Ex-post Evaluation

1.1 Background of the Project

The prevention and control of the infectious disease is one of the most serious problems for the Ghana health sector, as diseases such as malaria, diarrhoea, respiratory diseases are prevalent in the country. Besides, the countermeasure against HIV/AIDS (Human Immunodeficiency Virus/Acquired Immune-Deficiency Syndrome) has become an urgent problem, since its threat has been escalating. With the increasing prevalence of HIV/AIDS, the other opportunistic infectious diseases such us TB (Tuberculosis) have also been increasing. The Infectious Disease Project at NMIMR in Ghana was planned to cope with such a situation.

Japan began the technical cooperation with the medical department of the University of Ghana in 1968. Based on its outcome, NMIMR was established by Japanese Grant Aid in 1979, where the technical cooperation was continued.

At the end of "Noguchi Memorial Institute Project Phase II", the necessity to cope with the infectious diseases was advocated and the request for the technical cooperation concerning the study/countermeasure of HIV/AIDS and Vaccine Preventable Diseases was made. In response to the request, JICA started "The Infectious Diseases Project at NMIMR" from 1 January 1999.

1.2 Project Overview

Unlike the former projects which focused on the development of research capability for basic medical sciences, this Project aimed at contributing more directly to public health issues; by giving NMIMR a foothold, through the development of its research and training capabilities, it aimed at the capacity development of health-related personnel who were concerned with countermeasures against infectious diseases sweeping in Ghana and improvement of their activities and policy-making process. For this sake, it was concerned not only with research capabilities but also with training capabilities and collaboration with other stakeholders to contribute to the policy-making process and the activities in Ghana Health Sector.

(1) Project Goals

Hyper Goal: The selected infectious diseases in Ghana are controlled.

Super Goal: Incidence and/or prevalence of the selected infectious disease in Ghana are reduced. (Control of the selected infectious diseases in Ghana is improved.)

Overall Goal: Recommendation from infectious diseases project has been adopted for implementation by 2004

(2) Project Purpose

Relevant research and training capability of NMIMR in collaboration with other public health institutions is strengthened.

(3) Outputs

a) Molecular epidemiology of HIV/AIDS in Ghana is delineated.

b) Epidemiology and etiology of STDs (Sexual Transmitted Diseases) in Ghana are delineated.

c) TB reference and research laboratory in Ghana is established.

d) Epidemiology and pathogenesis of the selected vaccine preventable diseases and the other/selected infectious diseases in Ghana are delineated.

e) Bio-safety control system is established.

f) Resources in infectious diseases research and control are developed.

g) Global Parasite Control Initiative is implemented at NMIMR

(4) Inputs (as of the Project's termination)

Japanese side:

a) Personnel

b) Equipment: US$624,000

c) Local cost: US$1,093,918.-
(including consumables & reagents: US$423,205.-)

Ghanaian Side :

a) Personnel

b) Expenses of Salaries, Equipment, Preparation and Maintenance of Facilities and Vehicles, VSAT Installation and Maintenance

3.1 Summary of Evaluation Results

(1) Impact

Achievement Level of the overall goal:

There were not sufficient available documents which can show the number and the contents of the recommendations from the Project and whether or not they were incorporated into the health policy in Ghana to be realized, since they have not always been recorded. Through the interviews and the discussion in the workshop, however, it was confirmed that NMIMR has been collaborating and interacting functionally/practically with MOH and GHS. Yet there is no legal link or institutional relationship between them and the collaboration has been being made according to rather ad hoc technical and financial necessities.

The smooth adoption of NMIMR research recommendations by the MOH and GHS has been influenced by the trends of national programmes and donors' concerns because the country is highly dependent on the donors' support in the public health matters. In other words, it is the most effective way in a sense for NMIMR to present their own research achievements in response to national programmes or along donors' cooperation lines in order to continue and develop their research on infectious diseases with sufficient funds; hence, while the achievement of the overall goal of the project is a direct consequence of the achievement of the project purpose, NMIMR is able to develop its research capability by responding to the needs and trends of national programmes supported by donors. In that sense, the overall goal of the Project was achieved, but it can be one of the conditions for the sustainability of the project as well as a result of the achievement of the project purpose.

