not happened for the reasons mentioned above. The following table shows the number of communities by health post catchment area by number of ACSs as of December 2003:

Health Post Number of communities Number of ACSs Male Female

Total ACS per community

Ajchilla 7 10 0 10 Buena Vista 6 11 6 17

Canchas Blancas 10 18 3 21 Collpa 4 8 1 9

Huañumilla 8 11 7 18 Palacio Tambo 6 14 3 17

Pirhuani 7 14 1 15 Sacavillque 5 10 0 10

Tambo Q’asa 6 12 1 13 Uruchini 2 3 0 3 Totals 61 111 22 133

Source: IMCC monitoring records The following table shows the status of ACSs per health post, as of March 2004: Health Post Project count (Dec. 2003) Evaluation count (March 2004) Active Passive Active Passive Ajchilla 10 - ? ? Buena Vista 14 2 11 3 Canchas Blancas 16 4 11 10 Collpa 7 2 ? - Huañumilla 13 4 10 8 Palacio Tambo 16 1 ? ? Pirhuani 9 6 ? ? Sacavillque 10 0 ? ? Tambo Q’asa 10 3 ? ? Uruchini 3 0 ? ? Total project count 108 22 ? ? The project’s own count as of December 2003 shows that 29 ACSs are passive, i.e., that they do not work or have left the area. This corresponds approximately to a 21% drop out rate.


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IMCC only works with ACSs in the valley zones, where the need for assistance is greatest, i.e., in the districts of the following health posts and medical centres: • Uruchini • Buena Vista • Canchas Blancas • Huañumilla • Collpa • Pirhuani • Sacavilque • Tambo Q’asa • Ajchilla. • Palacio Tambo. The EPC (for a description of the EPC and its role in the project set-up, see below, section on implementation and institutional set-up) decided to execute two courses for the ACSs per year (based on the experience of the Azurduy and Serrano IMCC projects). One course located in a health post that the ACSs fall under, and the other course for all ACSs, held in a central location, e.g., Palacio Tambo. From April 2004, IMCC will hold two big courses per year in each health post. This strategy has been chosen in preference of running courses with upwards of 100 ACSs which are very difficult and expensive to organise for the hospital. IMCC believe the hospital will have more chance of sustaining smaller ACS courses in the future. Curative or preventive work? A project report13 mentions how the work of the ACSs in the valleys will have a preventive character, but that it will also be curative. This is in view of the very great distance from health infrastructure in the valley areas and the fact that curative work could save lives. The curative skills imparted to the ACSs do not, however, involve the use of medicines, but rather remedies falling within first aid. In 2002 the first aid courses covered basic first aid only: • Life saving • Wounds • Burns • Fractures and carrying patients with fractures • Snake bite • Disinfection of water by sunlight. .z Other training given to the ACSs In addition to training in first aid and management of accidents, the important training that the project has been giving to the ACS is in Community AIEPI (AIEPI comunitario). A number of problems surfaced in the community AIEPI training, for example: • ACS said they did not understand training materials, and needed more help in

understanding them • Materials were reportedly not robust enough, despite being covered in plastic.

13 IMCC San Lucas. Informe semestral. Primer semestre 2002, p. 8.


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In addition to AIEPI, the ACSs have been taught about the following subjects, in addition to, or complementing, first aid, SUMI, and AIEPI: • Refresher courses on the danger of death, coughs, and diarrhoea • Fever • Problems with hearing / with the ears • Malnutrition/ anemia • Danger of death in infants under two months • Health preventive measures • Refresher courses on AIEPI and SUMI • Educational methods for home visits and health talks.

A key project objective on sustainability grounds is that the auxiliary nurses will be able independently to train and supervise the ACSs in the future. This strategy has apparently been included into the AIEPI strategy, and appears thus to be sustainable14. The training financed by IMCC also includes grants for ACSs who wish to study auxiliary nursing. To date (April 2004) two ACSs have received IMCC grants to permit them to study in CENPRUR college in Ocuri. Training of health staff other than ACSs Auxiliary nurses Training for auxiliary nurses is shown in the following table: List of training for health staff has included: • Use of ultrasound (for doctors) • Management of hospital human respources • Quality of care • SUMI • Clinical AIEPI • TB • Refresher courses • Obstetric emergencies15. The following are subjects that the auxiliary nurses want training courses in: Clinical AIEPI TB Pharmacology ITS How to make a PAP test Violence in the family. They have recently been trained in clinical AIEPI and TB. The other topics are outstanding.

14 IMCC San Lucas. “Informe semestral. Primer semestre 2002”, p. 8. 15 Source: IMCC Semester Reports (2002, 2003).


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Training of hospital ward staff The following table shows the training for hospital personnel: Topics Target group Quality of care All hospital staff Management of ultrasound All doctors Basic anaesthetics plus ECG All doctors

Nurses: management of ECG Care of the neonate and Paediatrics All ward staff Management of the pre- and post-operative patient and sterile work Nurses ATLS (acute traumatic life support) All ward staff

Administration of health systems Management and administration Source: IMCC Semester Reports (2002) Training of village men and women through the Peasant Union Centralía In 2002 the following training was given to village men and women members of the peasant union: Law of Popular Partcipation Plan for employment Rights of men and women Duties of community leaders Peasant union structure Law of municipalities (ley de municipalidades) Land and territory16. In 2003 the following training was given: Information about the OCIACS Safe motherhood Information about SUMI Strengths and weaknesses of the system of ACSs Rights and organisation Health, organisation and leadership Environment Health and Constitutional Referendum. Training and forming of women’s groups (Inti Pallay) No training was given in 2002 or 2003. None has been given yet in 2004 (March 2004). However, in the second half of 2003, IMCC held some meetings with the two Inti Pallay women’s groups they work with on how to organise for the future and how to plan for the institutional training that they are to receive17. In the evaluation team’s opinion, progress with the Inti Pallay women’s groups is too slow. Recommendation: It is recommended that the IMCC project free up some more of the social worker’s time so that she can make more progress with the work of training and capacity-building of the Inti Pallay women’s groups, because this is an important aspect of the project sustainability.

16 Presumably this topic included the Law of INRA (ley de INRA). The semester report (IMCC San Lucas. Informe Semestral del Segundo Semestre, 2002) gives no more detail on this topic. 17 IMCC San Lucas. Informe Semestral del Segundo Semestre, 2003, p. 21.


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3.1 Investments in health infrastructure, including investments in health equipment Each year a programme of infrastructure repair and upgrading, as well as construction of new health facilities, has been implemented. There have been some delays and problems of poor quality construction, but in general the programme is on track, and quality problems are to be redressed. Two drinking water systems have also been constructed. Equipment donations – ultrasound and dental equipment, as well as labour beds and cots for new borns, even mules for transporting patients!, have improved the quality of health services on offer in rural areas. X-ray equipment, which is on the POA for 2004, will be purchased it is hoped, in 2004. 3.2 Research into health and illness concepts and into health seeking behaviour The main research has been: Baseline survey Anthropological study Both baseline and anthropological reports were delayed. In addition to the delay, some important questions on maternal preferences and beliefs about birth and labour were omitted. The project volunteers and hospital staff now agree that these questions need to be included. The evaluation team has recommended elsewhere in this report that these questions be included and fielded as soon as possible so that the vital question of project impact on maternal mortality can be measured when the baseline is repeated in 2006. The anthropological report was delayed for at least six months because the Danish consultant who did the work at a low “solidarity price” did not deliver her report on time. The report she has delivered is substandard – although it does have a lot of useful information - and cannot be used in its present form without a lot of revisions and editing. IMCC staff in San Lucas are not qualified to apply the findings of the anthropological report, because a qualified medical anthropologist is needed to do this work. Sufficient funds need to be budgeted for in the future to use this knowledge for strengthening the project’s intercultural component. The need for money to work on the anthropological report is urgent, however, since the first phase requires the anthropological report findings to be used for designing intercultural health training modules and strategies. The lesson learned from this experience is that for a possible new phase, sufficient funds need to be requested from Danida in the budget to allow a consulting firm to do the baseline work quickly (one month instead of eight) and the anthropological work (one month instead of eight) as well. Alternatively, a replacement for the social worker (or an additional member of staff to complement her) could be hired in the future, who would be qualifed to do sociological/socio-economic/KAP baseline studies and data analysis.


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3.3 Institutional set-up and the project implementation arrangements The project document lists the following stakeholders and committees as being the essential elements of the project set-up: Hospital (EPC) SEDES Vigilance Committee Municipality of San Lucas Peasant Organisation Female social worker / anthropologist Technical Health Committee (no longer exists: has been merged into the EPC) Training Courses Committee (no longer exists: has been merged into the EPC). The main aspects of the institutional set-up of IMCC San Lucas are still quite similar to their original description in the project document, although there have been some additions and changes. The stakeholders are currently as follows: IMCC out-group EPC Hospital of San Lucas SEDES DILOS (municipal health committee) Comité de Vigilancia (Vigilance Committee) OCIACS-MSL (the organisation of the ACSs) (this organisation still does not have juridical personality; it was set up by the project to enable sustainability; it is extremely weak and practically non-functional at present (March 2004). The EPC and DILOS are the most important formal vehicles for implementing the project. IMCC project budget and activities are discussed and approved in the DILOS (in which the vigilance committee is also represented). Budget is not dicussed in the EPC. The EPC groups together the important project stakeholders (IMCC, hospital, ACSs, and NGOs). The Manual de funciones (Operations Manual) for the EPC, which was made in June 2003 defines EPC as:

“A multi-disciplinary team charged with planning, executing and evaluating strategic training programmes for health staff and community human resources in health, aiming at obtaining inter-institutional, community and municipal integration and coordination”.

For the rest of the byelaws and regulations of the Operations Manual see Annex 11. EPC EPC is characterised by problems, mainly due to the persistent crises in hospital senior staff. Since these problems are not likely to go away, and are part of the Bolivian political reality, it would be advisable for the project to obtain a formal stand-in for the hospital chief medical officer so that the stand-in can take decisions on behalf of the hospital as and when necessary.


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Recommendation: It is recommended that IMCC ask SEDES to approve as soon as possible another member of the hospital staff, perhaps the head nurse, to have an executive function on the EPC so that project courses can go ahead as scheduled. Not essential for the execution of the project, but nonetheless playing an important role, are the following stakeholders: • Health staff in the Red Camargo • Inti Pallay (women’s groups) • Technical staff in the NGOs; ADRA and Esperanza • Confederación Sindical Única de Trabajadores Campesinos de Bolivia (Sole Union

Confederation of Peasant Workers of Bolivia, CCSUTC) • Comités de Análisis de la Información / Information-Analysis Committees (CAIs) • Ayllus. To date, the two Inti Pallay groups IMCC work with are still weak. They are dependent on the project (and also on other NGOs, the PASACH programme, and other organsiations) for their functioning. The CCSUTC function as recipients of project benefits (money for training). The ayllus, for a variety of reasons, do not figure in the project, except on paper: their reported aim is to get rid of NGOs and the State18, so it is likely that the project will not be able to work with them. (The project has not been able to work with them so far). A participatory methodology is the basis for the training of the ACS In order to plan the type of training and course content for the ACSs, the project makes use of the CAI. There are three types of CAI: • CAI communal: Community CAI • CAI municipal: Municipal CAI • CAI distrital: District CAI. CAI-comunal The CAI communal, or community CAI, is a forum of the hospital staff to carry out health visits to communities. IMCC is usually given a slot of one or two hours in which to find out what are the issues that the community wants covered in the ACSs courses. The IMCC strategy is to to arrange for zone courses to coincide with community CAIs in order to obtain improved coordination. In this way, IMCC is also able to attend CAIs and inform villagers about progress / problems with the ACS training, the first aid kits, and the involvement of women as health workers in the project. By attending the community CAIs IMCC volunteers are able, it is hoped, to gain the community’s confidence and especially that of the village authorities. IMCC has participated in community CAIs in 2002 in Canchas Blancas, Ajchilla and Pirhuani.

18 Source of information: Meeting with executive staff of the CCSUTC.


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IMCC has an agreement with the hospital to use one or two hours during community CAIs in order to present the project and discuss the health promoter system with community leaders. The project hopes that these occasions will promote an understanding about the project, the ACSs, and will increase understanding and hence support for the ACSs, and strengthen popular participation. Another objective of the communal CAIs, according to the IMCC monitoring reports, is to find out the needs in the communities in order to incorporate the findings in the ACS training. The project strategy documentation mentions that in the community CAIs IMCC will also discuss the different ways to maintain the first aid kits with the community leaders. IMCC stresses that the first aid kits are the property of the communities and not of the ACS himself. The strategy allows for the election of a new health promoter, in which case the first aid kit would be passed on to the new ACS.


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4. POSSIBILITY OF ACHIEVING OBJECTIVES WITH THE CURRENT STRATEGIES Immediate objective 1 “Improved knowledge and improved practices of the target group, i.e., of the rural population, in relation to illness and health”. Background The target group’s knowledge and behaviour regarding health and illness are the focus of this immediate objective. Based on its experience of working in other Andean Quechua communities, the project is aware that the rural population of San Lucas has beliefs about the body, illness and health, which are very different from the Western biomedical model, based on germ theory. As is corroborated by the baseline data, rural women and men believe in mystical causes of diseases such as goitre, malnutrition and Chagas. Preventable diseases such as diarrhoea and ARIs are believed to result in excesses or deficiencies in cooling or heating properties of foods and emotions, although villagers are also aware that cold and rain also cause ARIs in children. People are believed to fall ill as the result of angering the gods or deities of the earth and mountains. There is a host of conditions caused by the earth, wind, lightning and streams. The cure for these mystical conditions is to have recourse to a ritual specialist, known as a curandero or jampiri, or, in Quechua, as a jampiq (healer / doctor). The project wishes to teach villagers about the causes and prevention of childhood killer disease such as diarrhoea and ARI, as well as teach them about how to reduce maternal infant mortality rates, which are still very high in the zone, by encouraging women to give birth in the health post or, at least, to go for regular prenatal checkups. Following WHO PHC policies which are tried and tested, the project – which follows government of Bolivia policy – is working from the assumption that the Community Health Worker (CHW) or barefoot doctor can impart knowledge and provide a front line health worker service. In the IMCC project, as in the rest of Bolivia, the CHWs are now known as ACSs. The project, unlike its predecessor, the IMCC project in Belisario Boeto, does not train the ACSs to use the health worker manual, Where there is no doctor19. Instead of using a book, the project develops its own training materials in collaboration with SEDES and also uses material produced by SEDES for its health programmes and other material developed by international organisations such as UNICEF and WHO. The main emphasis of the project is to impart knowledge to the ACSs who will, under supervision and back up from the auxiliary nurses working out of the nearest health post, teach village women about the need to go to prenatal check ups, vaccinate babies, and how to prevent diseases such as diarrhoea and ARI. For this reason, emphasis is on community AIEPI and SUMI for the ACS’s. In addition to the important preventive work of the ACSs – especially in recognizing difficult birth, signs of malnutrition in under-fives, and anaemia and malnutrition in pregnant women, the ACSs have been trained in first aid.

