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Ex-post Evaluation

Latin America and the Caribbean

1. Project Outline

  • Country: Brazil
  • Project title: The Maternal and Child Health Improvement Project in North-East Brazil
  • Sector: Health Insurance / Medical Care
  • Cooperation scheme: Project-type Technical Cooperation
  • Division in Charge: Medical Cooperation Department
  • Total cost: JPY 900 million
  • Period of Cooperation: R/D: from 04/01/1996 to 03/31/2001
    Extension: No
    F/U: No
  • Partner Country's Organization: Ministry of Health, Brazil / Secretariat of Health, State of Ceará
  • Organizational support in Japan: JICA, Health Planning: JICA, International Health Policy and Planning Department - Faculty of Medicine - The University of Tokyo
  • Related cooperation
    National Conference on Humanized Maternity Care(August 1998)
    International Conference on Humanization of Childbirth and Maternity (November 2000)

1.1 Project Background:

According to the 1993 United Nations Statistical Survey, the Federative Republic of Brazil had a population of circa 150 million people, with a 1.5% average growth rate and infant mortality rate of 57 per 1,000 habitants. The indexes of health and hygiene for the whole nation are equivalent to those of a developing country. Nevertheless, the basic infrastructure in the North and Northeast regions in these areas is fragile, the mortality rate is 92 and the average life expectancy is 51, both per 1,000 habitants. The health indexes in these regions are so low as those in Sub-Saharan Africa.

Aiming at the elimination of the disparity between North and South, the federal government of Brazil created the Unified Health System (SUS - Sistema Unico de Saúde), in order to promote the consolidation of the health and medical systems.

In addition, though the efforts, such as setting up health care planning on infant and mother, have been made to improve the medical care of the socially vulnerable people, access and quality of the medical care services to the low-income classes in the Northeast region are still far from the satisfactory level.

JICA has implemented a basic survey on population, and maternal and child health care in March of 1994 in order to clarify the current medical care situation in the Northeast region and probe the possibility of further cooperation. The results of the survey indicate the need for improvement of the conditions related to the introduction of appropriate family planning, along with maternal and child healthcare in the poor areas of the Northeast region.

Under these circumstances, in November 1993 the federal government of Brazil requested that the government of Japan implement a maternal and child health care project based on medical care support for newborn babies, management of patients with diarrhea, midwife care, family planning, etc.

1.2 Project Overview:

(1) Overall Goal:

Improvement of maternal and child healthcare services in Brazil's Northeast area.

(2) Project Purpose:

Improvement of maternal and child healthcare in the state of Ceará.

(3) Results Expected: (Outcome)
  1. Improvement in awareness, knowledge and technical skills of those engaged in maternal and child health care.
  2. Improvement of reference hospitals and maternity hospitals in the pilot area in the state of Ceará.
  3. Dissemination of the "Humanized Maternity Care" concept throughout all the state areas. (campaign for the reduction of unnecessary medical care intervention and promotion of reasonable and natural childbirth)
  4. Improvement of local residents' awareness and behavior towards the prevention of sexually transmitted diseases.
(4) Output:
  1. Implementation of different types of training in order to reeducate those engaged in maternal and child health care related to childbirth, child delivery assistance, prenatal and postnatal health care, family planning, and emergency birth control methods.
  2. Introduction of LDR (LABOR, DELIVERY, RECOVERY) in maternity hospitals and promotion of the building of "casas de parto" (Childbirth waiting rooms), as well as development of delivery beds suitable for the LDR system and their dissemination throughout the state.
  3. Strengthening of public relation activities and promotion of healthcare education concentrated in the pilot area. Preparation of teaching aids for the visual and hearing-impaired, needed in the referred activities.
  4. Implement a program to promote the use of contraceptive devices (condoms).
(5) Imputs:
Japanese side:
Long-term experts: 8 Equipment: JPY 170 million
Short-term experts: 34Local cost:JPY 90 million
Trainees received: 16Others:
Brazilian side:
Counterparts placement, purchase of equipment, responsibility on local costs, etc.

2. Evaluation Team:

Member of Evaluation Team:
Local Consultant(Ms. DAPHNE HATTNER)
Period of evaluation:
from 1/21/2004 to 3/8/2004 (45 days)
Type of evaluation:
Ex-post Evaluation

3. Results of Evaluation:

3-1 Summary of Evaluation Results :

(1) Project Overview (for details refer to subitem 4. Conclusions).

Overall Goal(Improvement of maternal and child health care services in Brazil's Northeast region):

  • At this moment the super goal has not been accomplished for states other than Ceará, as there was almost no ripple effect from the referenced project to other target regions of Northeast Brazil. However, the concept of "Humanized Maternity Care" has spread in the South region, particularly in the states of Rio and São Paulo.