Other Impact:

i.Some secondary effects of the training activities have been recognized. Various training activities have enabled some of the trainees employed at different levels of NMIMR and the training in specialised disciplines has brought about the establishment of collaborative research programmes with beneficiary organisations and trainees.

ii. The change in the incidence and prevalence level of each disease which this Project is intended for varies from disease to disease. But because the diseases whose prevalence is being controlled are more then those whose prevalence is becoming higher, the super and hyper goals of this Project are possibly being achieved. The present achievement level of the super and hyper goals as regards each disease is as follows:

• As for measles, the impact is high as the country has not experienced any deaths from measles for the past four years, it has been officially reported as having been controlled and the diagnostic capacity of NMIMR contributed to this achievement.
• As for HIV/AIDS, TB and Schistosomiasis, although their incidence and prevalence has not been reduced to the extent as was expected at the planning stage, they are showing the decreasing trends; the 2005 HSS Report concluded that the overall prevalence in Ghana may be reaching a stabilization stage; although the prevalence and mortality rate of TB decreased only slightly and slowly, its cure rate increased from 55.1% in 2002 to 66.2% in 2005; the incidence cases of Schistosomiasis decreased from 9,834 in 2002 to 4,229 in 2006. The National Programmes on HIV/AIDS and TB have realized positive developments in controlling the disease with research and laboratory support from NMIMR. Concerning Schistosomiasis, there is no national programme and it is difficult to verify the causal relationship between the decrease of its prevalence and this Project.
• For the other two infectious diseases, that is, STDs and VHF (Viral Hemorrhagic Fever), the fact that their prevalence was controlled was not recognized; Syphilis, for which testing has been the most consistently observed among all STDs because it is an important co-factor for HIV transmission, recorded the highest level of prevalence in 2004 since the monitoring of syphilis under the HSS started; VHF prevalence level in Ghana did not change significantly although it has long been relatively lower than in its neighboring countries. It is thought that the results of this Project had no opportunities to be applied practically since neither significant national programme nor donors' funding support has been extended to these diseases.

(2) Sustainability

Research:

HIV/AIDS and TB are included among the diseases which the 2nd Health Sector Programme of Work (2002-2006) designated as priorities, and National Programmes have been being evolved, with which NMIMR is concerned. The research activities and the publications/presentations of research findings on these two diseases by NMIMR have been more active since the terminal evaluation. Therefore, only in these areas, the sustainability of the Project is high, while the researches on the other diseases have been relatively less done.

Training:

NMIMR has been highly sustaining their training capacity. NMIMR has continued to provide training for post graduate students in medical research, undergraduates and public health personnel and the number of students trained at the NMIMR increased. Interest in the NMIMR training has also increased, as the number of applicants or enquiries for students' training/mentorship has increased about 50% annually in 2004-2006. Although the current number of personnel is enough to support the requisite training in infectious diseases, the expansion of scope in research to cover new diseases demands a corresponding increase in personnel to sustain the training components.

Collaboration:

The sustainability of the Project concerning the collaboration with other health institutions and communities is high with reservations; Since 2003, NMIMR has been actively engaged with at least 4 national disease control programmes, particularly using its research, laboratory and training expertise. NMIMR has also provided active inputs on diseases that were not addressed by the Project, like Malaria and Polio, in collaboration with MOH and GHS. NMIMR has established a role within MOH and GHS specifically in areas of quality assurance testing, vaccine/drugs efficacy testing, confirmation of safety and efficacy of traditional medicine, training of laboratory personnel, prevalence, etymological and transmission studies of diseases, etc. But, although NMIMR's research findings have been disseminated to other health collaborators, for example through an Annual Review Meeting, there are no systematic documentations of critical discussion on public health issues, nor is there any groundwork to reach consensus; hence, the limited extent of collaboration.

Financial Situation:

As GOG funds mostly serve the personnel emolument requirements of NMIMR and the institute is obliged to seek sources of revenue for other requirements externally (mainly to donors engaging NMIMR for certain researches), it is crucial for NMIMR to disseminate their research findings through presentation or publication. In this situation, it can be said that NMIMR has been conducting such activities diligently; when this evaluation study was conducted, NMIMR was concerned with at least 17 projects supported by various international organisations or other donors, besides WACIPAC supported by JICA, and there were some projects among them which tackle the same diseases, like HIV/AIDS and TB, as this project.

Yet, although NMIMR's research results have been widely spread, for lack of any legal link or institutional relationship between NMIMR and other health-concerned institutes/organizations in Ghana, each budget support tends to be a single act and NMIMR's financial situation is liable to be influenced by the concerns or interests of other stakeholders.

3-2. Contributing Factors

(1) Factor that has contributed to Impact

Because some national activities to tackle HIV/AIDS and TB have been continuing through National Programmes after the Project terminated, in which other donors also engage themselves, there have been a lot of opportunities for NMIMR to intervene and contribute to those activities directly by making full use of their research and training capabilities.