19 D. Werner et al., Where there is no doctor: a village handbook (in Spanish, Donde no hay doctor: una guía para los campesinos que viven lejos de los centros médicos). London. TALC, 1980.


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For the villagers who live far away from health posts, and where there are no roads for ambulances to drive on, having a health worker who can treat fractures and snake bites, burns and wounds is very important. The perceptions of rural women about the biomedical ideas promoted by the health staff and ACSs of the project will be measured by the baseline monitoring exercises. The project document foresees that the inhabitants of the rural areas of the project – especially women and parents of under-fives – will, as a result of the project’s educational activities through the medium of ACSs and auxiliary nurses, enjoy improved knowledge of the causes and of the prevention of the prevalent diseases in the area. The baseline study, carried out in 2002, shows that: • A high percentage (75%) of the surveyed population do not carry out actions to

prevent diarrhoeal diseases (EDAs), and that 55% of the surveyed population treat the under five in the house and that 35% go to the health post

• 75% identify “bad smells” as the cause of malnutrition, whose connotation has a magical character.

In general the perception of causes of diseases has a magical connotation (susto and similar ideas), or the respondents does not know (24% for EDA, 7% for IRA, 61% for Chagas, goitre 87% and malnutrition 89%). Impact It seems that the strategy of training in first aid is working – the ACSs have learned skills, but their first aid kit is very modest and the stock of bandages and oxygenated water are not being replenished. This sustainability problem will ultimately threaten the possibility of achieving the objective of having a well-functioning ACS who can prevent diseases and treat accidents and fractures. Another sustainability problem which threatens the possibility of achieving the objective of having a well-functioning ACS who can prevent diseases and treat accidents and fractures, is the drop-out rate (around 20%), and the fact that after three years of the project the community are still not taking over the faenas (obligatory village tasks) of the ACS, as they have undertaken to do in the convenio (formal agreement) between IMCC and the community. Added to this problem is the fact that the ACSs receive no salary, and may only charge small amounts for the bandages and other materials they use. Despite the fact that the selling price is roughly the same as the purchase price, the ACSs report having problems replacing the materials, mainly, it would seem, due to a lack of money in the rural economy and some unwillingness on the part of some villagers to pay for the service the ACSs provide. In the FGD (see Annex 5) the ACSs requested a number of things – a hat, with an IMCC logo, to give them credibility and visibility in the community, a tent, sleeping bag or blanket and rucksack. These things have been given to the health staff such as auxiliary nurses who already have a salary, so why can’t they have these things as well?, they reason.


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It might be psychologically important to give them these few things, the cost of which is minimal. A suggestion to generate income and to cement sustainability and ownership of the work of the ACSs would be that women in Inti Pallay make hats and blankets for the ACSs which the OCIAC’s then distribute to the ACS, according to whether they are active or not, and that the community pay for these items by a communal contribution. To judge from the comments made by the approximately 80 women and 30 men interviewed in the FGDs during this evaluation (see annex 6), there is still a very strong adherence to humoral (hot / cold balance) and mystical notions of disease causality and appropriate treatment. Prevention of disease is still seen to be a matter of avoiding strong emotions or of being careful not to offend Pachamama, the Earth Mother who, if angered, can provoke a range of conditions such as susto (illness from fright), virginasqa (illness caused by Pachamama which can cause diarrhoea in children), and related conditions such as rayo (lightning), Gloria (Glory, i.e., an extension of God or the supreme deity which, if offended, causes disease) and pujyu or manantial (stream, i.e. infection by the waters from a stream), wayra (wind illness) or tierra20 (earth). The logic underlying these beliefs is that the natural world – mountains, streams, trees, wind – is alive and inhabited by nature spirits. They need to be appeased through periodic rituals such as the ch’alla (aspersions to Pachamama with maize beer); and the worship of apachetas (stone shrines commemorating the ancestors) and of the urqu (mountain spirits or gods). Despite the persistence of these mystical and humoral notions of causality and treatment, the FGDs show evidence that some germ theory ideas have broken through. Several women said they were aware that dirt, dirty drinking water or flies getting onto food caused diarrhoea, and several women and men also said that children’s hands should be kept clean and that clean plates should be used for putting food on to avoid disease. Of particular importance is the fact that the ACSs reportedly give talks on clean birth and on the importance of attending prenatal check ups. In one FGD, eight women said they had attended talks on clean birth and antenatal check ups. Other women reported having had been taught about how to look after children and to feed them properly. The ACSs give both community talks – to all the community – and heath talks in individual homes. Problems Several women in FGDs said that they like the “charlas” or talks given by the ACSs in their own homes (the ACSs make some home visits to give talks on health matters) and by the auxiliary nurses in the health posts. On average, the ACSs report making between one and three home visits per month. The IMCC project hopes that this will increase as a result of the training the ACSs have received in community AIEPI. However the women said that because they could not read or write, they could not make notes and thus easily forgot what the ACS or auxiliary nurse told them. Some of the women also said they could not understand the educational material used by the ACS and other health staff: they did not understand the pictures. Some women said that if they went to their ACS, that he or she would just refer them to the health post anyway because the ACSs – who do not have medicines - cannot cure

20 Tierra is related to illness from Pachamama. In Quechua, the illness “tierra” can be known as jallp’a jap’isqa (grabbed / captured by the earth).


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them for any disease. The women said they found this unsatisfactory and that they would like the ACS to be able to treat them in the community. The women interviewed in FGDs said that they would value the service of the ACS much more, and find it much more useful to their needs if the ACS could be trained to be a midwife. This was because even though some women like to give birth in the health post, often it is not possible for them to walk all the way, or to be carried, when labour starts. And also several women in the FGDs said they are afraid to give birth in the health post and that they prefer a home birth and that therefore they would prefer to have a health promoter deliver them at home. Importantly, the village women mentioned that the ACS attends them at the health post when the auxiliary nurse is absent: thus the ACS fills an important stand-in function in the first level health services. For some three years IMCC San Lucas has tried to get SEDES and the hospital to sanction the idea that the ACS be paid for looking after the health posts in the three week holiday period when the auxiliary nurse is on holiday and the health post is normally closed. Finally, women in the FGDs said that they would value the ACS more if he could teach them about plant medicines. Because money is in short supply for them, because they cannot always go to the health post to see the auxiliary nurse, and because plant medicines are culturally acceptable, they would value help in understanding how to use traditional plant medicines for a number of minor ailments including ARIs and diarrhoeal disease. The problem of some ACSs stopping work or even leaving the village entirely emerged in the evaluation. Obviously the ACSs who leave need to be replaced as soon as possible otherwise the key person in the village who is supposed to teach village women and to recognise difficult births and refer them to the health posts is removed. Finally, because of extreme poverty levels and a lack of resources such as fertile land and water for irrigation, a large proportion of the households in the municipality of San Lucas suffer food insecurity with resultant malnutrition and disease such as stunting and wasting of children. Because of the extreme poverty levels and lack of sufficient food, it is difficult for many women and men in the villages to put into practice what the health staff (ACSs and auxiliaries) teach them about good nutrition and care of children. This problem is not being tackled by the project. A kitchen garden component (“huerta familiar”) or low-cost green house (“carpa solar”) component in similar PHC projects around the world can sometimes have a positive effect on nutritional levels in resource-poor households. The project should consider adding these elements to its teaching work. Way forward The project has only run for some three years. It is not likely that deep-felt beliefs will change in such a short time. The project strategy of teaching and imparting knowledge is a rock hard strategy: it is just a time consuming one and it takes time to change ideas and practices. Mentioned elsewhere in this report is the generalized problem of adult – especially female – illiteracy. Many adult women, and even women in their twenties who are now bearing children, have not been to school, or have dropped out before learning very much.


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Illiteracy is a major challenge to the work of the ACS – they give talks and distribute or show educational materials, but often the women cannot read or understand them. The way forward is for the project to tackle the problem of adult illiteracy in the province together with the municipality education staff, and to work out a joint strategy that takes account of the potential and limitations of the IMCC and other projects in San Lucas. A suggestion for the recommended new project phase would be to employ adult literacy specialists and a school health educator who could work with parents (who meet, or who are supposed to meet regularly, in the junta escolar (school boards) under the EIB educational reform programme. Also, as appears to be project strategy, the women who meet in the Inti Pallay women’s group should receive systematic and high quality literacy training (if they want it), so that they could form a potential cadre of literate female ACSs to replenish ACS who drop out and to redress the gender balance in the project health promoter cadre. PHC projects take a long time to achieve tangible results in the area of changing KAP about health and disease. But the evaluation team believes the strategy is the right one. As for improving nutritional levels, this is a difficult problem to solve in the absence of a kitchen garden / agronomy component. It is beyond IMCC’s capacity to deal with these issues directly. Perhaps IMCC could coordinate more with the Danida-financed PASACH programme which has a technical advisor in Camargo. Perhaps some small agricultural activities – for example, greenhouses (“carpas solares”), composting, fruit trees, small gravity irrigation systems and simple erosion control measures - could form a sub-component for the recommended Phase II. This type of activity – which is directly aimed at improving food security – could easily be part of an expanded set of training and demonstration plot activities organised through the Peasant Union Centralía headquarters and financed by IMCC and partly financed by HAM. Immediate objective 2 “Improved and expanded health services of the municipality of San Lucas”. Background There is a two-pronged approach to this immediate objective: • Improve the quality of the health service personnel by training them in new ideas,

especially PHC precepts, and training them in the use of new equipment aimed at helping prevent maternal mortality and helping reduce infant mortality

• Improve existing health infrastructure (hospital building, health posts, and health staff accommodation) by upgrading and adding new facilities such as bathrooms, septic tanks / latrines, water supply, build new infrastructure, and make medical equipment donations.

Impact of PHC training The health staff interviewed express satisfaction with the training they have received in PHC principles and in certain key areas, such as use of ultrasound equipment; management of obstetrical emergencies; and first aid courses. The auxiliary nurses express satisfaction with the fact that they now receive much more practical and hands-


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on training. In the original health diagnostic21, the auxiliaries complained how the training received was too theoretical, not applicable and planned at times inconvenient to them. Health staff interviewed during the evaluation all mention the fact that the training they now receive is more practical and more relevant to their needs. A major problem that goes against the possibility of achieving the project objective of improving the quality of the health staff by training them, and which is especially mentioned by the ACS (see Annex 5) and the auxiliaries (see Annex 4) and the hospital staff (see Annex 3) is the lack of coordination in planning the health courses and training programmes, and the fact that the municipality allegedly does not fulfil its obligations in a timely manner in the training courses and other health counterpart budgeting. From the point of view of the interviewed village women, the training that their ACSs receive, and the training that the ACS in turn impart to them, is not always relevant or is lacking. Since it is now government policy to train ACSs in midwifery, it is likely that the village women will find their ACSs more important for them in the future, and this will make the ACSs more relevant to their needs. Problems The major problems affecting the possibility of achieving the objective of improved KAP of health and illness in the rural villagers through the training strategy are the problems that the EPC faces in organising the project activities, mainly the training, the internal staff rotation of the hospital staff who are responsible for the training (which mainly affects sustainability), and the lack of coordination between SEDES and the project as regards use of staff for project training activities. Another problem is the fact that the municipality is reportedly often late in meeting its counterpart funding requirements for training courses, and the relative weakness of DILOS which is only a few months old. Way forward The team has recommended in this report that the ACS be trained in midwifery as soon as possible. Indeed, SEDES personnel informed the evaluation team that it is now health policy to train health promoters in midwifery. Training needs to be improved and made even more practical so that ACSs learn to use more didactic, practical methods that village women can apprehend. The ACSs requested (see Annex 5) cameras and tape recorders so that they can make their own practical teaching materials and in order to make more comprehensible their health talks to the village women. The project should provide these things on a buy-back basis so that the ACSs take care of and own the equipment. Impact of infrastructure investments The project’s poverty reduction objective is to ensure that 80% of its infrastructure and equipment donations are made outside San Lucas municipal area and in the countryside where the poorest and most underserved segment of the population live. To date, 70% of the IMCC investments have been made in the rural areas, a very fine achievement, and close to the 80% target. It is likely that the end of the project Phase 1

21 IMCC San Lucas. Informe semestral, Segundo semestre 2001, p. 12-15.


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will achieve the 80% target. The municipal council through its agreements with IMCC have had to make available financial counterpart funds, and this bodes well for the sustainability of the infrastructure. A major impact then is to have used the lion’s share of the infrastructure budget on PHC health infrastructure outside the municipal area. This means that the health service for the rural poor has improved. The perception of health staff, town council officials, and of village men and women is that the quality of the municipality’s health service provision in the province has definitely been improved as a result of the IMCC investments in infrastructure and equipment. Problems A few problems of poor quality workmanship or poor quality materials in construction have been noted, and long delays in acquiring the municipal counterpart funds which in turn delays the disbursement of IMCC funds and the execution of the work on time and within the budget year, have been noted. It seems clear that it is necessary to improve the health infrastructure in order to offer some basic health services to the population. It also seems clear that it is difficult to support, train, and supervise the ACSs without the presence of well-functioning health infrastructure and without well-trained auxiliary nurses staffing them. Way forward There appears to be no preventive maintenance budget and this needs to be set up, and financed by HAM funds, as soon as possible. The examples of poor quality workmanship need to be put right, and work completed on time. IMCC need to reiterate that if HAM does not act in a timely fashion, that IMCC is obliged to repay budgeted monies for construction to Danida. The following table shows the summary investments in infrastructure and equipment paid for by the IMCC project: Table: Summary of IMCC investments 2002-2003 with HAM counterpart funds: Year IMCC HAM Total

amount % IMCC

IMCC amount rural area

IMCC % rural area

HAM amount rural area

HAM % rural area

2002 Equip. 107,362 68,500 175,862 61% Construction 79,677 297,677 377,353 21.1% Total 2002 187,039 366,177 553,215 33.8% 77,039 41.2% 68,176 18.6% 2003 Equip. 92,753 30,424 123,177 Construction 138,000 172,000 310,000 Total 2003 230,753 202,424 433,177 53.3% 215,364 93.3% 194,035 95.9% Total 2002 –2003

417,792 568,601 986,392 42.4% 292,403 70% 262,211 46.1%

Source: IMCC out-group Annex 7 provides the above figures for infrastructure and equipment in detail for the years 2003-2004.


