Ex-post Evaluation

1.1 Background of the Project

The health status in the Indonesia was improving but infant mortality rate and maternal mortality are lower than those of other ASEAN countries. In Indonesia, there were big differences among provinces and between urban and suburban areas on health indicators. The Government of Indonesia proposed the project to assist the human resource development in the island of Sulawesi where the health situation was worse than that others areas.

The project would intend to strengthen district services through the three sub-project as follows; (i) Human resources development to reduce preventable death, (ii) Introducing problem-oriented action research (PROAR) in the three pilot areas, and (iii) Strengthening the district laboratory system through introducing quality assurance in the three pilot areas.

1.2 Project Overview

Project for Improvement of District Health Services in South Sulawesi consist of Human Resource Development (District Health Manager and Mother Child Health), Problem Oriented Action Research (PROAR) and Laboratory Quality Assurance.

(1) Overall Goal

To contribute to reduction of deaths through strengthening of district health services in South Sulawesi Province

(2) Project Purpose

To strengthen district health services through the three sub-projects as follow,
a) Human resources development to reduce preventable deaths,
b) Introducing problem-oriented action research (PROAR) in the three pilot areas (Pilot Project),
c) Strengthening the district laboratory system through introducing quality assurance in the three pilot areas (Pilot Project).

(3) Outputs

a) Human Resource Development

• Heads of district health officials develop their capabilities to manage district health service
• Officials of provincial health service (offices), and district hospitals develop their capabilities to train district health personnel
• Doctors, nurses, midwives and village midwives develop their knowledge and technical skill to practice essential medical care for reducing preventable deaths.
• Staff of health centers develops their capabilities to improve daily services by introducing the quality assurance method.
• Staff of provincial health laboratories develops their capabilities to train district laboratory technicians.
• Training methods and modules for improvement of district health services are strengthened

b) Problem-oriented action research (PROAR)

c) Strengthening district laboratory system
The Laboratory Quality Assurance system is introduced in the pilot areas.

(5) Inputs

Japanese side:

Indonesia side:

3.1 Summary of Evaluation Result

(1) Impact

The project decreased Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR) and improve health management in the districts health service. It improved the human resources capabilities in provincial/district health services, central laboratories, PUSKESMAS staffs, doctors, nurses, and midwives. The overall goal of the project to contribute to in reduction of deaths through strengthening of district health services in South Sulawesi Province has been highly achieved.

The other positive impacts of the project is establishment of network cooperation among the provincial/district health services, Hasanudin University, Faculty of Public Health and other universities in Java.

(2) Sustainability

Even the executive training stopped since the completion of the project, the Health Policy & Administration Postgraduate Program and Hospital Administration Postgraduate Program, Hasanuddin University continue by self-financial funding from the government. The students not only come from Sulawesi but also from Maluku and Kalimantan.

The training of PROAR, MCH and Postgraduate Program, and laboratory activities are financed by the central government through APBN and province government through APBD. The institutions, which organize the trainings, are District Health Officials, Central Laboratory, Faculty of Public Health Hasanuddin University, and Siti Fatima Hospital Makassar.

The equipments provided by the project in Central Laboratory are operated and maintenance well.

From the fact mentioned above, it can be concluded that the project is highly sustainable.

3-2 Factors that have promoted project in the aspect of:

(1) Impact

The commitment of the dean, all lecturers of Postgraduate Program University of Hasanuddin and cooperation with the universities in Java are very high. Central laboratory is an excellent and reputable laboratory, having capable human resources and complete equipments and recommended as reference laboratory in East Indonesia.

In some PUSKESMAS, the programs and activities are controlled, monitored and evaluated based on standard quality indicators. In addition, midwives and village midwives should have APN Certificate to open the midwives practice, for controlling the quality of midwives.

All the mentioned factors have promoted the project impact.

(2) Sustainability

The alumni of Health Policy & Administration and Hospital Administration Postgraduate Program Hasanuddin University promote the programs in where the alunmi works. Central Laboratory is in an accreditation process that will improve the quality and strengthen the human resources of the central laboratory.

The financial subsidy from Central Government supports the sustainable of PROAR training, MCH and Postgraduate Program, and laboratory activities. Government regulations with regard to the decentralization system are appropriate and support the districts to develop PROAR. The province government supports the districts to develop the model of PROAR.

The acceptance of APN as a curriculum at Academy of Midwives and Faculty of Medicine become also the factor that has promoted the sustainability of the project, beside the factors mentioned above.

3-3 Factors that have inhibited project in the aspect of:

(1) Impact

The project impact has inhibited by the cost of executive training and postgraduate program that is considerable high. Some hospitals laboratory have no complete equipments and instruments, less PROAR supervision to PUSKESMAS, and less APN supervision after the trainee back to his/her workplace by the Province/Districts health official become also the factors that have inhibited the project impact.

(2) Sustainability

Less budget for financing the activities of province / district health services become the factor that inhibited the project sustainability. Other factors are capabilities of lecturers, skill of Health Policy and Administration staffs and laboratory technicians that need to be improved for supporting the sustainability of the project.

3-4. Conclusion

The purpose of the Project for Improvement of District Health Services in South Sulawesi has been achieved and contributed in reduction of deaths through strengthening of district health services in South Sulawesi Province. The impact of the project is spreading in the districts of the province in high sustainability; even there are some factors that inhibit the project impact and sustainability.

3-5. Recommendation

To enhance further impact of the project, the following recommendations are suggested to the Provincial and District Health Services in South Sulawesi:

1) To promote PROAR training in districts, strategic training of trainers is required in districts that were not attended the PROAR training previously. Supervision and monitoring of PROAR trainer alumni at their workplace is necessary to evaluate the implementation and dissemination of training result.

2) To improve the human resource development, the provincial and districts health offices are suggested to sustain executive training and post graduate program of mid-level district health manager in cooperation with the Faculty of Public Health, Hasanudin University.

3) The provincial and districts health offices are suggested to sustain APN training of doctors, nurses, midwives and villages midwives for developing their knowledge and technical skill in practical essential medical care for reducing preventable deaths.

4) To conduct workshop or seminars about bottom-up policy for planning of PUSKESMAS program and supervise, monitor and evaluate the PUSKESMAS for future improvement.

3-6. Lessons Learned

For more effective and efficient of the similar project in the future, such as "Improvement of Health Service in Sulawesi", improvement of lecturers' capability and skill of Health Policy & Administration is important. Government supports in view of policy, regulation and financial are essential.

3-7. Follow-up Situation

The provincial health services continues to disseminate the project impact by conducting training of PROAR, APN, Laboratory Quality Assurance for doctors, nurses, midwives and village midwives, head of PUSKESMAS and the staff and laboratory technicians in district level. A system for monitoring the implementation of training result at their institutions will be set-up.