Project Objective (improvement of maternal and child health care services in the state of Ceará):

  • Improvement of maternal and child health care services was confirmed particularly in the pilot area where the activities of the Project were implemented, in the contiguous areas, and in the organizations where the people engaged in the project operate. The objective of the project continues to be accomplished.
(2) Impact:

The following has been confirmed as to Impact:

  • The referenced project contributed to the introduction of the "Humanized Maternity Care" concept in Ceará state and other regions in Brazil (namely Rio and São Paulo).
  • In the state of Ceará, the dissemination of the "Humanized Maternity Care" concept was restricted to the pilot area and its surroundings. This was because the Secretariat of Planning of the State of Ceará did not participate as a counterpart (the counterparts were the Brazilian Ministry of Health and the Secretariat of Health of the State of Ceará), which made the development of the movement for dissemination to other regions of Ceará state insufficient.
  • The "Humanized Maternity Care" concept spread in states other than Ceará, namely in Brazil's South region (particularly in the states of Rio and São Paulo) and the operations based on this concept have been developing actively. It is hard to affirm that the dissemination of the referenced concept to all regions of the Brazilian Northeast, which was the super goal, has been accomplished, as for states other than Ceará. In Brazil's Northeast region, the independent spirit has been historically high, without the habit of cooperation in executing businesses. Although the Brazilian Ministry of Health, one of the counterparts, had the role to disseminate the activities to other states of the Northeast region, it did not make sufficient effort to do it.
(3) Sustainability:

Sustainability has been confirmed as follows:

  • At the Secretariat of Health of the State of Ceará there was no continuity in the "Humanized Maternity Care" activities. There was neither continuity in the execution of training for persons related to obstetrical care, nor budget availability. There is no specific policy on that matter from the state government. The activities continue to be carried on by the personal efforts of leaders at the municipal level as there has been no policy implemented by the state government. In order to carry on these activities, it would be important to make local government leaders understand the relevance of the theme.
  • These activities continue to be carried on by the municipal secretariats of health and the medical service entities of the surrounding areas of the pilot area where the Project is being implemented.

3-2 Factors promoting sustainability and impact

We confirmed that the "Humanized Maternity Care" concept spread over the pilot area, the place where the training was implemented during the Project, as well as among the training participants, through the execution of training as a Project activity. Although the activities based on this concept have not spread to all areas of the state of Ceará, the concept has spread and is recognized. Regarding the activities of buying and selling condoms, there was an increase in stores dealing with condoms in the state of Ceará and the use of this contraceptive device has spread. In addition, through the holding of an international seminar, the results of these activities were conveyed not only in the Northeast but also throughout Brazil and abroad. In Brazil, particularly in the Southeastern states of Rio and São Paulo, the activities carried on have been influenced by this Project.

3-3 Factors inhibiting sustainability and impact

The awareness regarding "Humanized Maternity Care" by the government of the state of Ceará and among people involved in the health care policy at the municipal level is low and the perception of its relevance and need is quite low. In addition, even if there were people interested in this concept in the local government authority and willing to spread the activities, it would be impossible to maintain policy continuity because of the high turnover in staff.

In the 90's, the Ministry of Health created the new "obstetrician nurse" license (which is obtained by the nurse after completion of a one-year specialized course in obstetrics). As nurses who obtained the license should receive remuneration for childbirth care, there was fierce opposition from obstetricians who wanted to protect their vested interests. This Project also faced the opposition of many obstetricians and maternities, such a organization as the Ceará State Obstetricians Federation (SOSSEGO).

A reshuffling of the concerned health care policy staff occurred following the change in political power in Ceará state. Besides, due to the high turnover rate of the people engaged in the field of health medical care on estate and municipal level (obstetricians, midwives, etc.), it was difficult to maintain policy consistency and continuity. The internal structure of the policy implementation is vulnerable to political power changes and staff turnover.

3-4 Conclusion

The Conclusions are as follows:

  • Improvement in awareness, knowledge and technical skills of people engaged in maternal and child health care:
    Through the reduction of infant mortality rates, and increased use of machines and equipment supplied by the Project, we consider that there was an improvement in the awareness, knowledge and technical skills of people engaged in maternal and child health care at the Project counterpart, as well as the reference hospitals in the areas of Project activity and the pilot area.
  • Improvement of the services of reference hospitals and maternity hospitals in the pilot area in Ceará state:
    Most machines and equipments donated to reference hospitals in this project and in the pilot area are being used (except for a few machines and equipments which are not used due to lack of maintenance).
    Based on the frequent use of those machines and equipments, we may affirm that the services of obstetric installations of reference hospitals and hospitals in the pilot area improved significantly.
  • Dissemination of the concept of "Humanized Maternity Care" through all the state areas:
    Almost all reference hospitals and people engaged in child health care in the pilot area, which were the target of this Project, are aware of "Humanized Maternity Care" and continue to carry on their activities based on this concept. Nevertheless, in other regions there is no implementation of activities despite the awareness of this concept. Also in the case of Ceará state, budget for the implementation of trainings related to this Project has not been secured. Based on the above mentioned, there is no possibility of confirming whether the "Humanized Maternity Care" concept was disseminated to all areas of the state.
  • Improvement of local residents' awareness and behavior towards the prevention of sexually transmitted diseases:
    The most successful component of the project was the program for buying and selling contraceptive devices(condoms). Until now, the program has been actively developed, and the changes in the awareness and behavior of local residents have been confirmed.