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Finally, it will be important for the EPC and DILOS to take active and proactive action concerning the planning for new infrastructure, human resources training, and preventive maintenance programmes so that a measure of sustainability can be ensured. Immediate objective 3 “Strengthened organisation of the rural population in the field of health and heightened understanding of the concepts of health held by the rural population, with the aim of improving the collaboration among the community volunteers, the ACSs, the municipality, the hospital and other institutions”. The emphasis of this immediate objective is that biomedical health staff learn about traditional Quechua and Andean nosologies, symptomologies, treatment beliefs, and practices. The government policy is to promote ‘salud intercultural’ (intercultural health). By this is meant respect for, and understanding of, traditional Andean medical belief and practice. If, the logic continues, biomedical staff learn more about these beliefs, they will, it is hoped, learn to understand and respect the rural population. This should mean a rapprochement between the two ‘systems’. For example, women interviewed in the evaluation said they are afraid to give birth in the health post because: • They are afraid to show their bodies • They are not allowed to give birth in a squatting or standing position with their

clothes on • They will get cold because the health post staff do not give them a warm mate

(herbal infusion): (Birth is conceived as a dangerous, liminal state, and cold must be kept at bay.)

• They are not given the placenta or after-birth for burial Once the biomedical health staff (many of whom probably know these things, since they are Andean, speak Quechua, and many of whom come from the area) are exposed to these ideas, it will not require much effort to initiate culturally acceptable labour arrangements in the health posts and the hospital. In Europe and Canada, campaigning for ‘natural birth’ (e.g. Le Boyer) or for home-births, and a move away from the medicalisation of a natural process (birth and labour) has resulted in services that European women are happier with, and has resulted in choice. In England, a woman can give birth in the hospital with her own G.P. if she likes. Also in England, a woman can have a home birth with her husband in attendance if she wants, and she is given the after-birth, if she wants. The main activities for the third immediate objective include: • Action research into Andean concepts of health and illness and health seeking

behaviour • Exposure of health staff, including doctors and nurses, as well as front line

(auxiliaries and promoters) in Andean concepts of the body, health and illness with


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the aim of promoting a rapprochement and intercultural understanding between biomedical and Andean traditional medical systems

• Training in organisation and leadership and in health themes of women’s groups. As mentioned elsewhere in this report, it is too early to measure any change in beliefs and behaviours due to the project. Any statistically revealed change cannot be shown until the baseline is repeated again. As mentioned above under Immediate Objective 1, comments made by village men and women about teaching suggest that a more practical approach, and more time is needed, to teach illiterate or semi literate village women and carers of children. Equally, the men and women who attend training and teaching session in the Peasant Union courses also struggle with reading and writing. The consultants (who are not hired by IMCC and who are therefore not answerable to IMCC quality control checks) reportedly do not appear to use didactic methods which are appropriate or user friendly for illiterate / semi literate villagers. On both fronts IMCC needs to encourage more hands on, more practical, teaching methods, and needs to encourage use of tape recorders and the setting up of a tape library and radio so that villagers can at least go and listen to talks and lectures on different subjects delivered four times each year. In the Log Frame matrix it is hoped that the strategy of training in leadership and public information about rights, laws, new strategies, and responsibilities of villagers in the health field in women’s groups and through the Peasant Union courses will lead to improved organisational capacity of the rural population concerning prevention of illness and improving health. In the Log Frame matrix it is also hoped that the strategy of training biomedical health staff in intercultural health ideas will ultimately lead to changes in perceptions of the health staff about the project and about the rural population’s health and illness behaviour. If the staff are committed, if the training is well done and exciting and captures the imagination of the health staff, then this strategy has a good chance of paying off. One issue concerning attitudes of health staff to Andean beliefs is monitoring: it is vital that the project start monitoring now health staff attitudes about Andean health and disease concepts. The project ought to include some simple monitoring tools to measure any changes in perceptions of the health staff about the rural population’s health beliefs and cultural practices relating to birth and the management of illness. Recommendation: It is recommended to start giving short written questionnaires to health staff about their attitudes to the health and illness beliefs and behaviour of the rural population, and to relate these questions to the type of health services they provide. This information would provide very useful data for the future impact monitoring. A consultant medical anthropologist (see recommendation below) could do this. The project does not have the internal capacity22 to use the anthropology report findings and to turn them into a series of impactive intercultural teaching modules, and to

22 No trained anthropologists are among the new batch of volunteers for the project.


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introduce changes in hospital clinical practice such as introducing culturally acceptable labour and birth in the hospital and health posts. Recommendation: It is recommended to hire a (preferably) female medical anthropologist consultant – if possible, one who has specialised in nursing, PHC, and midwifery questions - as soon as possible to use the anthropology report findings to make intercultural teaching modules, and to help introduce culturally acceptable changes in hospital clinical practice. 4.1 Special considerations Danida’s NGO strategies vis-à-vis the IMCC project The IMCC project’s objectives and strategies fit into Danida’s NGO policies for strengthening civil society23. In particular, the IMCC project, which is trying to help form women’s self-help groups, and trying to train village women and men through their existing peasant union organisations, is following a tradition of Danish NGOs trying to support the organisations of the poor, namely informal self-help groups, traditional organisations, local women’s groups, etc. Changes in Bolivian national health policy regarding PHC In the 1980s, when the first IMCC PHC project started, the role of the ACS, who was at that time called the health promoter or “promoter de salud”, included curative procedures. The health workers were trained in use of antibiotics and other drugs. In the 1990s, the policy changed, and health workers were no longer trained to cure disease with medicine: they were now to educate, recognise problems, and refer the patient up the line, mainly to the auxiliary nurse in the health post or doctor in the medical centre. In recent years health workers have not been trained as midwives, although they were some 6 to 8 years ago. In the province, they have also been trained in the past by Esperanza and ADRA. But these promoters and midwives have been abandoned by the Esperanza and ADRA projects as soon as the donor funds stopped. As Esperanza staff say: “When there is no project, and when we have stopped giving them free oil and flour24, the promotors have stopped working”. From April 2004, the evaluation team has been told that the ACSs are again to be trained to perform an institutional birth, i.e., a hygienic birth in the home or in the health post. For this reason the evaluation team has recommended that future IMCC training for ACSs include teaching and techniques for hygienic home and health post birth. Adherence of project to WHO PHC guidelines The IMCC health project, unlike the other NGOS in the prpject area, adheres completely to the WHO primary health care guidelines, as first laid down in the Decalaraion of Alma Ata (see Annex 9). In particular the project by working through the peasant base organsiations (the Centralía), and by trying to teach CHWs and village women, by strengthening their women’s organsiations, is fulfilling the following clause of the Declaration:

23 “Strategy for Danish Support to Civil Society in Developing Countries, including Cooperation with the Danish NGOs analysis and strategy document”. Ministry of Foreign Affairs, Danida, October 2000. 24 The USAID-funded health projects of Esperanza and ADRA supplied free food to women’s groups and health promoters. These strategies are notorious for being unsustainable and dependency–creating, and they often have documented negative impacts on local agricultural economies.


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“IV: The people have the right and duty to participate individually and collectively in the planning and implementation of their health care”.

The project also fulfills the fifth declaration. By building health infrastructure and improving the training of front line health staff, the project is enabling the government of Bolivia to provide basic health services to underserved or previously non-served rural populations:

“V: Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organisations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice”.

The project also, by providing cheap and affordable health services in the person of the ACS, the village health worker who lives and works in the community, is adhering to the sixth clause of the Declaration, that is providing health services that “the community and country can afford to maintain..”. The project also adheres fully to the principles of the sixth clause of the Declaration, namely, in particular the following sub-clauses: • “Addresses the main health problems in the community, providing promotive,

preventive, curative and rehabilitative services accordingly”; • “Includes at least: education concerning prevailing health problems and the methods

of preventing and controlling them;….an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries;……”;

• “Requires and promotes maximum community and individual self-reliance and participation in the planning, organisation, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate”;

• “Should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need”;

• “Relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community”.


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5. RELEVANCE OF THE PROJECT The justification for the project was based on the following six key issues: 1. Lack of knowledge among the rural population about basic health 2. Health infrastructure characterised by poor quality building and insufficient

resources 3. Health staff are poorly trained and do not always understand the rural population’s

problems and needs 4. Training of volunteer community health workers (originally called “Responsables

Populares de Salud” (Popular Health Workers), now called ACSs) is insufficient 5. Women are only minimally involved in local development, including health 6. The peasants’ poor organisation weakens their potential influence on the area’s

development. These six key problems are being addressed by the project and are still major problems in the project area. The following section analyses briefly the main points of relevance being addressed by the project: Lack of knowledge among the rural population about basic health The KAP baseline study provides considerable evidence of mystical attribution and magico-religious and humoral notions of disease causality and treatment. However, from a strictly culturally-relativistic point of view, Andean traditional mystical and humoral notions are, clearly, not in themselves evidence of a “lack” of knowledge. On the contrary, they are evidence of a vibrant Andean system of beliefs that derive from Andean Quechua culture. They are, however, also to a certain degree “obstacles” to the prevention of several diseases of poverty (mainly diarrhoeal diseases, ARIs, goitre, and Chagas) and the prompt, low-cost, and effective treatment of the diseases of poverty. Studies of “Western “cultures show that beliefs in themselves are not the problem. The main health problem for the poor rural inhabitants of San Lucas is mainly poverty and exclusion from basic services. In the high income countries, clean drinking water, sanitary drainage, sanitation and sewerage treatment, public health measures against vectors are taken for granted and also prevent the vast majority of preventable diseases, especially of the diseases that affect women in childbearing age and children under five. When people are not poor, they can eat well, and when they do not suffer from malnutrition it is more difficult for them to get ill, and when public health services are good, many of the diseases of poverty become less serious or disappear. Thus, while it is relevant for the project to tackle beliefs and prejudices against good health practices (such as vaccination for babies or prenatal check-ups), it could also be argued that the project would also find it very relevant to focus on the causes of poverty (such as land-insecurity and food-insecurity due to poor production techniques, lack of irrigation and water-recharge infrastructure, and soil erosion and desertification processes in parts of the project area). The Danida-financed Agricultural Sector Programme (PASACH) operates in the province and it is hoped that this programme will have some positive poverty-reduction impact that might have a spin off effect on the IMCC target group. However, it should


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be pointed out that PASACH does not work with the poorest of the poor, but with peasants with resources. However, the project is a health project and is correctly concentrating on health technical and knowledge transfer activities, rather than becoming involved in activities that would characterise a natural resources protection and integrated rural development project. The project staff and budget do not have the capacity to branch out into new areas, or risk dissipating the effect of the project. What is important is for the project to involve in constructive engagement with the traditional rural population and promote respect for intercultural health programmes. This is the aim of the third Immediate Objective of the project. Training Health staff at the beginning of the project were poorly trained and did not always understand the rural population’s problems and needs. The training for health staff has been shown to be relevant for all levels of staff that have benefited, because: • The training follows national PHC and international WHO guidelines • The training fits within and reinforces current programmes, mainly AIEPI and

SUMI • It reinforces the critical role of the auxiliaries in the AIEPI programme as trainers

and supervisors of the ACSs • The training is low-cost and uses simple materials and is aimed at the poor (thus

respecting PHC principles/WHO guidelines) • There is a need to promote respect for traditional Andean illness and health beliefs

and to promote culturally acceptable practices, such as Quechua birth. Infrastructure and equipment investments Health infrastructure at the beginning of the project was indeed poor, and has now been considerably improved. It is known to be relevant to build new health posts, improve the hospital facilities and renovate existing health posts because: • Auxiliaries will be happier, have greater job satisfaction, and have a safer working

environment • Health posts will have hygienic facilities that they previously lacked and labour

rooms and equipment to facilitate hygienic deliveries • Auxiliaries will be more easily retained, thus there will be staff in situ to supervise

ACSs • If health staff do not have proper facilities, such as drinking water, accommodation,

bathrooms and toilets, it is more difficult to attract them to the post • By improving the quality of the health posts, and, in particular, improving the

facilities for labour by providing labour beds and cots for new born babies, is attracting more women to give birth in improved, safer, and more hygienic surroundings in the health posts.

The hospital donations have greatly improved the hospital operating theatre so that caesarean sections can be done much more safely. The donation of an ecograph and the training of doctors in how to use ultrasound units has improved mother-baby safety.


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Training of health promoters (ACSs) The training of the ACSs has been highly relevant because: • It offers low-cost, appropriate technology training for the first aid role of the health

worker • It reinforces the ACSs’ central role in the community AIEPI programme • It has trained to promote women in development, and this respects and reinforces the

gender equity laws of Bolivia • The ACS is, apart from the curandero and partero – many of whom are dying out –

the only human resource in health in many very remote villages, and thus it is is a relevant poverty-alleviation strategy to train the ACS. This follows WHO poverty-reach principles for PHC programmes.

The position of women Women have been, and continue to be, marginalized. By trying to get women elected as ACSs and by training women in health and leadership themes via the Inti Pallay women’s groups, the project is trying to educate and liberate 50% of the population (women), and is attempting to help the person who is most vital for infant and child health – the mother. By targeting MMR and the subjugation of women, the project is highly relevant for the struggle to reach gender equity and reduce gender inequalities in health. Organisation of the peasants Due to a variety of factors, the peasant’s organisations have been weakened. By offering them training and education in topics that can promote democratic inclusion is highly relevant for the National Poverty Reduction strategy. 5.1 Relevance of the project organisation: the IMCC model Pros and cons of the IMCC model There are several advantages to the IMCC model: • The project serves as training ground for Danish medical students, many of whom

go into public health or who go into the Danish resource base of health consultants • It would undoubtedly be much more expensive, but probably much more effective,

to use professionals rather than volunteers students to run this type of project • The project allows Danish and Bolivians to work together. This promotes inter-

cultural understanding and is good for international relations. • The project allows Danish ideas of equity and freedom and respect for all persons to

be put into play in a highly segregated and still racially-divided society. There are however several disadvantages to the IMCC model: • The fact that IMCC uses medical students means that they can only commit to 14

months away from their studies. Two or three years minimum would be a much more effective time span for the volunteers to work in the project in Bolivia because they would learn Spanish properly, get to know the Bolivian staff and rural populations very well, and be able to ensure more continuity and less staff change to the project.


