Ex-post Evaluation

1. Outline of the Project

Country:

Zambia

Project Title:

The Project for Improvement of the Department of Pediatrics and Child Health of the University Teaching Hospital

Issue/Sector:

Telecommunication

Cooperation Scheme:

Grant aid

Division in Charge:

Grant Aid Management Department

Total Cost:

804 million yen

Period of Cooperation

FY 1995

Partner Country窶冱 Implementing Organization:

University Teaching Hospital, The Ministry of Health

Supporting Organization in Japan:

Related Cooperation:

Project-type technical cooperation 窶廰usaka City Primary Health Care Project窶鴀
Grant Aid 窶廰usaka City Project to Provide Basic Medical Equipment窶鴀 Technical guidance on maintenance of procured equipment provided by Japan Overseas Cooperation Volunteer.

1-1 Background of the Project

With a population comprising of over 70% women and children in Lusaka, the capital city of Zambia, strengthening maternal and child health services centered on primary care*1 was regarded as the most important issue. Although the city had 23 urban health centers providing basic health services as a primary medical institution, insufficient consultation techniques among medical care providers created a tendency for citizens to go directly to the University Teaching Hospital (UTH). This led to UTH being unnecessarily congested, hindering its proper function as a top referral health institution. In view of this, the government of Zambia requested the Japanese government to provide a Grant Aid in order to strengthen the function of the University Training Hospital.
*1 A health concept promoted by the World Health Organization (WHO) which is comprehensive, encompassing health services such as initial treatment for illness, check-ups and vaccinations.

1-2 Project Overview

The objectives were to strengthen the function: Firstly as a tertiary medical institution by implementing Grant Aid to construct / remodel and expand an outpatient and isolation ward for the hospital窶冱 pediatrics unit and an admissions ward*2; secondly, as a center of outreach activities to staff at urban health centers (UHCs). By attaining these objects, the project focuses on improvement in the city窶冱 overall health and medical system.
*2 This is the facility which enables 24 hours supervision of patients with relatively serious medical problems to determine their need for medical treatment.

(1) Overall Goal
The health system of Lusaka City is improved.

(2) Project Purpose
The functions of the University Teaching Hospital are intensified.

(3) Outputs
1) An outpatient ward and outreach center are constructed.
2) The isolation ward is upgraded.
3) The admission ward is constructed and expanded.
4) Medical equipment is provided.
5) An incinerator is installed.

(4) Inputs

Japanese Side:

804 million yen

Zambian Side:

Land and Facilities

2. Evaluation Team

Members of Evaluation Team

Planning of survey: JICA Zambia Office Post evaluation: Robert Haloba, DMCG Edward Maembe, DMCG

Period of Evaluation

December 17, 2002 - January 7, 2003

Type of Evaluation:

Ex-post Evaluation by Overseas Office

3. Results of Evaluation

3-1 Summary of Evaluation Results

(1) Impact
The project succeeded in strengthening the hospital窶冱 role as a tertiary medical institution. According to the head of the pediatrics department, only 5% of its patients visit the hospital directly. Most patients go to the Lusaka urban health centers for their first visit and then referred to the hospital. There has also been an increase in the number of patients at the urban health center. The three urban health centers surveyed in this evaluation, all stated that the number of patients has dramatically increased and that the center窶冱 medical skills have improved.

Changes in number of patients at Lusaka窶冱 urban health centers

(2) Sustainability
After the project was completed, the number of outpatients began decreasing after a peak in 1998, while the number of patients in the admissions ward increased until 1999 and continued to stabilize. As a result, the percentage of patients in the admissions ward increased from 52% in 1997 and has fluctuated in the 70% range since 1999. This was because the proportion of patients admitted to the hospital with relatively severe symptoms increased, and the underlying system had also strengthened. The number of patients admitted to the isolation ward increased from 4,981 patients in 1997 to 9,218 patients in 1999, fluctuating more than 8,000 after this point.

The decrease in the number of outpatients and the increase in the number of examination rooms resulted in an increase in the length of the average medical examination, from an average of four minutes (prior to the project) to about fifteen minutes at of the time of this evaluation. The outreach activities that the hospital staffs were expected to run were commenced after the project was completed, targeting some urban health centers. However these ceased to be continued since 1998. It was received that part of the ward was damaged by rainwater and water leaks from the distribution pipes, but the hospital and the constructor working for the project made repairs and the problem cleared up.

On the other hand, the University Teaching Hospital has long suffered from employee losses due to staff leaving to study abroad or changing jobs. Although they attempted to resolve the problem by raising salaries, the hospital has not secured the necessary doctors and nurses. Where 55 doctors are needed, the hospital has only 30, and only 155 nurses where 239 are in need (as of 2002). Some of the equipment do not function efficiently because it is necessary to obtain spare parts and components in the Republic of South Africa , but it was confirmed that most of the donated equipment is maintained by staff in the biomedical engineering department who were training in a JICA cooperation project in the 1980s.

Additionally, operating costs of The University Teaching Hospital are covered by about three quarters of government budget and independent income from medical payments. The government窶冱 budget is increasing nominally but it actually fluctuates a great deal and it is unstable. Converting the budget to US dollars reveals that it is actually decreasing. According to the University Training Hospital窶冱 management committee, the government budget only covers about a third of the necessary sum for operation costs, and occasionally stocks of medical products runs out. Therefore, the hospital窶冱 financial sustainability appears to be quite weak.

3-2 Factors that Promoted the Realization of Effects

(1) Factors Concerning the Planning
N/A

(2) Factors Concerning the Implementation Process
1) The implementation of 窶廰usaka City Primary Health Care Project窶鴀 targeted the urban health centers at the same time and led to improvements in the treatment capacity of the urban health centers and the development of the city窶冱 overall medical system. The project窶冱 impact was intensified.
2) The current national five-year health plan (2001-2005) prioritizes provision of primary health care at the community level. The Zambian government further encourages NGOs to continue collaborating and co-operating in strengthening the provision of primary health care at the community level, which led to strengthening the development of the impact.

3-3 Factors that Impeded the Realization of Effects

(1) Factors Concerning the Planning
N/A

(2) Factors Concerning the Implementation Process
The direct cause of the outreach activities窶餀 discontinuation by the hospital staff was the inability to come up with the money for fuel for the transport to the urban health centers. This problem was due to the fact that the hospital and related organizations did not share the responsibilities for the necessary personnel and budget ahead of time. Currently, the pediatric department has agreed to provide staff and vehicles, and the Lusaka Urban District Health Management Board to bear the cost of petrol.

3-4 Conclusion

The health system of Lusaka City has improved since project completion. The referral system between the urban health centers and the University Teaching Hospital has strengthened, and the number of outpatients at the hospital decreased, with over 95% of them referred by the urban health centers. At the same time, the number of health center patients dramatically increased, which indicates that their medical skills has improved. As the Grant Aid project donated equipment to the health center and was a project-type technical cooperation project that targeted the urban health centers, it consecutively brought about synergy effects. On the other hand, in the University Teaching Hospital, there are still various problems concerning the lack of necessary staff due to the employees窶餀 leave, and the sustainability of the financial aspect such as the decrease of budget.

3-5 Recommendations

The survey revealed that the staff at the urban health had further demands of training. It is expected that The University Teaching Hospital begins its outreach activities based on the agreement as soon as possible.

3-6 Lessons Learned

N/A

3-7 Follow-Up Situation

N/A