Ex-post Evaluation

1.1 Background of the Project

HIV prevalence in Thailand exceeded 1 %, and there is a need for not only preventive measures against HIV infection, but the establishment of a care system to enable social/institutional mechanism to cope with preventive measures against HIV infection as well as construction which makes it possible for people to coexist with AIDS patients in the society.

The Thai government founded the National AIDS Prevention and Alleviation Committee of Thailand in 1991 and formulated the "National Plan for Prevention and Alleviation of HIV/AIDS 1997-2001", and had actively promoted preventive measures until today. Based on the request of the Thai government, Japan implemented the "Project for Prevention and Control of AIDS" for three years from 1993 onwards.

After the implementation of the project, taking the outputs into account and based on the social situation concerning AIDS mentioned above, the Thai government requested the Japanese government cooperation in establishing a care system in districts where a full-scale approach had not yet been initiated.

1.2 Project Overview

Japan provided cooperation in capacity development in the field of health care, the establishment of HIV prevention and a care system, and implementation of community activities, in order to develop the process model of HIV/ AIDS prevention and care in Phayao Province.

(1) Super Goal

1. The number of new HIV infection cases is reduced.
2. Quality of life of people with HIV/AIDS and their families is improved.

(2) Overall Goal

The process model of HIV/ AIDS prevention and care through "Learning and Action Network on AIDS" (LANA) is introduced to other provinces.

(3) Project Purpose

The process model of HIV/ AIDS prevention and care through LANA is developed in Phayao Province.

(4) Outputs

1) Health manpower for solving HIV/ AIDS related problems is developed.
2) An HIV/ AIDS prevention and care system is established.
3) Community response to HIV/ AIDS is promoted.

(5) Inputs

Japanese side:

Thai Side:

3.1 Summary of Ex-Post Evaluation Result

(1) Impact

a. Super goal level

Impact at super goal is evaluated as “high” due to the decreasing of new infection cases in the target provinces and the improved quality of life of the People living with AIDS (PHAs). Data in 2005 reveals the decrease of new infection cases in all targeted provinces comparing to the numbers in 2003.

(CM- Chiang Mai, LPN-Lampun, LP-Lampang, PR –Prea, NN-Nan, PY-Phayao,
CR – Chiangrai, MHS- Meahongson, YST-Yasoton)

Since the target provinces have learned from Phayao Public Health Office (PPHO) experience in HIV/AIDS prevention and care through direct participation in learning process or series of workshop and study visit, it is assumed that the reduction of new HIV/AIDS cases is partially the effect of Learning and Action Network on AIDS (LANA) project. On the other hand, the UNICEF report reveals that, there might be other causes of the reduction such as the commitment of central government to launch national campaign against HIV/AIDS, education efforts, promotion of condom use and the capacity building of community to participate in HIV prevention. The quality of life of the PHAs has improved. 80 percent of them are physically stronger after receiving Antiretroviral Treatment (ARV). They can rely more on themselves in daily activities and less on their family members. However, income generation and food production of the PHAs could be better if the agricultural activities are promoted since most of them are farmers.

b. Overall goal level

The impact attained at the overall goal level is evaluated as “moderate” based on the facts that there were a few provinces that introduced process model of HIV/AIDS prevention and care: 1) Yasoton province introduced a component of care network by establishing a day care center in one community hospital and installing the information system making use of the study visit to PPHO, 2) Chiang Mai Public Health Office introduced a component of health manpower development by training 8 personnel as facilitators and establishing 6 sub-districts as the learning sites, and 3) Some provinces under Office of Communicable Diseases Control for Region 10 (CDC 10)* introduced a component of care network by adjusting their information system following the PPHO experience learned at workshops organized by CDC 10. However, it was found that none of the provinces have adopted the whole set of the process model due to the complexity of each component.

*CDC10 covers 8 provinces in the Northern part; Chiangmai, Lampun, Lampang, Prea, Nan, Phayao, Chiangrai and Maehongson

(1) Sustainability

Sustainability of the project is evaluated as “high” based on 1) technical aspects, 2) financial aspects, and 3) organizational aspects.

