Terminal Evaluation

1. Outline of the Project

Country:

Zambia

Project title:

Lusaka District Primary Health Care Project

Issue/Sector:

Health/Medical Care

Cooperation scheme:

Project-type Technical Cooperation

Division in charge:

Second Medical Cooperation Division, Medical Cooperation Dept.

Total cost:

850 Million yen

Period of Cooperation

17 March 1997 - 16 March 2002

Partner Country's Implementing Organization:

Lusaka District Health Management Team (LDHMT)

Supporting Organization in Japan:

Kibi International University, Niigata University,
Association of Medical Doctors of Asia (AMDA)

Related Cooperation:

Grant Aid; "University Teaching Hospital Neonatal and Pediatric Surgical Center"

1-1 Background of the Project

The health status of the people in Zambia was in a state of deterioration. Particularly, in the urban area of Lusaka, population growth and poor living conditions has combined to cause serious problems. But despite government efforts to improve the social infrastructure, the rehabilitation and strengthening of the rural health system remained a prime task in the health sector. To rehabilitate the national health system, the Ministry of Health (MOH) introduced Health Reforms which consisted of components such as decentralization, reconstruction and improvement of the operational management system, financial reform, and introduction of an Essential Package of Health Care. In the above context, the Government of Zambia requested Project-type Technical Cooperation from Japan with a long-term goal of "improving health conditions in Lusaka urban area".

1-2 Project Overview

The Project aims to improve the Primary Health Care (PHC) management system in the Lusaka District and strengthen the community health system through community participation from the urban slum area and function of the health center as a first-referral health facility.

(1) Overall Goal

The overall health status of people in the community of the Lusaka District is improved.

(2) Project Purpose

The primary health care management system is improved in Lusaka District in line with the Zambian Health Reform and Strategic Plan.

(3) Outputs

1) Community-based PHC programs are improved in response to the needs of the community in the pilot area.
2) The referral system (a system to introduce the appropriate medical institution to the patient based on the extent and seriousness of the disease) between the different levels of health care in the Lusaka District is operated effectively.
3) School health services are effectively operated (at the pilot school).

(4) Inputs

2. Evaluation Team

Members of Evaluation Team

Team Leader: Yujiro HANDA, Senior Advisor of Health, Institute for International Cooperation, JICA
Public Health: Hiroshi SUZUKI, Professor, Graduate School of Medical and Dental Sciences, Niigata University
NGO Coordination: Shigeru SUGANAMI, President, Association of Medical Doctors of Asia
Evaluation Analysis/Cooperation Planning: Goro YAMADA, Associate Expert, Second Medical Cooperation Division, Medical Cooperation Department, JICA

Period of Evaluation

15 September 2001 - 8 October 2001

Type of Evaluation:

Terminal Evaluation

3. Results of Evaluation

3-1 Summary of Evaluation Results

(1) Relevance

The Lusaka District Primary Health Care Project which targeted urban communities with low income residents in Lusaka was matched with the national health policy of Zambia, the needs of the residents (about 75 percent of the residents of this area lived under extremely poor health conditions) and the cooperation policy of the Government of Japan toward Zambia.

(2) Effectiveness

In conducting preventive and promotion activities in the Growth Monitoring Program plus (GMP+)(*), the underweight prevalence among children under five years old declined from 23 percent in 1999 to 15 percent in 2000, full immunization coverage of children under one year old increased from 15 percent to 61 percent, and the measles incidence among children under five years old declined from 8.5/1,000 to 1.8/1,000. These facts should be recognized as indicating that the primary health care activities in the field of water and sanitation have, for the most part, achieved their goals. However, the Project activities did not provide sufficient monitoring and follow-up of the training participants, so that it was difficult to evaluate the effects of the training for the staff of the District Health Management team and health centers. In the field of the referral system and school health service, the systems remain in the process of being formulated because of their wide range. The Lusaka District Health Management Team faced a chronic shortage of manpower and its PHC management capacity was insufficient. However, the community-based PHC management system was well established in the Lusaka District and the Project Purpose has been mostly achieved.