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• It is under normal circumstances very difficult to become fluent in Bolivian Spanish in the time that most students have to study Spanish (between 9 and 14 months before coming to Bolivia).

• It reportedly confuses some of the Bolivian personnel who have to work with a stream of changing Danish students, some of whom do not learn to speak very fluent or understandable Spanish, and some of whom have new ways of doing things.

• It is now possible for Danish medical and other students to do an M.PH in Denmark at the University of Copenhagen, and there are several Danida health sector support programmes employing Danish MPHs and providing the chance for training them. Therefore, one could argue, the IMCC model is not needed as a training groud any more.

• The model is relatively expensive and time-consuming: approximately 57% of the total project budget goes on training, language training, air travel, allowances and re-establishment allowances. (This sum also includes the cost for two external evaluations). This is some two and a half times bigger than the budget for construction, or that for training and countryside supervision visits, as shown in the following table of the budget: IMCC San Lucas PHC Project Total 5 year budget 2001-2006 in thousands of DKK Item Amount and % of total budget Amount % Investments 960,000 12.9 Running costs 950,000 12.8 Rural countryside visists / activities 975,000 13.2 Danish personnel, recruitment, administration in Denmark, evaluation

4,278,500 57.7

Information on the project in Denmark 250,000 3.4 Total (excluding unforeseen expenses) 7,413,500 100


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6. PROJECT SUSTAINABILITY This chapter analyses the main aspects of the three fundamental activities of the project: 1. Training; 2. Infrastructure and equipment investments; and 3. Research into Andean conceptions of health and illness.

The chapter also analyses the project’s institutional and implementation arrangements (section 4) from the point of view of sustainability. 6.1. Training, primary health care management, and human resources management The training component is the most important aspect of the transfer of technology. Training has included the following elements: • Training of ACSs • Training of auxiliary nurses • Training of hospital staff • Training of villagers through the Union • Training of village women through Inti Pallay • Training given to the organisation of the ACS (OCIACS- MSL) • Occasional training of adolescents in San Lucas through an NGO (CETA-ITALY,

financed by PASACH) in reproductive health and contraception. In as much as the project training for health staff, both salaried and unsalaried, has fallen within the national health guidelines within the national programmes AIEPI and SUMI, the training activities are sustainable in the sense that the current health staff are able to carry on the training and supervision since the training and supervision activities are theoretically included in the existing national PHC programmes. However, political in-fighting and frequent changes of hospital senior staff often mean that the hospital – which is the lynchpin of all health activities in the municipality of San Lucas – instead of effectively managing health activities, is frequently paralysed by politics and lack of senior management. When the management is being changed, or, when there is no senior management, the hospital activities are often delayed. For example, several important IMCC courses have been delayed due to crises in the hospital management and administration. The political system is probably - as in all other government sectors in Bolivia - the greatest threat to successful, cost-effective, and merit-based management and execution of public health functions in the province. Several staff in the hospital mentioned that if any member of staff works very hard, is enthusiastic, and tries to show initiative, he or she might be viewed as a threat to the status quo and probably sacked at the first opportunity! This kind of example – if true - is very depressing for the IMCC project staff, who have to work with the dispirited and unmotivated staff (if the reward for vigour and hard work is getting sacked, why bother to try!), and equally depressing for the Bolivian hospital staff who are embedded within this system. Although the government has created the Law of the Civil Service, and is supposed to be introducing an apolitical civil service mindset into all public institutions in Bolivia,


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the reality on the ground is that staff are hired and fired due to nepotism and political connections. The government has even made it legal for public health workers to pay a percentage of their salaries to political parties. When politics take precedence over proper management and administration of the hospital’s public health functions, then the efforts of projects like IMCC to build up staff competence and capacity can be wasted and become ultimately unsustainable. In addition to the problems of poor management and politicization of hospital staff posts, there is the problem of lack of coordination between the project and SEDES. On several occasions, despite having copies of the project monthly course and training plans, SEDES will suddenly announce its own plans that may conflict with the project’s. Several times this has resulted in delays to courses since hospital staff are requisitioned at short notice by SEDES. The solution to this fact of life would be for the project to ensure that each trainer has at least one stand in. Finally, on a positive note, the fact that the project trains volunteer ACSs who, despite not being paid and despite some 20% of them dropping out, still continue to work in their communities is a very positive sign. It is on this aspect that the project must continue to expend a great deal of energy: the ACSs who are encountering problems must not be abandoned. They need more support and more training, and a solution needs to be found to the non-replacement for those stopping work. It is also very important, and a sound strategy, for the project to concentrate on the auxiliary nurses manning the health post. The auxiliaries do not suffer very high staff turn over rates, are close to the ACSs on the ground, and are thus more likely to keep sustaining the vital supervision and back-up support work with the ACSs in the villages. A problem of sustainability concerns the fact that the ACSs are encountering difficulties in getting patients to pay the very minimum charges (1 BOB = USD 0.13) for first aid services. The result is that essential first aid kit supplies, such as bandages and Vaseline and oxigenated water are running out in the kits inspected by the evaluation team. This is happening despite the fact that the selling price is reportedly roughly the same as the purchase price of the materials for the first aid kits. The ACSs suggested that they receive a salary, but the team has not recommended this because it is not feasible and not governmemt policy. However, one possible solution might be to get a consultant - such as Dr Miguel Isolá of Sucre, who is a traditional medicine expert - to look at natural alternatives to things such as bandages and sterile liquids for cleaning wounds. Indeed, the ACSs have been taught to boil bandages after using them so that they can be reused. Perhaps some traditional remedies exist to go directly onto wounds to clean them25, to make the service more affordable to the villagers. A positive sign of sustainability of training for health promoters is the fact that some health training courses for ACSs are now conducted entirely by hospital staff without

25 For example, Cinchona calisaya Wed., in Spanish “quina morada”, is referred to as an antiseptic in Manuel de Lucca D. and Jaime Zalles A., Enciclopedia boliviana. Flora medicinal boliviana. Diccionario enciclopédico. Editoral Los Amigos del Libro. La Paz, 1992, p. 95. The bark of this tree is used by the famous Qallawaya healers against fever and as an antiseptic agent.


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IMCC intervention26. In 2004, the POA details the fact that the municipality will pay 70% of IMCC project costs for training courses. This is laid down in the convenio (agreement between HAM and IMCC), which establishes that by 2007, 100% of project training costs will be assumed by the HAM. Inti Pallay At the moment this activity is very much dependent on the project. The activities only started at the end of 2003, so it is too early to evaluate their sustainability or not. Training through the Centralía Peasant Training Centre In discussions with the leaders of the Centralía, illiteracy of the men and women who attend training and teaching session in the Peasant Union courses emerged as a key problem. The consultants (who are not hired by IMCC and who are therefore not answerable to IMCC quality control checks) reportedly do not appear to use didactic methods which are appropriate or user friendly for illiterate / semi literate villagers. Unless IMCC encourages more practical teaching methods, it is likely that the knowledge imparted in the training sessions will not be sustainable in the long run. It will be forgotten, or the message will be confused since no documents are handed over for future reference. However, the strategy of training villagers in leadership and public information about rights, laws, new strategies, and responsibilities (with a focus on health) will likely lead to an improved organisational capacity of the rural population concerning prevention of illness and improving health, as long as the quality of the training is good and designed for the audience of mainly illiterate Quechua speakers, and as long as the consultants change their working practices and leave a much more tangible record of the training. The ACSs’ first aid kits The problem of non payment for first aid remedies and the fact that the ACSs interviewed encounter probelms in replenishing their first aid kits because patients either do not pay them or do not pay them enough to meet the costs, is to be anlaysed by IMCC in the period April to October 2004 when they plan to visit all the health posts. As mentioned elsewhere in this report, it would be most important to study the posssibilities of using appropriate technology and local knowledge: i.e., the use of plant and tree products that could be used to replace some of the shop-bought supplies. It is recommended that the project consults with local curanderos about this, and that they also confer with acknowledged traditional medicine experts like Dr Isolá. 6.2. Infrastructure and equipment investment One new health post has been constructed and six others have been repaired. Given that the village women interviewed perceive the health post as the most important item in the health service of the community, the impact of the health post programme cannot be over emphasized. Without the health posts the villagers have no health infrastructure near their communities. It seems probable that the increase in health post births (“partos institucionales”) is due in part to the new construction work and the upgrading of existing facilities.

26 E.g. the course in Palacio Tambo, 21-22 September 2003. Reference: IMCC San Lucas, Informe semestral, segundo semestre, 2003, p. 11.


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Showers / toilets / sanitary drainage Although in some cases the quality of construction of showers and toilet facilities has been below standard, IMCC San Lucas has informed the evaluation team that repairs are being made to put right poor construction work. In one or two health posts, water supply systems were constructed before ascertaining the presence of an adequate supply of suitable water. A lesson has been learned from this type of poor planning, and IMCC and the municipality have taken steps to redress the problems (in both cases a water supply has been secured or is being secured (April 2004) so that the two schemes are no longer white elephants). The evaluation team have recommended that as soon as possible the project - working through DILOS – work out a preventive maintenance strategy, with a budget in the POA for this year and for each year in the future. A lesson learned from several Danida evaluations27 is that if preventive maintenance is not included in health projects, then the infrastructure does not last. Hospital infrastructure and equipment improvements The hospital expansions and operating theatre work has been very important. Surgical procedures can now be carried out in a safer environment and caesarean sections, if necessary, can be done, thus improving the chances of survival of women experiencing difficult labour. Equipment donations As long as the municipality ensures that the POA includes funds for regular maintenance (including stocking spare parts) for health equipment donations, the equipment should be sustainable for as long as it can be reasonably expected to last, or as long as its technological level remains up to date. Drinking water supply schemes To date one village drinking water scheme has been constructed, and another is currently under construction. As with the building and equipment donations, as long as the municipality ensures that the POA includes funds for regular maintenance (including stocking spare parts), the hardware (pipes and tanks) should be sustainable. 6.3. Research and baseline work The research into illness and health conceptions and the baseline surveys cannot realistically be supposed to be sustainable activities. However, whilst the baseline serves a specific purpose for measuring before and after impact, the medical-anthropological action research is important for promoting interculturality in the biomedical health services. When IMCC stops funding its project it is unlikely, however, that SEDES will take on such work in San Lucas or in similar areas. It is important that the project get a small pilot intercultural mini-project to function. By hiring a medical anthropologist consultant, on a needs basis, to design intercultural modules, the health staff can be trained in intercultural ideas. This could increase the possibility of sustainability of the intercultural component. In the future, it would not be unreasonable to imagine the following intercultural health services being offered in the hospital:

27 See e.g, Evaluation of the Rural Development Fund, Kenya. Danida. 1997.


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• Quechua traditional birth with matés, the husband present, squatting position allowed, and presentation of the placenta to the parents for ritual disposal

• Presence of a traditional healer once a week in the hospital selling and advising on traditional plant medicines to patients and staff alike

• Curanderos used in the hospital for susto and other Andean nosologies • Parteros being trained and used inside the hospital and health posts if requested by

women who want to give birth. 6.4. Institutional aspects and implementation arrangements DILOS IMCC project budget and activities are discussed and approved in the DILOS (in which the vigilance committee is also represented). DILOS (municipal health committee) was created by the law of SUMI and legally constituted in the second half of 2003. DILOS will be sustained as long as its existence is required under the above-mentioned law. To date there have been seven meetings of DILOS, which is the highest health authority in the municipality. IMCC has been able, with DILOS’ influence, to push through its investments in infrastructure. Additionally, DILOS has been able to obtain the HAM’s compliance and fulfilment of its budgetary counterpart obligations under the POA. EPC Equipo de Planificación y Capacitaciones / Planning and Training Team IMCC staff believe that the “EPC is the forum on which the sustainability of the project will depend. It is the forum that will need to continue, along with DILOS in the municipality, after the project stops. The main purpose of EPC is to to allow coordination and interchange of experiences between IMCC and hospital staff. Courses are no longer planned in EPC. The EPC is an interdisciplinary team composed of health personnel and representatives of the organisations in San Lucas. Current members are: • The chief doctor • The head of nursing • The ward doctor • The hospital’s institutional strengthening adviser (a doctor, who is paid by ADRA) • 2 auxiliary nurses • 1 ACS (represents all the ACSs) • 1 member of Esperanza • IMCC. The IMCC out-group volunteers believe that the “EPC is the most important work forum of the project”, because it is the place where the project is designed and defined by the EPC team members. In late 2002 or early 2003 the EPC began to invite NGO staff (from ADRA and Esperanza) to participate in project planning meetings. This innovation has been successful, and bodes well for future institutional collaboration between the three “health NGOs” in San Lucas. The EPC is supposed to meet each month, but this does not always happen if the chief hospital staff are being changed28. In the first half of 2003, there was a serious delay in

28 IMCC. “Informe semestral”. Julio 2003, p. 8.


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the planning of the project because the chief doctor who changed was not replaced for a couple of months. Recommendation: For the EPC to work, there must be a system of delegation: if there is no chief doctor in a given month, then the EPC must meet anyway with a stand-in with authority to sanction the courses. It is recommended therefore that IMCC request SEDES to delegate another two other members of the hospital staff as soon as possible to be used whenever there is a lack of a chief doctor. The project intends the EPC to continue its work after IMCC withdraws from the project. However, the hospital and IMCC staff pointed to a number of problems in the EPC, mainly the problem of inability to coordinate activities properly. The EPC plans the training for: • Health staff (auxiliaries, nurses, doctors, and ACSs) • Administering the auxiliary nurse study grants. A Manual de Operaciones (Procedures Manual) for the EPC has recently been made. OCIACS: The organisation of the ACS A problem noted in chapter 4 is the weakness of the O.C.I.ACS-MSL, the Integrated Peasant Organisation of the ACS of San Lucas Municipality. This organisation does not yet have its juridical personality. It is an organisation set up with encouragement by the project and thus liable to fail when the project withdraws. This report recommends extensive capacity strengthening for the O.C.I.ACS-MSL, but a more important issue is how to tackle the fall-out of ACSs who are not being replaced and whose absence is not even being registered by a peasant base organisation that is not dynamic and that lacks resources to do much work29. The villages, or their leaders at least, seem indifferent (or perhaps they are not aware due to internal dissension, lack of monitoring systems, or lack of communication), to the fact that some of the ACSs are stopping work and even abandoning the area altogether. The project needs to study and address these issues in a participatory way, together with the affected communities. The IMCC out-group is aware that the OCIACS is very weak and dependent on IMCC. IMCC pays the participants (an admittedly very small sum of) money – a sort of standing allowance - to come to the meetings. Paying people money to come to meetings is not sustainable and creates dependency. On the positive side, the participants did however arrange for their own transport (they persuaded the NGO Esperanza to pay for their transportation).