3-5 Recommendations:

Based on the results of a site survey, the following is recommended for the attainment of the project goals, at both the state and federal levels.

At the level of the state of Ceará:

  1. Concerned people at the Ceará state government, obstetricians and other interested parties should be involved in activities of "Humanized Childbirth" (including symposiums and seminars)in order to be aware of the relevance of the concept.
  2. Database on important health indicators such as infant mortality rate for each municipality of the state of Ceará should be prepared, opened and made available in public to local government authorities, medical institutions and local habitants in order to make them aware of current health problem, mobilize and involve them in the discussions.

At the federal level:

  1. The federal government should elabrate policies on "Humanized Childbirth" through exchange of information on experiences with international cooperation agencies
  2. Information, data, activities, etc. on experiences of other countries in this field should be introduced in seminars. Well known researcher's presentation on this field should be made.
  3. Technical literature on "Humanized Childbirth" should be made available to people engaged in medical care, such as maternity doctors, etc.. In addition, in order to make information in this field available to the general public, brochures should be prepared and distributed. This would contribute to improvement of the health care services through the increase of general public awareness.
  4. Some maternities in the various regions, which are well known in terms of practice of "Humanized Childbirth" activities, should be designated as reference centers. These reference centers should be regional cores of provision of training and seminars on "Humanized Childbirth" in order for people concerned with health care policy, obstetricians, midwives, etc to improve their techniques .
  5. The training of obstetricians and midwives should be strengthened throughout the country. All activities on "Humanized Childbirth" throughout the country, such as training in the Japan, workshops and others, follow up surveys on the trainees who received JICA's training.
  6. Intensive public relations on JICA's activities in this field should be made in medical magazines, symposiums, academic meetings.

3-6 Lessons learned:

On Impact:

This Project is highly appraised among obstetric midwives and people concerned with medical care related to childbirth and maternity. There are good response and high appraisal from other regions other than the state of Ceará, where the Project has been implemented, all regions of Brazil(particularly the South region), Japan, and countries of Central and South America. This is a fruit of the intensive public relation activities of the Project (especially preparation of home page, and the holding of the international seminar). Even now, particularly in the Southern states of São Paulo and Rio, several activities based on the "Humanized Childbirth" concept have been implemented. However, the dissemination of this concept to the entire Northeast region of Brazil, the super goal of this Project, has not been achieved. In the planning activities of this Project, there was a need to strengthen cooperation between the federal government (Ministry of Health), the Secretariats of Planning of other states in the Northeast region and other state government organizations, with entities engaged in medical care (especially associations related to medical care), NGOs, etc. (this approach may be effective for Northeast states, where there has been a strong tradition to rely on strong local politicians leadership due to fragile basic education and inequitable allocation of resources).

On sustainability

The Project activities received appraisal during the implementation of the cooperation, but the activities related to "Humanized Childbirth" has been removed from the policy priorities of the Secretariat of Health of the State of Ceará, the implementation agency at the time, also as a result of the change in the political power, and the budget at the Ceará state government has not been secured for training of obstetrician midwives and operation of maternity clinics. In addition, activities of the trainees who received training in Japan and the midwives who received local training are not longer considered as part of the state government policy. They continued their activities based on "Humanized Childbirth" concept by their own effort.

Thus, the changes of policy resulting from the changes in the political power in the state government, together with the strong opposition of the Obstetricians Association, led to a situation where it was difficult to obtain sustainable results, with the strengthened actors and investments isolated during the term of Project implementation. The obstetricians and other concerned people continued to carry on the activities individually, and it became complicated to obtain sustainable development of the referenced activities in a social environment where the importance of the "Humanized Childbirth" concept has not been sufficiently understood.

It is necessary to work continuously until the activities related to "Humanized Childbirth" can develop in a sustainable manner.

3.7 Follow-up situation:

The trainees who received training in Japan under this Project has proposed to JICA of holding a "Seminar on the Dissemination of Humanized Childbirth" as a follow-up cooperation. The state government leaders and the representatives of concerned medical care organizations of the state of Ceará and the other regions of all the Northeast states (8 states) will be invited to participate in this Seminar. The leaders and concerned medical care people related to the Project in the state of Ceará at the time should reconfirm their understanding of the relevance of the "Humanized Maternity Care" and a introduction should be made on the relevance of the activities to concerned people in the government of other states and people concerned with medical care, who have never had opportunity to know this concept.


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