| BackgroundIn response to "2000 Health for All" initiated by the World Health Organization, the Chinese Ministry of Health has been using World Bank loans for the construction of health services since 1984. So far, China has carried out 10 sanitation projects in cooperation with the World Bank, which provided US＄910.6 million loans in total.The eighth health project carried out by the Chinese government by using World Bank loans is aimed to "strengthen basic health services in China's rural poverty-stricken areas", and it is hereafter referred to as the "HealthⅧProject" (H8P). The British Government also granted fund to support projectsⅧ(referred to as H8SP), the focus of which is to strengthen national, provincial expert capacity-building, and to establish a 6 million Innovation Fund for the township level health innovation projects.The overall objective of the H8P is to improve supply capacity of health services in poverty-stricken areas and to improve health services utilization level. By ensuring that local residents have access to basic health care services in rural poverty-ridden areas, health improvement can be achieved among the poor county population. Covering China's 10 central and western provinces, municipalities and autonomous regions, this project is wide-ranging geographically and benefits a large population.H8P was divided into two parts: Part A, also known as the "basic health services component", covering 71 counties in Shanxi, Anhui, Henan, Chongqing, Guizhou, Gansu, and Qinghai provinces (municipalities); part B, also known as the "Qinba health component ", covering 26 counties in. Shaanxi, Ningxia, Sichuan and other provinces and autonomous regions.The total project investment is 1.069 billion yuan. Basic health services component is 887 million yuan, while the left belonged to Qinba health component. Project loan is allocated among the provinces as follows: US＄7.107 million for Qinghai Province; US＄12,198 million for Henan Province; US＄10,209 million for Chongqing Municipality; US＄11,098 million for Guizhou Province; US＄10,143 million for Gansu Province; US＄12,188 million for Anhui Province; US＄7.057 million for Shanxi Province; US＄2,216 million for Ningxia; US＄5,303 million for Shaanxi Province; US＄7,481 million for Sichuan Province.As one of the basic health services component provinces in H8P, Qinghai Province has been implementating H8P since 1998.Qinghai Provincial Government, as required by the World Bank and the Foreign Loans Office of the Ministry of Health and according to the requirements of the prior agreement, formed the World Bank loan "H8P" leading group, headed by the vice governor of Qinghai province.According to the standard set by the World Bank and the Foreign Loans Office of the Ministry of Health, Qinghai Provincial People's Government selected the follwing 12 counties as the project counties: Ledu, Huangzhong, Huzhu, Datong, Xunhua, Tongren, Dulan, Menyuan, Xinghai, Dari, Yushu and Minhe.The total project investment was 90.7521 million yuan, of which the World Bank loans amounted to 58.9881 million yuan (about US＄7,107 million), accounting for 65 % of the total investment, the domestic support accounted for the 35% of the investment. The provincial investment was 15.97 million yuan, accounting for 50.3% of the domestic support.Major project investments were spent on the transformation of township hospitals, necessary equipment, allocation of medicines and materials, personnel training, technical assistance, project management and operation of the project activities, and so on.H8P has been fully concluded in June 2007. Consequently, the components of the projects were also concluded. As a project component, the H8P disease intervention had ended by the end of 2005..In 2006, under the leadership Foreign Loans Office of the Ministry of Health, the provincial H8P organizations started to carry out the final evaluation and examination on H8P in 10 project provinces. Therefore, from the end of 2006 to June 2007, the focus of H8P was to carry out project evaluation. The specific interventions were no longer carried out.This study is a subset of H8P overall evaluation. Commissioned by the Office of the Qinghai Provincial Health, Fudan University would carry out the final evaluation study on the H8P implementation in Qinghai province.ObjectiveThe purpose of this study is to evaluate comprehensively the implementation of the H8P in Qinghai, making a summary of the experience gained in the project and the shortfalls found in it. It is expected that the lessons and reference will be useful for the non-project areas in Qinhai Province.Methods1. Descriptive research method. To understand the development of the H8P project counties, we have used quantitative method to make an analysis of the completion of the health monitoring indicators which were demanded by the H8P since 1998 in Qinghai province.2. Qualitative research method. Using the focus group interview, as well as in-depth interviews, we have had an evaluation on the implementation of H8P in Qinghai, from which we want to understand the problems existing in the project and find the counter measures and suggestions for the non-project counties in the future.3. Health statistics method. We have made a comparison between the final assessment in Qinghai and those of the other H8P provinces. Using random sampling method, we have selected the Qinghai project and non-project counties, both in township hospitals and village clinics, as well as residents of the building of the health situation KAP scores compared comparative analysis.4. Comprehensive evaluation method. Using the composite Index method, we have made a comparison between the implementation of Qinghai and that of other H8P provinces.5. Stakeholder analysis method and Policy Analysis Method. In the case studies, we have used stakeholder analysis and policy analysis method to conduct a systematic analysis of the feasibility and implementation difficultiesResults1. We have made an analysis on the unified indicators of H8P from the World