1. Technical aspect is evaluated as “high” based on the good maintenance and calibration of equipment and the continuous use of laboratory equipments. The counterpart agency has maintained and calibrated the project equipment properly. 10 items were replaced with other compatible equipments because of the high cost for maintenance and operation, leakage and difficulties to find battery. Blood testing equipments in the Phayao Provincial Hospital Laboratory have been used continuously in good conditions after the Project.

* CD4 is a type of white blood cell that fights infection.
** Viral Load testing measures the amount of HIV in the blood.

2. Financial aspect is evaluated as “high” since the amount of budget allocated for HIV/AIDS related activities has increased since 2003. See the budget sheet below.

* Ministry of Public Health

3. Organizational aspect is evaluated as “high” based on 1) the revision of Phayao Provincial HIV/AIDS Prevention and Care Committee where PPHO staff played important roles in providing information and coordination with different government organizations, 2) the maintenance of PPHO staff to take care the man power development, information system, laboratory, community response and aids action center, 3) the collaboration with other provincial offices, and 4) the increase of trained staff from 32 to 40 during 2004-2005.

4. Sustainability of the project effects are evaluated according to 3 project outputs; health manpower development, care network and community response. They are evaluated as “high” based on the facts that 1) PPHO staffs are practicing the lessons learned from community assessment activity and applying those lessons in their daily work. 2) The number of PHAs who visit day care centers increased and one more information system was established. 3) AIDS committee at a sub- district became a decision making body for the sub-district development activities.

3.2 Factors that have promoted project

(1) Impact

Factors contributing to the project impact are 1) the MOPH policy on the National Access to Retroviral Program for PHA (NAPHA). This program enables the PHAs to have better access to medical treatment. As a result, they are physically stronger and earn enough income to sustain themselves in daily lives. Their quality of life has improved. 2) HIV/AIDS Prevention and Care received financial support from International Organizations. The supports are for clinical system development, technical training of health staff, education and food for children and conclusion of lesson learned. 3) Support from NGO and The Daughters of Charity of Saint Vincent De Paul on the child right, occupation promotion, and education and social welfare. It is considered that their contributions have supported the care network effectively. 4) CDC10 supports Health Manpower Development. Man power development is one of its major policies. Specialized health officer teams have been established and strengthened to improve the health service system. The policy could improve both health manpower and care network. 5) Transfer of the well trained health officers to other districts is proved to be an appropriate approach in order to expand the project effects.

(2) Sustainability

Decentralization Policy to Local Administration Organization. Central government allocates budget to local administration organizations to support the PHAs in their responsible areas. In the fiscal year 2005, the local administration organizations start to allocate the total amount of 2,982,000 Baht to support PHAs in Phayao province. The budget allocation to these organizations to support PHAs tends to increase year by year according to the decentralization policy of the central government.

3.3 Factors that have inhibited project

(1) Impact

Followings are the factors inhibiting the project impact: 1) Complexity of the process model which prevents the dissemination of the whole set of process model to other provinces. It requires time, budget and resource persons to transfer knowledge on Health Man Power Development and Community Response to other provinces. 2) Lack of coordination with government agencies dealing on agricultural development issues even though the majority of the PHAs are farmers.

3.4 Conclusion

After the project completion in 2003, the project impact at super goal is evaluated as “high” due to the decreasing of new infection cases in the target provinces and the improved quality of life of the PHAs. The impact attained at the overall goal level is evaluated as “moderate” as there were a few provinces that introduced process model of HIV/AIDS prevention and care, although none of the provinces have adopted the whole set of the process model due to the complexity of each component.

Sustainability of the project is evaluated as “high” based on 1) technical aspects, 2) financial aspects, 3) organizational aspects, and 4) project-effect aspects. In terms of technical sustainability, the counterpart agency has maintained and calibrated the project equipments properly. The blood testing equipments are continuously operated. Moreover, financial support to PPHO from different sources for HIV/AIDS related activities has increased since 2003. The sustainability of the organization aspect could be observed from the increased role of PPHO staffs in the provincial HIV/AIDS prevention and care committee to coordinate with other government agencies, the high maintenance level of the staff to implement the project related activities and the increased trained staff from 32 to 40 during 2004-2005. Sustainability of the project effects are evaluated according to 3 project outputs; health manpower development, care network and community response. They are evaluated as high based on the facts that PPHO staff could apply the lessons learned from community assessment activity in their daily work, the number of PHAs who visit day care centers increased, and AIDS committee at a sub- district becomes a decision making body for the sub-district development activities.