29 The management of the Centralía informed the evaluation team that the leadership of the ayllus (the caciques and corregidores) is allegedly actively discouraging village members from paying their union dues, with the result that 50% and more of the membership fees have been lost in individual communities.


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OCIACS has made its byelaws, made in the first general assembly (August 2003). If they obtain their juridical personality, the OCIACS will be included in the POA and possibly get money from the town council, thus increasing their chances of sustainability. IMCC is aware that OCIACS needs to write more detailed guidelines for its future work. In 2004 IMCC willl try and make OCIACS responsible for administering their own accounts. IMCC will train an OCIACS member to do simple accounting of the money that IMCC give them to fund meetings and other activities. The social worker is responsible for OCIACS, and participates in monthly meetings and helps the steering committee to prepare presentations to institutions such as the Peasant Union30. IMCC wants in 2004 to get OCIACS to participate in the municipal health meetings, i.e., to be part of the members of DILOS, in order to institutionally anchor OCIACS in the municipal set-up. This is perhaps the most creative idea to give the OCIACS a measure of sustainability. The IMCC out-group has tried to promote the idea that the OCAICS should be responsible for stocking and selling the replacement remedies for the first aid kits. Recommendation: Althought the OCIACS steering committee reportedly now meets every month, the funds for travel and food, as mentioned above, are currently paid by IMCC. As a priority the OCIACS must get its juridical personality processed as soon as possible and the HAM must start including a fund for running costs for the OCIACS in its POA in 2004. The OCIACS members will need continual support for a year or two to build them up and train them in running an organisation that is supposed to: • Effectively monitor and evaluate the status of ACS members • Meet and discuss strategy and make it known to the municipality and other

stakeholders such as IMCC through DILOS • Sell and keep a sustainable stock of items for restocking first aid kits. Sustainability of the IMCC model Inasmuch as Danida is committed to supporting Bolivia in the long term, and as long as IMCC respects Danida poverty-reduction objectives, it is likely that the model of sending out IMCC volunteers will continue sustainably. Pros and cons of the IMCC model There are several advantages and disadvantages to the IMCC model. These are discussed in chapter 5, Relevance.

30 Source of information: IMCC out-group and Fagbrev 16, January 2004, p. 32.


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7. CONCLUSIONS AND RECOMMENDATIONS For reasons of space, most of the conclusions which have led to the recommendations are not repeated here, since the conclusions are found in the earlier chapters of the report and in the Spanish Executive Summary. This chapter in the main aims to present the recommendations in one place, grouped usefully together for use in the future as a project monitoring tool or check list.

Recommendation: In view of the considerable and tangible achievements of the IMCC project in the first three years, it is recommended that the project continue for at least an additional five-year phase. However, there are a number of problems, mainly focused on cost-effectiveness, implementation and sustainability. It is a pity that the IMCC volunteers only come for 12 months of work (five weeks are for holidays). In this time they can more or less become properly acquainted with the Spanish language (some of the volunteers do not speak good Spanish at all and this creates problems of communication in Bolivia) and the Bolivian staff and people they are to work with, but then they return home just as they have settled into the project. It is quite wasteful of project resources to train so many volunteers who come for a relatively short time, and it adds a strain of the proper implementation of the project since a lot of time is spent on acquainting the new volunteers with the work before the “old” volunteers return to Denmark. On the other hand, the training of so many IMCC volunteers does have a positive trade off, because it provides a resource base for the Danish development personnel. The implementation problems mainly concern the working of the EPC and the hospital collaboration with the IMCC volunteers. A few practical recommendations have been made to try and solve the problems of delay in the EPC. The implementation and cost-effectiveness problems also concern the “flat” structure of IMCC. Whilst it is a very democratic model, there are a number of problems that could be avoided if alternative arrangements were introduced. One model to improve the effectiveness of project implementation and reduce administration of costs of training the volunteer students could be to have a small, permanent, professional staff in place in San Lucas (at least one of whom would be a permanent, international project manager), helped by one or two medical student volunteers who would come out to Bolivia for a minimum of two years. This model would save some money. It would be quite feasible to finance a small staff of professionals from some of the money saved by reducing the number of volunteers and the amount of air flights / language courses in Spain or Guatemala and re-establishment funds. Perhaps equally important as the modest improvements in cost-effectiveness by using this model, much more continuity in the project implementation and relationships with counterpart Bolivian staff would be achieved. Another model would be to dispense with medical or other types of students altogether, and convert the project into a purely professional enterprise, staffed by one long-term international doctor / public health specialist, one international medical anthropologist, and one or two Bolivian community development and institutional strengthening


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specialists. It would be possible to finance over five years this type of staff cadre and keep within the approximately four million DKK or so currently spent on personnel. Recommendation: It is recommended that on cost-benefit and efficiency of implementation grounds that IMCC consider seriously these proposed changes. If this proposal to professionalize IMCC were accepted, IMCC would be able to advertise for its professional staff in the normal way and thus be assured of getting suitably qualified professionals. An IMCC project staffed by professionals together with one or two long-term Danish medical students or MPH31 or medical anthropology students would not lose its status as “an IMCC project”. The project would still “belong” to IMCC, but IMCC would be able to work more efficiently. The sustainability problems concern the ACSs, their medical first aid kits, and the infrastructure investments. As regards sustainability of the ACSs, there are several serious problems, not least the fact that some 20% and possibly a larger percentage have already dropped out mainly for economic reasons or because of the need to migrate temporarily or permanently elsewhere. Only a very few of the ACS have been replaced, betraying a lack of urgency (or a lack of organisation) on the part of the village authorities). The organisation of the ACS, the OCIACS-MSL, is very weak and does not really function yet. A first step will be for the OCIACS-MSL to obtain its juridical personality and then to receive considerable support from the project. It will be also be necessary to define what its role and functions are to be. Meetings between the communities and the health and municipal authorities will need to discuss this and come up with a set of guidelines for the OCIACS-MSL. In the following sections, the recommendations are grouped according to the three main project activities: 1. Training and improving PHC human resources management; 2. Infrastructure investments and equipment donations 3. Research and development. The important questions of monitoring, sustainability, gender equity, and poverty reach of the project are considered as cross-cutting themes and are not separated out, but are subsumed under these three main headings. 7.1 Training and strengthening of PHC management and health resources management Recommendation: It is recommended that each month during the EPC the agenda include information on what training courses are being offered by IMCC (the evaluation team has been reported that this practice is happening already). It is also recommended that the director of the hospital draw up a human resources plan for training the personnel and that this be presented to IMCC during the EPC monthly meetings.

31 MPH and “folkesundhedsvidenskabsstuderende” students will soon work on the project in Bolivia.


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Recommendation: It is recommended that dates for courses be planned in close coordination. Recommendation: It is recommended that SEDES and IMCC set up a sure channel for communication and exchange of activity plans to avoid planning problems for training in the future. Recommendation: It is recommended that the hospital ensure that SEDES receive activity plans at the latest on the 24th of each month, and that SEDES take account of and respect the activities. Recommendation: It is recommended that IMCC request HAM and SEDES to stabilize the health staff in the hospital and the health posts, by employing people on merit and not according to political affiliation or other reasons. Recommendation: In view of the fact that the “nuevo modelo de servicios de salud prenatal” (“new model of pre-natal health care”), is coming into effect, and under which terms ACSs and male / female midwives will be trained in clean birth techniques, it is recommended that the ACS are trained by auxiliary and hospital health staff with IMCC funds as soon as possible. It is recommended that the hospital and IMCC inform SEDES of the need for training the ACSs on subjects related to labour, especially those ACSs that work in the valley areas. Recommendation: Regarding drop-out rates of the ACSs, neither the hospital nor IMCC can assume responsibility for informing SEDES if an ACS stops working. It is the task of the union, and of the community leaders, to warn the health post auxiliary under which catchment area the ACS came under. The union also ought to elect a new ACS as replacement. Possibly this would be a duty of the O.C.I.ACS-MSL. It is recommended therefore that IMCC, each time they go out into the rural area, always revise with the auxiliary nurses the list of ACSs to do a very simple check of whether the ACSs are still active, and to assist in identifying new ACSs. It is, however, not the responsibility of IMCC either to identify or to select replacements. This is the responsibility of the community organisations with the auxiliary health staff. At this juncture IMCC should also promote the selection of women as replacement ACSs in order to redress the gender balance in the project. Recommendation: In order to inspire and provide ACSs with more motivation to stay in their jobs, and in view of the fact that it is not feasible to recommend that they receive a salary, some of the following steps could be taken: • Accreditation signed by SEDES, Red Camargo and the Hospital that the ACS can

work in the health sector. All the ACSs who have so far been trained (March 2004) reportedly have accreditation and an ID card. New ACSs will need this accreditation after being trained

• Processing of the juridical personality of the organisation representing the ACSs (the O.C.I.ACS-MSL).

Recommendation: Regarding another way to inspire ACSs to stay in the job, and to offer them the hope of becoming an auxiliary nurse one day, it is recommended that IMCC finance one or two grants32 each year for those ACSs with low grade educational

32 Approximate estimated cost is between 800 BOB and 1600 BOB per person pr annum.


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qualifications and for those ACSs who say they want to continue their studies. The ACSs can study in CEMA, about one and a half hours from San Lucas. Recommendation: It is recommended that the problems causing the ACSs to give up their work as health promoters and their economic problems be analysed in greater depth in a workshop with all health staff in the period April 2004 to October 2004. During this period IMCC is planning to visit all the health posts. Recommendation: It is recommended that the problem of non-replacement of material in the ACSs’ first aid kits be analysed in greater depth during the country visits planned by IMCC and the health staff in the period April 2004 to October 2004. Recommendation: It is recommended that the project offer both traditional midwives and ACSs training courses on hygienic birth, and that they receive certification from SEDES and Red Camargo in the community when they complete their training. Recommendation: SEDES should consider the possibility of the Hospital of San Lucas and IMCC offering ACSs training in recognition and handling of medicines under medical supervision in the health posts in emergencies (when medical or auxiliary staff are absent). Recommendation: It is recommended to use hospital trainers who speak and write Quechua fluently so that ACSs can understand the training they receive. Recommendation: Since some ACSs are already prescribing and handling biomedicines, it would be advisable that they receive training in the dangers of incorrectly prescribing them. It is recommended that by means of this report SEDES and Red Camargo consider this problem and that they inform the hospital and IMCC of their opinion and recommendations as soon as possible. Recommendation: It is recommended that the project analyse ways to improve the coordination in the rural areas, between the health post / medical centre and the ACSs, possibly by buying some radios, or perhaps by introducing better M&E systems and systems for informing about planned training activities. Recommendation: It is recommended that the project insist on new women ACSs being elected in order to re-establish gender equity in the project and to replace those ACSs who have stopped working, or have died. It will be necessary - by means of IMCC’s work with Inti Pallay - to analyse what type of woman should be elected, and how. The project should include also female health promoters33 who are already working for free but who were not chosen by the peasant bases, which are male dominated. Recommendation: As regards improving the sustainability and quality of the training given at the Peasant Union Centralía training school, and in order to make the consultants more accountable to the project’s quality goals, it is recommended that: • The consultants34 who already have done training courses write short reports on

what they did and that they present them as soon as possible to IMCC to be handed

33 An example is in the community of Pulquina, where Doña Eulogia has attended IMCC courses and is now working in the village and is by all accounts an important health resource in the community. 34 Jacob Paredes; Fernando Albarado; Trifón Ramón; y Lucio Chino.


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over to the Training Centre. The Centre ought to file reports and other course material to make a small didactic and bibliographic resource;

• In the future consultants ought to be furnished with TOR and ought to sign contracts specifying the need to produce a written memoir of the course content and a brief report about what they taught;

• Gender consultants ought to be hired so as not to forget the gender dimension and the problems of peasant women in the project area;

• IMCC ought to oblige the Centre to file away in a proper way the course memoirs; • A member of IMCC ought to be present at the inauguration or closing of each

training course in the Centre. This would enable IMCC to describe in its M&E reports (Semester Reports) what courses and topics have been taught in each year.

• Consultants skilled in teaching illiterate people should be hired. The consultants should use mnemonic methods and media that are appropriate.