Bank. The results is shown as follows. By the end of 2006, all of the 12 H8P counties in Qinghai have completed every indicator in the fields of Part A of H8P. In the fields of Part B1-- improving health services delivery system—the completion rate of all indicators achieved 80% by the end of 2005. One exception is the X-ray protection rate as required by the state, only 23.16 percent rural hospitals met the standard. As for the use of the drug directory, hospitals and village clinics respectively reached the ratio of 100 percent and 93.81 percent. In the field of Part C1, that is, developing the cooperative medical system, all the 177 surveyed participated in the CMS, covering a population of 1,922,066, accounting for 89.6% of the total project area. It can be concluded that cooperative medical system has met the expectation. By 2006, health assistance for those extremely poor has been implemented in all the 12 counties which were included in H8P; Among the intervention projects from 1998 to 2006, 66.7% of the counties participated in tuberculosis intervention, 50% counties participated in the intervention against maternal and child diseases, and only one county participated in the intervention against cataract and insecticide. Qinghai Province did not participate in the disease intervention projects added to the list after the 2002 mid-term evaluation.2. We have made a comparison between Qinghai province and other H8P provinces. The results are as follows. In the period of the H8P, Qinghai Province has consolidated provincial supervision for 3,102 persons, which was 3.6 and 5.0 times compared to the average of the H8P provinces and the average of 7 provinces in Part A among H8P respectively. Qinghai Province has conducted short-term professional training for 1,742 per person, which was 0.5 and 0.4 times compared to the average of the H8P provinces and the average of 7 provinces in Part A among H8P respectively. All of the H8P counties in Qinghai had established cooperative medical system and given medical assistance to those extremely poor, with both rates higher than the national rate in Part A of the seven provinces and the average level. By the end of 2006, the percentage which the county participated in either CMS or medical assistance occupied 100 percent in the H8P counties in Qinghai, both of them were higher than the average of the H8P provinces and the average of 7 provinces in Part A among H8P.Among the H8P focus interventions in Qinghai Province, the percentage which the county participated in TB control interventions occupied 66.7 percent in the H8P counties in Qinghai, which was the highest in the H8P focus interventions, followed by the intervention immunization, which the ratio was 58.3 percent. In both of the two focus interventions, Qinghai Province had achieved a higher participation percentage than the average of the H8P provinces and the average of 7 provinces in Part A among H8P. For the maternal and child health intervention, its percentage was 50 percent, lower than the average of the H8P provinces and the average of 7 provinces in Part A among H8P respectively. By the end of 2006, there was only 1 county respectively which did iodine deficiency disease prevention and control, eliminate cataract, children intestinal insecticide, STD / AIDS prevention, reproductive tract infection control, pre-injury accident six projects intervention. The participation percentages of the above control interventions were lower than the average of the H8P provinces and the average of 7 provinces in Part A among H8P respectively. For the indoor pollution prevention fluorosis, no Qinghai county had carried out this project, while the other H8P provinces had done it.3. In this study, we have used the composite index method to make the systematic evaluation of Qinghai and the average of 7 provinces in Part A among H8. The results is shown as follows. Except the CMS and medical assistance, the remaining seven categories of H8P in Qinghai were lower than the average level of 7 provinces in Part A among H8P. The final comprehensive evaluation results showed that the score of the composite index were 6.613, which was lower than the average level of 7 provinces in Part A among H8P whose score was 11.679.4. Based on the comparison between the Qinghai H8P counties and the non-project ones as regards the point of township hospitals and village clinics, as well as residents of the building of the health control KAP scores, we can understand that the health service abilities either in the township hospitals or in the village clinics, were higher in H8P counties than non-project counties; as for the KAP on health, the scores of the citizens in H8P county were higher in the non-project counties.InnovationH8P was concluded in June 2007. This study as the final evaluation is of great practical significance and is carried out in a timely manner. The main findings of this study have been handed over to the Foreign Loans Office of the Ministry of Health in the form of a report titled "Completion of the H8 Project in Qinghai Province" in June 2007. Through verification, the accreditation experts agreed that the evaluation report on the H8P in Qinghai was accordant with the actual situation in Qinghai and meet the requirements set by the Foreign Loans Office of the Ministry of Health and the World Bank.The study is the final evaluation on the H8P implementation in Qinghai. We have used the implementation data of the average of the H8P provinces and the average of 7 provinces in Part A among H8P as the external control. At the same time, we have chosen the comparative non-project counties as the internal control in terms of township hospital and village clinics construction, as well as the scores about the KAP in the residents. For the problems identified through the comprehensive evaluation, we have analyzed the reasons and the difficulties in the form of case study by employing various methods, such as stakeholders, policy analysis method, etc.
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