Capacity Building within Healthcare (CBH) – End term Evaluation Report

Background:
Capacity Building within Healthcare (CBH) is a project implemented in Somaliland by the Norwegian Lutheran Mission (NLM) operating under the local name Nooleynta Naruurada Mustaqbalka (NNM). The project has been piloted since 2008/9 - 2011 in partnership with Somaliland Ministry of Health, Edna Adan Hospital, Hargeisa Group Hospital and the University of Hargeisa Medical Faculty.

The Somaliland Republic is faced with the challenges of providing necessary basic conditions to facilitate preventive and curative health care services to its population during this phase of reconstruction that followed the destruction caused by the civil war of 1988-91.The following are some of the  problems in the Somaliland healthcare systems; inadequate or lack of regular remuneration of healthcare workers, poorly equipped hospitals and movement of doctors from public hospitals to private practice leaving the poorer part of the population with no access to healthcare services. These were the main reasons to initiate the project.

The immediate beneficiaries of the CBH project’s pilot phase were the medical and nursing students, clinical workers at partner hospitals and academic staff at health teaching institutions. The projects’ long term beneficiaries were the general population of Somaliland with particular focus on mothers and children.

Purpose/objective:
The evaluation sought to address the following issues regarding the project relevance and the effectiveness of the approaches used by the CBH project, the scope and focus of the project, viability of the options for using the existing scripture mission structures to support the project, the utilization of resources and project implementation in the context of insecurity, overall impact of CBH in comparison to other projects implementing similar initiatives and possible recommendations related to future objectives.

Methodology:
The methodology used for the evaluation purpose is specifically highlights the design of the evaluation, sampling process, data collection tools and data analysis. The evaluation applied mainly qualitative methodologies and the data collection tools used was; questionnaires and in-depth interview guides. The evaluation employed a cross-sectional type of design involving the use of both qualitative and to a limited extent, quantitative techniques. This design was considered suitable as it allowed for determination of the degree of influence of the different CBH interventions on the different changes desired as well as their relevance in context of the framework of needs to be addressed, resource availability and partnerships. A mix of approaches that were mainly participatory and non-extractive in nature was employed to collect the necessary information from the project implementers, beneficiaries and other stakeholders.

Key findings:
The findings are organised according to the main themes that were guided by the evaluation questions namely; the relevance and the effectiveness of the approaches used by the CBH project. The findings show that the project addressed the relevant needs that had earlier been identified during the baseline survey/preliminary visits. Some of the prioritized needs addressed by the project mainly targeted the marginalized groups within the Somaliland society and they include high incidence under five mortality, low uptake of ANC, low number of deliveries taking place in facilities with advanced obstetric emergency care or under skilled attendants, low iodine intake, and low doctor to patient ratio among other challenges to health of the population.

The CBH approach to target the medical and nursing students, clinical workers at partner  and academic/health institutions was found to be relevant in mentoring and imparting the relevant knowledge, skills and patient care attitudes/values to the students and junior health care workers that would still serve the public before reverting back to private practice. Moreover, the project strategy for recruiting short and long term personnel was found to be effective since all the partners reported being able to plan and implement the CBH interventions.

Recommendations:
Based on the findings and the discussions in in the main evaluation report, there exists a need for the NNM/NLM to do some serious critical strategic thinking on Somaliland and the needs of the people.  More important experiences acquired by the CBH during the pilot phase should be taken into account in order to identify the best role of CBH project in future. Whatever the NLM decides, they should not give up on Somali people. The need to address the poor health outcomes in Somaliland is still enormous, it is therefore critical that the reflection by NNM/NLM considers how the seeds sown would be better nurtured and enabled to realize the much anticipated fruits.

Based on the findings and the discussions, the current approach (many short terms and few long term personnel mix) would remain a more effective way of building the capacities of the healthcare workers and medical students. This evaluation has noted that this approach has been frustrated by numerous challenges regarding the recruitment process. The evaluation recommends that the NLM address the recruitment challenges facing the project by any of the following; widening the scope of their recruitment beyond the East African region in order to attract high qualified personnel with required values, allow the staff to use their networks and recommend the possible candidates for recruitment, delegate the responsibility of to the project manager/coordinator.

Comments from the organisation, if any:
NLM has considered the recommendations from the evaluation report and prepared a new 5 years Project Document (2013 – 2017) and submitted to Digni. The focus of CBH is Building Capacity of health professionals to challenge the issue of gaps in knowledge and skills within healthcare system by supporting academic Health Institutions, Hospitals and Ministry of Health.