Recommendation: Since illiteracy is holding women back in the project, and since women mention illiteracy as a problem for them, it is recommended that IMCC, by means of the medium of the courses for Inti Pallay women’s group, identify solidarity organisations such as NGOs that might be able to offer long term high quality literacy classes for at least two years for Inti Pallay women group members. Recommendation: In order to tackle illiteracy, and to promote synergies in health education between the project and the school system, it is recommended that IMCC in a new phase work with the teachers within the frame of reference of the EIB. It would be important for the auxiliary nurses and ACSs to give talks in the schools on contraception and prevention of illness. Furthermore, IMCC could work with the teachers and pupils in identifying, using PRA methods (and by means of the forum of the school board), problems that threaten health in the community: problems that IMCC with HAM might be able to solve with the full participation of the community, teachers and pupils. Recommendation: Even though the representatives of the ayllus have reportedly rejected advances from the project to work with them, it is recommended that IMCC continue to invite representatives of the four ayllus in San Lucas to meet with them. But it is recommended that the money for activities with them – if not used - could be used to finance grants for ACSs, or midwives, or to finance training and literacy classes for women and men in the Training Centre of the Centralía or through the Inti Pallay women’s groups. Recommendation: As regards the M&E of IMCC project activities, it is recommended that serious problems such as the occasional lack of coordination between IMCC and SEDES be set out at the front of the semester reports in the form of a brief executive summary. This would provoke discussion and, it is hoped, the rapid resolution of the problems threatening the smooth functioning and sustainability of the project. 7.2 Infrastructure and equipment donations Recommendation: It is recommended that HAM with help from the project, and together with the other relevant actors (hospital, auxiliary nurses, ACSs, community leaders), as soon as possible set up a preventive maintenance system. This is a best practice and requirement of Danida for this type of donation. The counterpart funds for O&M should be included in the annual POAs. Recommendation: It is recommended that SEDES be informed via this report about the problem of extreme isolation of the rural population of the valleys (about 10,000


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thousand persons) and that this isolation is a health risk. It would be useful for the project to know of SEDES is considering creating one or two staff items for possible new health posts in the area of the remote valleys. Recommendation: IMCC and HAM ought to ensure by means of supervision of construction works and supervision of personnel that the engineers of the HAM be of an acceptable calibre to guarantee the good quality of the construction works financed by IMCC. At the same time, HAM should ensure adequate supervision of the construction to avoid quality problems. Recommendation: It is recommended that IMCC increase the annual budget for drinking water systems, possibly with the construction of some latrines in key places (schools, health posts) or simple sanitary systems. It is also recommended that IMCC continue to offer training courses (utilizing the services of the ACSs) on health and disease prevention topics that could include participatory diagnostics on the situation relating to health, drinking water, and sanitary services in each community. Recommendation: In order to reduce delays in construction work, it is recommended that the project and hospital require in writing of the HAM that they disburse monies for project activities in a timely fashion and that they keep the counterpart funds in POA for each eventuality. 7.3 Research and baselines studies Recommendation: It is recommended that hospital health staff and auxiliaries hold meetings to identify problems related to the provision of intercultural and integrated health services. The end result of these meetings would be a prioritization of problems and the drawing up of a health staff-training project to solve the problems. A first stage would be to study the Anthropological Study written in 2003. A practical “hands on” methodology is foreseen for this task, by means of which doctors and auxiliary nurses would be observed whilst they attend patients in the rural areas. Recommendation: It is recommended that in the future for the repetition of the baseline study that a consulting company with a team of about 10 surveyors be hired, so that they could do the entire study in four weeks, as follows: • Four days for training the five teams of surveyors and travel to the survey place; • 10 days for the pilot test and execution of the survey including journey time and

logistics, and • Six days for data analysis and generation of tables, and • Eight days to write a short report. For the current phase, and due to the current budget limitation for the baseline, extra money will need to found from another research or training category. For the recommended new phase, the budget for the baseline study would have to be significantly increased to cover the use of more consultants, but it would be worth spending more money and doing the study quickly and thus free up the social worker who is not actually qualified to do baseline survey work. Recommendation: Due to internal disagreements in the original IMCC out-group, some vital questions were omitted from the original baseline survey design. The current out-group members have now written these questions in draft. It is therefore recommended to


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contract one or two consultants to carry out the missing questions on maternal and reproductive health in the baseline survey, under IMCC’s supervision, and to use the same methodology and universe that were used in the original study (random sampling). When the baseline is repeated in 2005, it will therefore be possible to demonstrate the impact of the project in the important area of KAP of birth and pregnancy. Recommendation: In order to promote intercultural medicine and improved understanding of Andean medicine among the biomedical health staff, it is recommended that a social anthropologist from the Andean area, or a qualified person who understands the reality in the Andes concerning sickness and health, assist the IMCC and hospital personnel to design brochures and educational materials using sections of the anthropological report. These brochures and educational materials could be utilized in training courses on health and illness concepts and about health seeking behaviour of the rural population. Recommendation: Concerning the promotion in the project of appropriate technology in the form of traditional plant medicine (which village women and ACSs have requested), it is recommended that health staff and IMCC volunteers study other primary health care projects that have a traditional medicine component, in order to see what possibilities exist to include this sub-component in the project. A project that the ACS, auxiliary nurses, and other medical personnel and village women could visit is run by the Danish NGO Diálogos, under the management of Dr. Miguel Isolá. Recommendation: Concerning the M&E of intercultural concepts among biomedical health staff, it is recommended to start giving short written questionnaires to health staff about their attitudes to the health and illness beliefs and behaviour of the rural population, and to relate these questions to the type of health services they provide. This information would provide very useful data for the future impact monitoring. A consultant medical anthropologist (see recommendation below) could do this. The project does not have the internal capacity to use the anthropology report findings and to turn them into a series of impactive intercultural teaching modules, and to introduce changes in hospital clinical practice such as introducing culturally acceptable labour and birth in the hospital and health posts. Therefore: Recommendation: It is recommended to hire a (preferably35) female medical anthropologist consultant – if possible, one who has specialised in nursing, PHC, and midwifery questions - as soon as possible to use the anthropology report findings to make intercultural teaching modules, and to help introduce culturally acceptable changes in hospital clinical practice. 7.4 Institutional, implementation, and monitoring aspects Recommendation: For the EPC to work, there must be a system of delegation: if there is no chief doctor in a given month, then the EPC must meet anyway with a stand-in with authority to plan the courses.

35 It is preferable to hire a female because female medical anthropologists traditionally specialize in maternal and child health questions such as labour, birth, nursing, etc.


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It is recommended therefore that IMCC request SEDES to delegate another two other members of the hospital staff as soon as possible to be used whenever there is a lack of a chief doctor. Recommendation: It is recommended that IMCC ask SEDES to approve as soon as possible another member of the hospital staff, perhaps the head nurse, to have an executive function on the EPC so that project courses can go ahead as scheduled. Recommendation: Although the OCIACS steering committee reportedly now meets every month, the funds for travel and food, as mentioned above, are currently paid by IMCC. As a priority the OCIACS must get its juridical personality processed as soon as possible and the HAM must start including a fund for running costs for the OCIACS in its POA in 2004. Recommendation: It is recommended that IMCC carry out institutional strengthening of the OCIACS-MSL, perhaps by using trainers from ACLO or IPTK. As regards the cost-effectiveness and pros and cons of the IMCC model of project implementation, an analysis, conclusions and recommendations have been made in chapter 4, and at the beginning of this chapter.


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Annexes


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ANNEX 1. ToR: midtvejsevaluering af IMCC San Lucas 1. Introduktion IMCC San Lucas er et primært sundhedsprojekt i San Lucas kommune, Chuquisaca, Bolivia, som er 100% finansieret af Danida. Projektets overordnede formål er at forbedre sundheden for landbefolkningen, specielt for kvinder og børn under fem år. Projektets delformål er at: 1. styrke målgruppens, dvs landbefolkningen, viden om og adfærd i forhold til sygdom

og sundhed 2. forbedre og udbygge kommmunes sundhedstilbud 3. styrke organisering af landbefolkningen på sundhedsområdet, samt øge forståelse for

landbefolkningens sygdomsopfattelse med henblik på et forbedret samarbejde mellem landsbyernes sundhedsfrivillige (ACSere), kommune, hospitalet og andre institutioner.

IMCCs primære aktiviteter kan inddeles i 3 søjler: • Uddannelse af ACSere, sygehjælpere og hospitalspersonale. • Investeringer i sundhedsinfrastruktur. • Undersøgelser af landbefolkningens sundhedsopfattelse og sundhedsrelaterede

handlingsmønstre.

IMCC arbejder således på at at styrke det eksisterende sundhedssystem i landdistrikterne ved at indgå i et tæt samarbejde med det lokale hospital på at uddanne sundhedspersonalet til at kunne varetage landbefolkningens behov for basale sundhedsydelser. Dette foregår på alle niveauer, fra læger til sygehjælpere, men med særlig vægt på det yderste led af kæden, ACSerne.

For at forbedre kommunens sundhedstilbud afsætter IMCC årligt et større beløb til investeringer i sundhedsinfrastruktur. Investeringerne udføres i samarbejde med kommunen og fordeles udfra et princip om, at 80% af pengene skal gå til projekter udenfor San Lucas by. IMCC har i 2002 gennemført et KAP (knowledge, attitudes and pratices) studie om landbefolkningens holdning til sundhed samt i 2003 en antropologisk undersøgelse om baggrunden for landbefolkningens holdninger. IMCC har iværksat disse undersøgelser for at øge forståelsen for landbefolkningen blandt hospitalspersonalet og for bedre at kunne tilrettelægge aktiviteter i overensstemmelse med landbefolkningens tankegang og verdensbillede. KAP studiet skal desuden fungere som baseline ift. slutevalueringen af projektet. Ledelsen af projektet varetages af 3-4 udsendte danskere og en lokalt ansat socialarbejder i samarbejde med kommende og tidligere udsendte i Danmark. Udsendelsesperioden er 14 måneder. De udsendte er medicinstuderende og folkesundhedsvidenskabsstuderende samt deres eventuelle partnere, der kan have en anden faglig baggrund.


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Projektet startede i 2001 og har finansiering frem til december 2005. I alt har Danida bevilliget 7.8 mill. dkr til projektet. 2. Målsætning for evalueringen Overordnet ønskes belysning af: 1. Mulighederne for målopnåelse med de nuværende strategier. 2. Projektets relevans, både ift. målgruppen og lokale samarbejdspartnere 3. Projektets bæredygtighed – særlig ift. uddannelse af ASC’ere Evalueringen skal føre til anbefalinger om, hvorvidt der bør søges om projektforlængelse, og om hvilke strategier, projektaktiviteter og eventuelle nye projektaktiviteter der i så fald bør følges under hensyntagen til Danidas NGO-strategier. Desuden ønskes overordnede anbefalinger om strategitilpasninger i indeværende projektperiode. Se desuden bilag 1 for uddybende spørgsmål. 3. Resultat Resultatet af evalueringen skal foreligge som en skriftlig rapport senest 4 uger efter at evalueringsholdet har forladt San Lucas. Rapporten skal afleveres i 3 eksemplar samt elektronisk i WORD 2000 format. Rapporten skal være på dansk med et kort resume på spansk. Inden evalueringsholdet forlader San Lucas skal der afholdes en debriefing med IMCC og de lokale aktører, som har deltaget i evaueringen, samt afleveres et kortfattet, skriftligt resume på dansk. Den danske konsulent skal umiddelbart efter sin hjemkomst holde et oplæg for San Lucas hjemmegruppen. 4. Metodologi Evalueringen skal dels baseres på en gennemgang af det på projektet tilgængelige, skriftlige materiale herunder halvårsrapporter til sundhedsministeriet på departementsniveau (SEDES, på spansk) og de halvårlige projektvisionsmøder (fra fagbreve, på dansk), dels på interviews med nøglepersoner og gruppeinterviews. Hovedvægten af arbejdet skal ligge i de omtalte interviews. Da det er af stor betydning for IMCC at opnå en øget viden om holdningen til IMCCs aktiviter og resultater fra samtlige niveauer i sundhedssystemet, fra SEDES til målgruppen, skal der som et minimum gennemføres interviews med flg.: • Hospitalet i San Lucas (administrationen og sundhedspersonalet) • Sygehjælperne på udvalgte sundhedsposter • Udvalgte ACSere • De udsendte IMCCere • SEDES • O.C.I.ACS-MSL (foreningen af kommunens ACSere) • Kommunen


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• Andre NGOer i San Lucas kommune, der arbejder med sundhed (Esperanza Bolivia og ADRA)

• Red Camago (distriktshospital) • Centraliet (bondefagforeningen) • Ayllus (traditionel organisering af bønder) • Gruppeinterviews i udvalgte landsbyer i målområdet

Hovedvægten af samtalerne skal være med hospitalet, sygehjælperne og enkelte ACSere, da IMCC i det daglige hovedsageligt arbejder med disse aktører. 5. Kronogram Evalueringen skal foretages i marts/april måned 2004 og have en varighed af 2-3 uger. 6. Krav til evalueringsholdet Holdet skal være uafhængigt af IMCC i sine anbefalinger og konklusioner, være i stand til at komme med konstruktiv kritik og klart kunne formulere projektets styrker og svagheder. Holdet skal ledes af en dansk konsulent, som har det endelige ansvar for rapporten. Den danske konsulent bistås af 1-2 bolivianske konsulenter. Eventuelt tilknyttes der en tidligere udsendt IMCCer, hvis opgave bliver at stå for de praktiske aspekter af evalueringen. Den tidligere udsendte IMCC’er vil desuden stå til disposition for de gruppediskussioner og spørgsmål, der vil melde sig undervejs i dataindsamlingsfasen og under bearbejdningen. Samlet bør holdet have et dybtgående kendskab til følgende aspekter: • Danidas politik og udviklingsstrategier, navnlig Danidas NGO strategier. • Det bolivianske sundhedssystems opbygning, målsætninger og strategier. • Primær sundhed i et udviklingsland, herunder WHO's Primary Health Care strategi. • Den politiske virkelighed i Bolivia. • Opbygning, planlægning og udførelse af rurale udviklingsprojekter, navnligt

indenfor sundhedsområdet. 7. IMCCs rolle De udsendte IMCCere på projektet vil ikke indgå som en del af evalueringsholdet, men vil være behjælpelige med at etablere kontakter og aftaler samt være til rådighed for interviews og spørgsmål fra evalueringsholdets side.