There are several factors that have promoted the impacts. MOPH policy on the National Access to Retroviral Program for PHA (NAPHA) helped the PHAs to get better access to medical treatment so that their physical health becomes stronger. International Organizations, NGOs and religious sectors provide financial support, occupation promotion, education activities and social welfare. CDC10 organizes specialized health officer teams to improve the health service system. Moreover, the transfer of the well trained health officers to other districts contributed to expand the project effects.

Decentralization Policy to Local Administration Organization is considered as promoting factor to the project sustainability. The local administration organizations could be able to support the PHAs in their responsible areas using the budget allocated by the central government under this policy.

Lack of coordination with government agencies dealing with agricultural development is considered as the inhibiting factor to promote food production or economic development of the PHAs since most of them are farmers. Moreover, the complexity of the process model has inhibited its introduction to other provinces.

Based on the above results, recommendations are developed for JICA and PPHO. Lesson learned is also presented.

3.5 Recommendations

FOR JICA:

The process model of HIV/AIDS prevention and care is developed successfully in Phayao province. More PHAs have better access to medical treatment. Health Manpower capacity is developed to analyze the PHAs situation based on the facts attained during the community assessment and plan for development. A community response learning process has been implemented. This process model could be of great contribution to the neighboring countries where HIV/AIDS is the major threat. JICA may organize study visit for public health officers from the neighboring countries to visit PPHO. A one week study tour could be enough to learn the essentials of the project components. Ban Tam sub-district of Phayao province is highly recommended for visitors to learn about community response. Chun Hospital and Phayao hospital are recommended for the demonstration of day care centers. Chiangmuan district health office and PPHO are the two offices where information system could be observed.

FOR PPHO:

(1) Promotion of the community response in other sub-districts.

Four sub-districts of Phayao province have been implementing the community response activities created during the Project. These activities were prepared based on the needs of the PHAs. It is proved that the activities could help the PHAs to overcome social and economic problems. However, this learning process has not been transferred further to other sub-districts systematically. Considering the fact that PPHO retains staff that could facilitate the process and set the four sub-districts as learning sites, it is recommended that PPHO organizes the transfer of knowledge to other sub-district using the available human resources. It could start with the sub-districts where people show their interest and commitment to help the PHAs. The AIDS committee of Ban Tam sub-district could be used as a model of development for others.

(2) Coordination with agricultural development organizations

Most of the PHAs in Phayao province are farmers. In the area, they have limited job opportunities in agriculture due to the decreased labor availability, landlessness and insufficient water for agriculture. PPHO should coordinate with organizations dealing with agricultural development such as office of agricultural extension and provincial irrigation office in order to create job opportunities for the PHAs. Self-sufficient agriculture may be introduced to secure food at family level. Traditional small scale irrigation may be constructed in the area where water resources are available.

3.6 Lesson Learned

The sustainability of the project effects on both Community Response and Care Network is evaluated as “high”. They are both needed in order to deal with PHAs' difficulties. However, to implement only one of the components may not produce enough results to overcome all the PHAs' problems.

The PHAs usually face four main problems; psychological, social, economic and physical problems. The Care Network provides medical treatment and psychological counseling. Eighty percent of the PHAs in the study area get better after the continuous medical treatment. As a result, they can rely more on themselves. However, they still face social and economic problems. The Community Response process helps them to overcome these problems. It facilitates the stakeholders at community level to take better care for the PHAs, to live with them without any distinctions and to raise fund to support them. The PHAs are encouraged to participate in the activities.

Ban Tam sub-district of Phayao province is the successful community where these two components were implemented and good outcomes were produced. On the other hand, Yasoton Provincial Health Office has learned and implemented only the care network component. It could increase the number of PHAs accessible to medical treatment and expand the network by organizing the youth camps. Nevertheless, supports from communities to the PHAs on social welfare and social awareness were not observed. Therefore, it can be said that implementation of both community response and care network should be considered to obtain higher results.