A different approach to evaluating PHC projects in developing countries: how acceptable is it to aid agencies?

A growing number of criticisms of health impact evaluations have emerged during the last decade, within the context of the health sector in developing countries. These criticisms are presented, and an alternative approach which focuses on ‘intermediate’ or ‘proximate’ determinants of health is described. If alternative approaches to evaluation are to be adopted, then they must be accepted by the policy makers who decide about funding. This paper reports on interviews held with key members of two major European bilateral aid agencies which fund numerous evaluations of primary health care projects (PHC) in developing countries. Differences in views between headquarters and field staff are reported. It seems likely that expensive, ill-designed and inappropriate health impact evaluations will continue to be implemented due to political pressures, which ignore the conceptual and methodological problems associated with such evaluations. It is suggested that this situation is an example of policy leading science, as opposed to science leading policy.