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Annex 2 List of Persons Met / Lista de Personas Entrevistadas Institution / Institución

Persons met & Topics Covered / Persona (s) encontradas y Tema(s) Abarcado(s). Cargo / Position

Date / Fecha

SEDES Entrevista: Dr. Carina Ortiga. Responsable AIEPI ¿? 12/03/04 SEDES Entrevista: Dr. José Luis Hurtado ¿? 12/03/04 Hospital de San Lucas

Mini taller de evaluación, día 1; problemas, logros, y soluciones a los problemas identificados por los presentes:

13/03/04

” Máxima Torres Calavi, Enfermera Planta Hospital ” ” Dr. Juan Antonio Cartagena C. ” ” Dr. Eduardo Méndez Ribera ” ” Dr. Nathaniel Perez. M. ” ” José A. Betanzos, Técnico Vectores ” ” Janeth Flores Cruz, Aux. Administrativa ” ” Elioamino Ochoa Garcia, Aux. Enf. Social Educadora ” ” Alejandre Cuellar Torrez, Enf. Aux. ” ” Sulma Martinez S. , Enferemera Jefa Municipio ” ” Dr. Juan José, Jefe Médico del Hospital ” Hospital / IMCC San Lucas

El personal del hospital del 13/03/04 más los voluntarios del IMCC: Maja Maraldo, Dr. Jacob Maraldo, Trine Christensen. Mini taller de evaluación, día 2: Resolución de problemas identificados por los participantes del mini taller más soluciones a problemas y recomendaciones hechas por los mismos

14/03/04

Puesto Sanitario, Palacio Tambo

Mini taller de evaluación; problemas, logros, y soluciones a problemas identificados por los auxiliares

15/03/04

” Don Walther ? Auxiliar de Pututaca ” ” Don Justo ? Auxiliar de Chini Mayu ” ” Don Andrés ? Auxiliar de Acchila ” ” Dr. John ? Médico del Puesto Sanitario, Palacio Tambo ” ” Don Adán Palacios, Auxiliar de Canchas Blancas ” ” Doña Esther Cortés, Auxiliar de Payacota del Carmen ” ” Don Pastor Arias, Auxiliar del Puesto Sanitario de Ocurrí ” Honorable Alcaldía de la Municipalidad de San Lucas

Reunión sobre el proyecto IMCC: Percepciones de los objetivos, logros, estrategia, relevancia, y sostenibilidad del proyecto, más consideraciones sobre el rol de la Alcaldía con respecto al proyecto.

16/03/04

” Sra. Graciela Malverde: Secretaria ” ” Sr. Victor Carlos, Consejal ” ” Sra. Virgilia Ramos, Consejal ” Reunión con los voluntarios de IMCC, San Lucas

Objetivo de la reunión: Revisión de la matriz del marco lógico del documento del proyecto.

16/03/04

Puesto Sanitario, Buena Vista

Reunión con 22 mujeres y 18 hombres de la comunidad; seguido por un grupo focal con las 22 mujeres sobre percepciones del trabajo de los auxiliares, de los ACSs,

17/03/04

“ Sra. Eva Cruz, Secretaria de Haciendas de la comunidad (y comunitaria), y promotora de Inti Pallay

”

“ Sr. Mauricio Condori, dirigente ” “ Sr. Feliciano Mendoza, Secretaria de Justicia, Buena Vista ” “ Sr. Luccano Condori, Trigo Q’asa ” “ Enfermera auxiliar, Sra. Agapa Esposo ” Puesto Sanitario de Canchas Blancas

Grupo Focal con 8 ACSs. Tema: Problemas en el trabajo del ACS y recomendaciones de los ACS para solucionarlos.

18/03/04

“ Don Gerardo Telez, ACS, Comunidad de Pirhuani “ Don Pedro García, ACS, Comunidad de Sacavilque Chico “ Don Félix Bella, ACS, Comunidad de Sacavilque Chico “ Don Félix Díaz, ACS, Comunidad de Sacavilque Chico


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“ Don Mario Iporre, ACS, Comunidad de Pulquina., Puesto Huañumilla

“ Doña Emiliana Luna, ACS, Comunidad Pasla, Puesto Canchas Blancas.

“ Don ¿? ACS “ Don ¿? ACS Puesto Sanitario de Canchas Blancas (seguido)

Grupo Focal con 25 mujeres de Canchas Blancas y comunidades cercanas. Tema: Percepciones de las mujeres del trabajo de los y las ACS, del auxiliar, del puesto, de las causas y tratamientos tradicionales de las enfermedades (Diagrama de Venn), y una discusión de comportamiento de las mujeres ante la enfermedad.

18/03/04 (seguido)

Centralía de Campesinos (Pututaca)

Reunión con personal de Centralía de Campesinos (Pututaca) sobre capacitación recibida y financiada por IMCC

24/03/04

Jaime Flores Cruz, Secretario Ejecutivo Primitiva Rodríguez, Secretaria de Relaciones Elias Hakuña, Secretario de Actas Carlso Peñas, Secretario Agropecuario Juan Moscoso, Ex Ejecutivo Pablo Llanos, Subcentral de Ayllu Yucasa


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ANEXO 3 Taller Hospital Problemas y Soluciones

13/3/04 HOSPITAL

GRUPO I

PROBLEMAS PRINCIPALES

1) Falta de Planificación y Coordinación entre Hospital e IMCC 2) Falta de Coordinación para elaboración del POA 3) Falta de un Personal Exclusivo para Capacitación

Menos Importancia

4) Falta de micro-planificación

5) Falta de cumplimiento de las funciones del EBC (Equipo de Planificación y Capacitación) (IMCC/Hospital/ONGs/de salud)

6) Falta de seguimiento en la cotización de contrapartes

13/3/04 HOSPITAL

GRUPO II

PROBLEMAS PRINCIPALES

1) Insuficiencia de coordinación interinstitucional

2) Falta de Equipamiento Hospitalario (p.ej Incumplimiento de compromisos de Fondo Nórdico)

3) Influencia política que estorba la buena gerencia

Menos Importancia

4) Hospital no hace buen uso de financiamiento IMCC potencial para capacitación de personal hospital

5) Falta de acercamiento entre el sistema hipocrático de medicina y la

medicina andina

6) Falta de estímulo y falta de reconocimiento a la labor de personal médico


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HOSPITAL

GRUPO I

SOLUCIONES A PROBLEMAS 1) Reuniones mensuales entre IMCC y jefatura de municipio (SEDES tiene que

respetar planificación de hospital e IMCC) (delegación)

2) Reunión con todo el personal de salud del municipio para formular y tener prioridades y hacer presupuesto (2/3 meses previo elaboración de POA)

3) Identificar un miembro del personal existente para asumir la responsabilidad y

hacer un manual de funciones para la persona (compromiso firmado entre IMCC y municipio)

4) (1)

5) Coordinación Inter.-institucional para reuniones y socializar el manual de

funciones (más un compromiso firmado)

6) Hospital e IMCC tienen que reunirse para analizar la compra de equipamientos y cada institución presente su cotización POA (presentar a DILOS) y firmarlo

GRUPO II

1) Concientizar mediante un folleto más compromiso firmado (incluye SEDES/RED Camargo)

2) Mayor socialización de ejecución y planificación de POA

3) ?

4) Reuniones de priorización y planificación de capacitaciones a cargo de la

jefatura médica

Sistema occidental - Hospital se reúna para identificar problemas relacionados a la atención

integral - - priorización de problemas y elaborar proyecto para solucionar


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ANNEX 4 AUXILIARY NURSES PROBLEMS / SOLUTIONS AUXILIARES GRUPO I

PROBLEMAS GRANDES

- Falta de accesibilidad a los lugares lejanos “valles” SOLUCION: Más apoyo en la infraestructura y equipamiento en los lugares mencionados

- Falta de viáticos a los ACS. en los cursos de capacitación SOLUCIONES: Buscar financiamiento o modificar el presupuesto anual para las capacitaciones

- Falta de capacitación a los A.C.S. en la atención de partos en los valles SOLUCIONES: Capacitar haciendo conocer al SEDES que es de mucha necesidad los parteros en el sector de los valles

PROBLEMAS DE POCA IMPORTANCIA Falta mayor coordinación hospital, H.A.M., IMCC para las capacitaciones

SOLUCION: Programar fijamente las fechas de cursos en coordinación

- Idioma inadecuado para las capacitaciones SOLUCION: Adecuarse al idioma nativo Falta mayor coordinación hospital, H.A.M., IMCC en la ejecución de obras SOLUCION: Exigir a la alcaldía para que desembolse sen en su debido tiempo lo asignado y mantener en el P.O.A. AUXILIARES GRUPO II

PROBLEMAS GRANDES

- Falta de capacitación a parteros (as) tradicionales para comunicación oportuna al Centro Salud.

- Falta comunicación (radios), transporte (ambulancia y motocicleta)

- Falta infraestructura y equipamiento (nueva construcción – ampliación)


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PROBLEMAS MENORES:

- Falta apoyo económico a los ACS

- Falta actualización al personal de salud en los diferentes programas y dotación de certificados

- Falta cumplimiento del POA de la alcaldía

POSIBLES SOLUCIONES

1. Contratar un facilitador (IMCC – HAM) para reconocer los signos de peligro

CPN – Parto – Puerperio y comunicación oportuna e inmediata

2. Dotación (IMCC – HAM) y mayor responsabilidad administración Puesto Salud. Radios – motocicletas y ambulancia para Canchas Blancas para evitarla muerte materna infantil.

3. Construcción – ampliación de servicio de salud más equipamiento (material instrumental de enfermería e inmuebles) en valles 1. Apoyo económico a los ACS por parte de las instituciones ONGs HAM mejorar

la responsabilidad

2. Actualizarse para mejorar la calidad de atención

3. Tener una copia los servicios de salud para su cumplimiento


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ANEXO 5. 18-3-04 TALLER CON ACS GRUPO CANCHAS BLANCAS

SOLUCIONES PROBLEMAS GRANDES

1. Para los agentes comunitarios de salud queremos pronto los medicamentos para primeros auxilios y pedimos capacitaciones de dolor de estómago también queremos mas equipamientos a los puestos

2. Hay que coordinar con las autoridades y el Profesores de Cerca para hacer

visitas domiciliares en la comunidad

3. Para que no debilite los A.C.S., tiene que haber pasajes viáticos y materiales completos para recibir cursos de capacitaciones y queremos para A.C.S. linterna, nylon de poncho, gorras de I.M.C.C., mochilas

PROBLEMAS MENORES

1. Hacer reuniones en grupos a las madres de cerca para hacer entender del AIEPI,

por nuestro trabajo y lluvia

2. Seguir dando orientaciones en las reuniones sobre primeros auxilios y con material de AIEPI mejorando y material

3. Que haya pronto las capacitaciones sobre los primeros auxilios, parto limpio,

higiene y autoestima y dolor de muela. EVALUACION CANCHAS BLANCAS PROMOTORES

TRES PROBLEMAS GRANDES DEL TRABAJO DE PROMOTOR DE SALUD

1. En botiquín no hay medicamentos de primeros auxilios y para dolor de

estómagos y otros (sostenibilidad)

2. Falta de coordinación con las autoridades para hacer vecitas domiciliares con el AIEPI en la comunidad

3. Se debilitan los agentes comunitarios de salud por factor del tiempo, falta de

estipendio, por mensual, como decir materiales cuaderno, bolígrafo, para dormir falta frazadas cuando hay cursos

PROBLEMAS MENORES

1. Por larga distancia y factor del tiempo no podemos orientar a las familias


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2. No hay entendimiento cuando capacitamos con el AIEPI

3. Más reciclaje sobre los primeros auxilios y del AIEPI y de otras enfermedades y en atención para parto limpio

GRUPO VALLES - CANCHAS BLANCAS SACAVILLQUE CHICO

TRES PROBLEMAS GRANDES DEL TRABAJO DE PROMOTOR DE SALUD

1. Por falta de estipendios por mensual y equipamientos para el promotor, y para el

puesto, y por falta de caminos, y por falta de capacitaciones del parto domiciliar, y no tenemos medicamentos

2. Por falta de equipamientos completos para los agentes comunitarios como para,

caminar de los valles lejanos de 25 km.; Necesitamos películas y grabadoras

3. Por falta de higiene no tenemos materiales para mejorar nuestras viviendas y no tenemos duchas

PROBLEMAS MENORES

LOS PACIENTES NO NOS QUEREN PAGAR

SOLUCIONES GRUPO VALLES SACAVILLQUE CHICO

1. Para solucionar nuestras familias para nuestra persona de promotores, con eso estipendios mensuales y como agente comunitarios queremos medicamentos y materiales y como ser cuaderno bolígrafo, lápiz, rota folios, y afiches y materiales para el parto.

2. Como agente comunitarios queremos equipamientos como, ser, mochilas,

esleepines, ulis, linternas, horarios, camperas para frió, gorras para frió, y abarcas, y zapatos, luego, queremos, películas para sacar fotos y grabadoritas para grabar en capacitaciones casa por casa

3. Nosotros como agentes comunitarios queremos materiales como ser, cementos,

yeso, calaminas y tejas tambadas, una letrina completa con su ducha y manguera y panel solar


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ANEXO 6 MUJERES GRUPO FOCAL 18/03/04 Canchas Blancas Grupo Focal 18 mujeres 1 hombre Impacto del proyecto: Ha mejorado la salud un poco desde que hay un puesto. Pero hay problemas de salud en los niños:

• Diarreas por el frió • Tos

A veces el puesto sanitario está vació porque el personal de salud está en el campo haciendo trabajos. Vamos a la promotora en Canchas pero ella dice: “va al centro a hacerse curar”. Utilizamos el promotor cuando no está el auxiliar en el centro. Antes hubo promotores de ADRA que daban charlas en el puesto-cada jueves. Ahora ADRA se reunía con madres con niños de menos de cinco años El auxiliar da charlas sobre vacunas, parto difícil, emergencias obstétricas. 9 mujeres presentes han asistido estas charlas 8 mujeres presentes no saben leer / escribir – les es difícil entender las charlas Aunque entendemos algo, no es fácil – olvidamos porque no leemos. Tal vez socio dramas serían mejor. Los que saben escribir pueden anotar y recuerden mejor Se necesita luz eléctrica para audiovisuales La promotora ha hablado de cómo hay que cuidar los niños Medición del impacto de las charlas: Percepción de cómo prevenir las diarreas / la tos: Percepciones de las mujeres: “Que no pase frío/que se abriga.” “Que no coman tierra los niños.”


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“Cuidar bien el niño/que no se mojen los niños.” “Que no coman con las manos sucias.” “Alimento en platos sucios.” “La comida guardada es fría y no calienta.” “Hay que lavar la ropa.” Ch’uju (Tos): Causas: Del frío – chirimanta Prevención: Cuidar del frió Los niños hurgan barro y agua fría en la escuela Tratamiento: Limón caliente Se exprime limón a orines para bañar al niño – fresco es el orín.

Se toma limón quemado para resfrío Baños de eucalipto Mates de flor de Pascua con pino para tos de niño

Fiebre Huevo batido – para bajar temperatura Linaza – molida y hervida al cuerpo Curación del asustado: El abortito de oveja se la frota al cuerpo del bebé. Una piedra del estómago de la llama, se le muele y mezcla con agua, se hierve con azúcar. Curación de la Gloria: Sacrificio de cordero en el cerro (se come y deja los huesos en el cerro). ¿Cómo se sabe si es enfermedad para el curandero o para el puesto, para Don Adán?