(*) GMP+: The activities regularly conducted every month in 19 sites at the pilot area, such as growth monitoring, nutritional consultation, immunization and vitamin A supplementation, which were originally implemented by the health center.

(3) Efficiency

GMP+ activities for child health, the priority area of the community-based PHC, was conducted with high efficiency because it integrated a variety of components as a package and conducted the activities regularly in the residence areas (more than 4,000 mothers and children a month joined GMP+. The population of under-5 children in the pilot area was about 8000; therefore, about half participated in the program). As for the construction of the VIP (Ventilated Improved pit) toilets and drain ditches, there were relatively few beneficiaries considering the quantity and cost. Expanding these over the entire area will necessitate a huge expenditure. Therefore, the effect on the Input is limited.

(4) Impact

There was no negative impact. Only positive impacts were found. As for the results of the practice of GMP+, GMP+ activities were extended to five compounds outside the pilot area, and reduced the overcrowding of the health center. The number of deaths by Cholera declined drastically from 70/10,000 in 1994 to 1/10,000 in 2000 through promotion activities emphasizing safe water use and environmental sanitation.

(5) Sustainability

Sustainability of the activities was considered from the planning stage, as the project took the approach of community participation. In particular, due to the collaboration among the health center, community organization, and local NGO, AMDA Zambia (implementation of literacy education to the local organizational members and cultivating soybeans at GMP+) was effectively conducted and some activities become self-reliant both in the financial and organizational aspects. However, ensuring management funds (the allowances and incentives especially for the staff of the health centers and members of community organizations) is the key to confirmed sustainability. In terms of the referral system and the school health service, the system has not been completely established, and so sustainability of activities in these two areas remains to be uncertain to some extent.

3-2 Factors that promoted realization of effects

(1) Factors concerning Planning

N/A

(2) Factors concerning the Implementation Process

The good cooperative relationship between the experts and counterparts, and between the staff of health centers and community organizations was established through the input of the experts who are specialists in the grassroots approach, the smooth management of the Project by the chief advisors, the project coordinator and by use of the participatory approach. As a result, the Project activities were implemented efficiently.

3-3 Factors that impeded realization of effects

(1) Factors concerning Planning

Promotion of an efficient referral system and efficient management of the school health service required a multiple approach beyond the project scope. The issue was too large to be implemented as one of the outputs of the Project. As a result, the Project design was insufficient and the project activities could not have a synergetic effect.

(2) Factors concerning the Implementation Process

N/A

3-4 Conclusion

In the pilot area, the capacity of the Health Center personnel and the people in the area was developed, the residents are able to organize and practice environmental sanitation activities and GMP+. The activities should be recognized as a model for PHC in urban areas and should be extended to other compounds of Lusaka and other urbanized areas of Zambia.

3-5 Recommendations

(1) The established community-based PHC programs should be recognized as a model for PHC countermeasures in the urbanized areas and its effects should be announced to other organizations inside and outside of Zambia so that they can learn from the model.

(2) The Government of Zambia should try to continue the cholera countermeasures and GMP+.

3-6 Lessons Learned

(1) Empowerment of the community in collaboration with the appropriate organization from the technical and administrative points of view, such as the health center, is a key to ensuring the activation of PHC activities. To guarantee sustainability, the participatory approach should be taken both in the planning and implementation stages.

(2) A method which offers multiple components in one package, such as GMP+, can be useful in the transfer of other important messages related to health promotion such as HIV/AIDS and safe motherhood.

(3) The components of the referral system and the school health service are topics which need a multilateral approach, so that they should be tackled as independent projects.

3-7 Follow-up Situation

The five-year Project-type Technical Cooperation "Lusaka District Primary Health Care Project Phase 2" has been implemented from 2002 to 2007, has focused on improvement of the health of under-5 children and its target area has been expanded.