(2) Factor that has contributed to Sustainability

In Ghana NMIMR has the singular expertise in specialized laboratory diagnosis, possessing the equipment, the technique and the professional scientists; hence, NMIMR has already attained the country-wide fame and social status. There is much expectation of the role of NMIMR to address the critical diseases and the institute can attract considerable attentions from other stakeholders.

3-3 Inhibiting Factors

(1) Factors that have inhibited Impact

• The insufficient human/financial resource and technique in MOH or GHS can make it difficult for them to recognize the significance of research findings of NMIMR as well as utilize them for decision-making.
• The Project Purpose includes the phrase of "in collaboration with other public health institutions" and the statement of "Major stakeholders remains committed to the Project" is among the important assumptions. Yet NMIMR does not have any legal or structural linkage with other public health institutions. Stakeholders should, therefore, have considered and contrive substantial and concrete measures to realize the collaboration during the planning stage. Provided that some activities and outputs had been incorporated into the contents of this Project in advance, each stakeholder would have deliberated this point more consciously, so that the achievement level of the overall goal could have been enhanced.

(2) Factor that has inhibited Sustainability

• NMIMR needs more staff to implement its very important research role.
• The poor infrastructure, especially the long-running electricity crises in Ghana is bringing about faster depreciation of facilities.

3-4. Conclusions

The impact and the sustainability of the Project are recognized with reservation.

The status of NMIMR as an autonomous Ghanaian medical research facility, collaborating with as many local and international organizations in medical-related researches has been unchanged since the terminal evaluation. It can even be said that NMIMR has grown in strength since the time of the terminal evaluation, establishing functional relationship with MOH and GHS. But the extent of the success of the Project has been influenced by the conditions of fund acquisition, hence by the concerns and interests of donors. This is also true of the institutional sustainability of NMIMR. The institute has to continue to develop the capacity to mobilize research funds that would reduce their dependence on donors.

3-5. Recommendations

(1) The Annual Review Meeting of NMIMR and Annual Research Dissemination Forum of the HRU (Health Research Unit) should incorporate mechanism for consensus-building on policy implications and research requirements, as well as follow-up steps to ensure continuity of decision-making; more ideally, legally framed institutional linkage between MOH, GHS and NMIMR should be given in order to establish a public health research agenda that balances scientific research and operational research;

(2) NMIMR should prepare and make always available the documents which summarize concisely their past research achievements and contributions to the nation's health policy so as to be able to represent clearly its own activities and significance publicly.

(3) NMIMR should review the option to improve the management of IGF (Internally-Generated Fund). The institutional research status of NMIMR, both locally and internationally, commands service rates that would cover actual cost of production and maintenance. Yet current charges for the use of facilities and acquisition of supply (e.g. animal models) remain at subsidized levels and NMIMR renders various services utilizing its capacities without charging enough/necessary fees.

(4) Areas of capacity building needed at present for the NMIMR should be identified for future planning by NMIMR, as well as for donors who may wish to support the role of NMIMR in the health sector.

(5) Both NMIMR and JICA should consider the principles of equal partnership for any future collaboration. After its establishment, Japan continuously supported NMIMR through a technology- transfer type of cooperation, so that NMIMR developed its own capabilities to be able to conduct researches independently. This Project, therefore, focused on the direct contribution of NMIMR to public health issues. There is, however, an impression that the project was implemented without clearing off the former style, a technology transfer type of cooperation. Now the personnel of both NMIMR and JICA should intend more deliberately to be premised on mutual trust, transparency, and accountability, to think of the ownership of NMIMR, and to respond to the priorities of NMIMR in the implementation of their mandate to support the aims of government to promote public health. Administrative systems should be also reviewed and enhanced, if necessary, in order to ensure that these principles are upheld.

3-6. Lessons Learned

(1) In case of a research/academic technical cooperation project/programme, an organization which conduct researches/academic studies and one which makes policies or applies research/study findings practically may often be situated separately. Therefore the legal relationship among stakeholders and fund flows should be considered and analyzed fully during planning stages. Significant assumptions should be also set on the bases of such consideration and analysis.

(2)The project planning stage should incorporate formal agreements between JICA and counterparts on the implementation of various levels of evaluation relating to the project. Roles, responsibilities, information required, and timing should form part of the agreement. JICA can also review the approach used by other donors wherein evaluation is one of the major outputs listed in the PDM. In this manner it becomes integrated in the overall planning and targeting.