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El curandero lee en la coca si es para la posta. A veces llevan a la posta pero no sana entonces recién consultamos al curandero. Caso: “Mi hija estaba con diarrea. Traje al bebe al puesto pero no se ha curado. Tenía asustado de virginasqa (enfermedad a causa de la Pacha Mama) con diarrea. En la posta se ha curado con cotimoxasol. No se sanó entonces se le llevé al curandero.” “El curandero curó con ofrenda de coca a Pacha mama, con llama untu (= grasa de llama), y otros rituales.” “Sería bien si los curanderos fueran elegidos para ser promotores – podrían trabajar de los dos lados.” Enfermedad del rayo: El rayo cae cerca, el humo se le provoca enfermedad a los adultos. Virginasqa / Susto Síntomas en el niño: diarrea; calentura; se enflaquece Curación: ir al curandero “Enfermamos mucho en el campo de las enfermedades místicas”

EVALUACION ¿Para que sirven los promotores? - queremos que los promotores trabajen con los jampis/medicinas del campo

- que trabajen con el auxiliar/cuidar el puesto

PARTERA de Canchas Blancas Doña Feliza Peñas:

- la partera es buena – trabaja con Don Adán (auxiliar) - a veces si ella no puede manejar el parto, Don Adán atiende el parto

Debilidad – Yuyay Chinkay (=se pierde / se le escapa el pensamiento) (Uma muyuy = la cabeza da vueltas) Tratamiento:

- colocar sueros glucosados


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- para niños – el tratamiento son rituales Ejercicio del diagrama Venn: ¿Cuál es el más importante de los 5 siguientes recursos humanos en salud: El Puesto; La enfermera / el enfermero; El ACS; La partera / el partero; El curandero? En tres ejercicios, las mujeres colocaron a estos 5 recursos humanos de la salud en el campo así en orden de prioridad e importancia, así (véase las fotos del ejercicio):

1. El Puesto 2. La enfermera / el enfermero 3. El ACS 4. La partera / el partero 5. El curandero

Se concluyó que el puesto es el recurso más importante de todo en la provisión de salud en el campo.


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ANEXO 7 Resumen de las inversiones del IMCC 2002-2003 II Equipamiento /constricciones

Monto IMCC

Monto HAM

Monto Total

% IMCC Destino Estatus

2002 1 Ecógrafo 70,000 40,000 110,000 63.6% San Lucas En uso

10 cajas de curaciones 10,230 0 10,230 100.0% Campo En uso

25 equipos de campo 15,000 15,000 30,000 50.0% Campo En uso

5 mesas ginecológicas 6,600 9,000 15,600 42.3% Campo En uso

85 Botiquines para los ACS's 5,532 4,500 10,032 55.1% Campo

En uso

6 baños 39,677 39,677 79,353 50.0% Campo Problemas36

Ampliación del Hospital 40,000 258,000 298,000 13.4% San Lucas Problemas37

Subtotal 2002 187,039 366,177 553,215 33.8% 2003 4 mesas ginecológicas 4,400 4,400 8,800 50.0% Campo En uso 4 balones/tubos de oxigeno 6,270 6,270 12,540 50.0%

Campo y San Lucas

En uso

2 kits de resucitacion 3,004 3,004 6,008 50.0% San Lucas En uso

3 oftalmoscopios 1,440 5,000 6,440 22.4% Campo En uso

18 pizarrones 5,400 0 5,400 100.0% Campo En uso

100 sillas 3,500 3,500 7,000 50.0% Campo y San Lucas

En uso

15 mesas 2,000 1,000 3,000 66.7% Campo y San Lucas

En uso

4 asèmilas 5,000 5,000 10,000 50.0% Campo En uso

1 Moto 27,000 0 27,000 100.0% Campo En uso

Equipamiento odontólogo 6,000 0 6,000 100.0% San Lucas

En uso

25 mecheros 500 0 500 100.0% Campo En uso

3 material AMEU 2250 2250 4500 50% Campo En compra

25 Linternas cabezal 2,660 0 2,660 100.0% Campo En uso

111 Materiales para los ACS's 23,329 0 23,329 100.0% Campo

En uso

Vivienda para medico en Ajchilla 25,000 25,000 50,000 50.0% Campo

En uso

Vivienda para medico y sala de partos en Canchas Blancas 27,000 20,000 47,000 57.4% Campo

En uso

Puesto de salud en Malliri 30,000 70,000 100,000 30.0% Campo

En uso

Sistema de agua potable en La Palca 22,000 22,000 44,000 50.0% Campo

En uso

Sistema de agua potable en Uruchini 34,000 35,000 69,000 49.3% Campo

En ejecución

Subtotal 2003 230,753 202,424 433,177 53.3%

Total 2002-2003 417,792 568,601 986,392 42.4%

36 Problemas con el tanque séptico en Canchas Blancas. Todavía no hay agua en Uruchini. 37 Algunos problemas nones vitales, por ejemplo con la madera que han usado para las puertas y ventanas.


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ANNEX 8 Programme of the Mission Programa de la Misión de Evaluación: 10 de marzo Salida de Dinamarca 11 de marzo 2004. Llegada de David a Sucre. 12 de marzo: Reunión SEDES (Ministerio de Salud), Sucre. Viaje a San Lucas (5 horas) 13 de marzo: San Lucas. Reunión y mini taller con personal del hospital de San Lucas. Tema: percepciones del personal boliviano de la gerencia y diseño del proyecto con respecto al grado de cumplimiento de sus objetivos y la sostenibilidad de sus esfuerzos. Percepciones sbre la población rural. 14 de marzo: San Lucas. Reunión con personal del hospital más personal danés de IMCC. Presentación de hallazgos del mini taller del día anterior al personal danés y comentarios / percepciones del personal danés. 15 de marzo. Palacio Tambo. Reunión / grupos focales con auxiliares. 16 de marzo: Mismo. 17 de marzo: Alcaldía municipal. Reunión con personal de salud / educación. Opiniones sobre el proyecto. 18-19 de marzo. Visitar comunidades y ACSs. Grupos focales. 20, 21, 22 de marzo. Canchas Blancas. Grupos focales con la comunidad y visitas a otras comunidades lejanas. 23 de marzo. Reunión con ONGs. 24 de marzo. Entrevista con las Centralías y autoridades sindicales. 25 de marzo. Reunión con personal de proycto / elaboración de resumen Ejecutivo en español. 26 de marzo. Presentación de la ayuda memoria y hallazgos, conslusiones y recomendaciones principales. 27 de marzo. Salida de David Moore a Santa Cruz. 28 de marzo. Llegada a Dinamarca


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Anexo 9 DECLARATION OF ALMA-ATA International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978 The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following Declaration: I The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. II The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries. III Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace. IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care. V Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organisations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice. VI Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self-determination. It forms an integral part both of the


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country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. VII Primary health care: 1. Reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience; 2. Addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly; 3. Includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs; 4. Involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors; 5. Requires and promotes maximum community and individual self-reliance and participationin the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate; 6. Should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need; 7. Relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community. VIII All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to


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exercise political will, to mobilize the country's resources and to use available external resources rationally. IX All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world. X An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world's resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, détente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share. The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies, nongovernmental organizations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries. The Conference calls on all the aforementioned to collaborate in introducing, developing and maintaining primary health care in accordance with the spirit and content of this Declaration.


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ANNEX 10 LIST OF DOCUMENTS CONSULTED IMCC documents Udenrigsministeriet Danida. Projektdokument. IMCC Primært sundhedsprojekt-San Lucas Chuquisaca departamentet Bolivia. IMCC. December 2000. Informe semestral, segundo semestre 2001. IMCC. Informe semestral, primer semestre 2001. IMCC. Informe semestral, segundo semestre 2002. IMCC. Informe semestral, primer semestre 2003. IMCC. Informe semestral, segundo semestre 2001. IMCC. Danida documents Evaluation guidelines. Ministry of Foreign Affairs, Copenhagn, 1999. “Strategy for Danish Support to Civil Society in Developing Countries, including Cooperation with the Danish NGOs analysis and strategy document”. Ministry of Foreign Affairs, Danida, October 2000. Publications about Primary Health Care Donahue, John. ”Health delivery in rural Bolivia”. In J. Bastien and J. Donahue (eds), Health in the Andes. Washington: American Anthropological Association, pp. 173-195, 1981. Kwast, Barbara. “Maternity care in developing countries”. In Health matters: Public health in north south perspective. Edited by Koos van der Velden et al., Royal Tropical Institute, Amsterdam, 1995, pp 175-183. Muller, Fritz, ”Contrasts in community partcipation: case studies from Peru”. In Morley, David, et. al. Practising health for all. Oxford, 1983. Muller, Fritz, ”Primary Health care: Lessons from 25 years of experience in developing countries”. In Health matters: Public health in north south perspective. Edited by Koos van der Velden et al., Royal Tropical Institute, Amsterdam, 1995, pp 253-262. Van Cleeff, Maarten, et al. ”Tuberculosis control in north and south: four strategies for different socio-economic sitiauns”. In Health matters: Public health in north south perspective. Edited by Koos van der Velden et al., Royal Tropical Institute, Amsterdam, 1995, pp 217-241. Werner, David et al., Where there is no doctor: a village handbook (in Spanish, Donde no hay doctor: una guía para los campesinos que viven lejos de los centros médicos. J.Maxwell, D. Werner et al.). London, TALC. 1980 etc.


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Publications about intercultural medicine: the interplay between Andean and biomedical medical systems, and about susto Bastien, J. 1981. 'Metaphorical relations between sickness, society, and land in a Qollahuaya ritual'. In J. Bastien and J. Donahue (eds), Health in the Andes. Washington: American Anthropological Association. Bastien, J. 1982. 'Exchange between Andean and western medicine'. Social Science and Medicine 16, 795-803. Bastien, J. 1985. 'Qollahuaya-Andean body of concepts: a topographical-hydraulic model of physiology'. American Anthropologist 87 (3), 595-611. Bastien, J. 1987 b. 'Cross-cultural communication between doctors and peasants in Bolivia'. Social Science and Medicine 24 (12), 1109-1118. Bastien, J. 1989. 'Difference between Kallawaya-Andean and Greek-European Humoral theory.' Social Science and Medicine 28 (1), 45-51. Bastien & Donahue, J. (eds). Health in the Andes. Washington: AAA. 1981. Logan, M. 'Variations regarding susto causality among the Cakchiquel of Guatemala.' Culture Medicine and Psychiatry 3 (2), 153-66, 1979. Van der Geest, Sjaak, “The efficacy of traditional medicine (and biomedicine)”. In Health matters: Public health in north south perspective. Edited by Koos van der Velden et al., Royal Tropical Institute, Amsterdam, 1995, pp 360-65. Rubel A. et al. Susto, a folk illness. Berkeley: Univ. Cal. Press. 1984. Publications on traditional plant medicines in Bolivia Manuel de Lucca D. and Jaime Zalles A., Enciclopedia boliviana. Flora medicinal boliviana. Diccionario enciclopédico. Editoral Los Amigos del Libro. La Paz, 1992. Other documents about evaluation, and the development of participatory monitoring and evaluation indicators Chambers, Robert. ”Participatory rural appraisal: analysis of experience”. World Development vol. 22 (9), 1253-1268, 1994. R. Chambers, “Participatory Rural Appraisal (PRA): Challenges, Potentials and Paradigms." World Development vol. 22 (10), 1994. Dyal Chand, Ashok and M. Ibrahim Soni, ”Evaluation in primary health care: a case study from India”. In Morley, David, et. al. Practising health for all. Oxford, 1983. Holland, Jeremy and Blackburn, James. Whose voice? Participatory research and policy change. Intermediate Technology Publciations, London, 1998. Mikkelsen, Britha. Methods for development work and research. Sage Publications, New Delhi, 1995.


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Nichols, Paul. Social survey method: a fieldguide for develoment workers. Oxfam, 2000. Rubin, Frances. A basic guide to evaluation for development workers. Oxfam, 1995, Oxford. ODA. A guide to social analysis for projects in developing countries. HMSO. London, 1995.


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ANNEX 11. OPERATIONS MANUAL. EPC. Manual de funciones del Equipo de Planificación de Capacitaciones (EPC). Primera Edición junio 2003. Definición: EPC es un equipo multidisciplinario encargado de planificar, ejecutar y evaluar programas estratégicos de capacitaciones para el personal de salud y recursos humanos comunitarios en salud, logrando integración y coordinación interinstitucional, comunal y municipal. Objetivo: Mejorar los conocimientos, actitudes y practicas de las comunidades y de esta forma elevar el nivel de salud del municipio. Funciones / reglas:

• Asistir a reuniones mensuales y reuniones extraordinarias según necesidad del equipo.

• Informar motivo de ausencia a las reuniones del EPC al encargado de IMCC. El lapso de espera para el inicio será máximo diez minutos.

• Tener conocimiento del presupuesto establecido en el POA y manejarlo, elaborando listas de las compras necesarios para el administrador del hospital.

• Elaboración de programas y cronogramas de capacitación para personal de salud (P.S) y para recursos humanos comunitarios (RR.HH.C) y autoridades.

• Ejecución de las capacitaciones al P.S y RR.HH.C y autoridades. • Evaluación de las capacitaciones al P.S y RR.HH.C y autoridades. • Seleccionar a RR.HH.C para la administración de becas de estudio para auxiliar

de enfermería. • Cada miembro funcionará como portavoz de la institución que representa. • Cada miembro integrante del EPC es responsable de transmitir a sus

instituciones de decisiones, acciones y determinaciones que se tomen en cada reunión.

• Mensualmente elaborar cronograma en coordinación con las diferentes instituciones.

San Lucas 3 de junio de 2003

Dr. Nataniel Pérez Lic. Sulma Martínez Dr. Josué Orellana Jefe Medico Jefa de enfermeras AFI San Lucas

Sr. Walter Janko Sra. Mercedes La Fuente Dr. Mario Villarpanqo Aux. P/S Pututaca Aux. P/S Padcoyo Rep. Esperanza Bolivia

Lic. Elizabeth Matha Lic. Anja Christoffersen Dr. Juan José Fernández Rep. ADRA Rep. IMCC Medico de planta

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