1-1 Background of the Project From the International Year of Child in 1979, the Egyptian government has prioritized policies that would improve the standard of pediatric health care. In support of these aims, the government of Japan supported the construction of the Cairo University Pediatric Hospital (CUPH) through Grant Aid in 1983 and implemented a six-year project-type technical cooperation beginning the same year (Cairo University Pediatric Hospital Project Phase 1). During this period, the Japanese government provided cooperation in both tangible and intangible areas, as with the expansion of CUPH in 1989, and helped to make CUPH the central institution for pediatric medicine.
After the technical cooperation was completed, the Egyptian government requested aid for the second phase of the project to further expand CUPH. Accordingly, a seven-year Phase 2 project was implemented, including a follow-up project focusing on pediatric heart disease. In addition, the Egyptian government designed a renovation plan to restore the functions of the entire facility due to increasing number of patients and deteriorating facilities. The Egyptian government applied again for Grant Aid cooperation to carry out this plan.
This evaluation report focused on Project-type Technical Cooperation Phase 2, and Grant Aid for the rehabilitation project. 1-2 Project Overview The project aimed to strengthen the functions of CUPH and improve overall pediatric medicine in Egypt by transferring technology related primarily to pediatric heart disease treatment, and restoring the decrepit facilities. (1) Overall Goal
To improve pediatric medicine in Egypt. (2) Project Purpose
To strengthen CUPH’s function as a key institution for pediatric medicine. (3) Outputs
1) Diagnosis and medical treatment technology related to pediatric heart disease is improved.
2) Pediatric nursing is improved.
3) ICU and NICU are improved.
4) Diagnosis and medical treatment technology related to pediatric medicine is improved.
5) Diagnosis and medical treatment technology related to pediatric surgery is improved.
6) Laboratory examination room and the x-ray room are improved.
7) System for managing and operating facilities is improved.
8) CUPH designs measures to prevent patients from being infected while hospitalized. (4) Inputs
1) Project-Type Technical Cooperation Japanese Side: Long-Term Experts 23 (phase 2 period) 6 (follow-up period) Equipment 289 million Yen Short-Term Experts 64 (phase 2 period) 24 (follow-up period) Local Cost 369 illion Yen Trainees Received 28 (phase 2 period) 15 (follow-up period) Egyptian Side: Counterparts 24 Land and Facilities 2) Grant Aid: Japanese Side: Total Input 1,412 million yen (1995: 706 million yen, 1996: 598 million yen) |
3-1 Summary of Evaluation Results (1) Impact
Pediatric health care in Egypt has gradually improved, and the infant mortality rate per 1,000 births fell from 119 in 1980 to 76 in 1990, and 37 in 2000 during the cooperation period. At the same time, numbers of doctors and nurses in Egypt has increased to 96,002 and 130,260, respectively. The number of people educated at CUPH, who received intensive practical training, has remained consistent for the past 20 years, with 1,000 students and 500 nurses graduating every year from the medical department. These figures indicate that CUPH trains about 20. 8% of the doctors and about 7.5% of the nurses in Egypt. (2) Sustainability
Due to the transfer of several outpatient clinics to other medical institutions, the annual number of patients has been on a decreasing trend since 2000, but has increased steadily most of the period since the completion of the project. The annual number of hospitalized patients doubled since 1996 (from 7,312 to 14,008), and the annual number of total patients increased by 7.5 times compared to 1983, and 1.4 times compared to 1989. Owing to the ICU which was renovated in the Grant Aid project, the number of newborn patients in the ICU has been maintained around the same level, at 1,261 in 1998 and 1,217 in 2002.
As for the pediatric heart diseases, which was regarded as an important area in Phase 2, the number of heart operations continued to rise (from 197 cases in 1996 to 445 in 2002) after the project implementation. Compared to 1989 when Phase 2 started, the number of cases has increased by ten times. Focus group discussions with the doctors revealed that out of the six important pediatric heart diseases*1, the examination technology for three of them, and the treatment technique for four of them have improved. These techniques were confirmed to be well established at present.
The establishment of knowledge and skill introduced and improved over the course of the project had been classified into three categories by the nurses who participated in the group discussion, as shown in the table below.
Well-established | Contagious infection prevention method in hospital; Cardio-pulmonary resuscitation | Partially- Established | Nursing practice standardization; Infant nursing; Pre- and post-operative management | Not established yet | In-service education at CUPH |
It was confirmed that the knowledge and techniques were established among nurses regarding the maintenance of an infection-free hospital through practice of cleanliness, and also regarding cardio-pulmonary resuscitation, and new nurses were being trained in these areas as well. Regarding in-service education, there are educational materials, as well as nurses who have enough knowledge and techniques to provide training in pediatric nursing. However, such training has been discontinued since the training rooms were converted to operating rooms due to the increasing number of patients.
Operation and management of the hospital facilities are gradually becoming entrusted to external businesses. They inspect central air-conditioning system, electricity units, telephones and elevators on a weekly or annual basis. The boiler system in the hospital, the management of which was the main focus of training during Phase 2, was confirmed to have been inspected and operated every day by CPUH staff members.
One of the things that has not really been established despite the project intervention was the concept of “teamwork for providing better medical services” among the doctors, nurses, and x-ray technicians. The weekly meetings between doctors and nurses, which had been held everyday during Phase 2, are currently held only in the surgery unit. The anesthesia record forms were not used because of limited compatibility. Other than that, “Standardization and digitalization of the patient and treatment records,” “Standard techniques acquisition in the laboratory examination room,” and “Improvement of in-hospital infection prevention” were not confirmed due to the lack of data collected during project period.
As evidenced by CPUH’s name change to Cairo University Specialized Pediatric Hospital (CUSPH) in 1999, the hospital has gained a position as an institution that provides specialized and advanced medical services. Although the number of doctors increased from 239 in 1995 to 361 in 2003 (increase of 122), the number of nurses only increased from 329 to 335 (increase of 6) over this same period. On the other hand, the retention rate of counterparts*2 who received training in Japan is generally high. While 15 of the 21 nurses (71%) and 31 of the 32 doctors (97%) are still employed at the hospital, only one (17%) out of the six medical equipment technicians has remained.
The hospital’s funds come from two sources: the Ministry of Higher Education (through Cairo University), and the Ministry of International Cooperation and the Ministry of Planning. The former is used for operation costs such as energy bills and expendable goods, and has been increased on a regular bases since completion of the project (from 5.46 million Egyptian pounds (115.3 million yen) in 1995/96 to 7.2 million Egyptian pounds (152 million yen) in 2002/03). The latter source budget is used for repairing the facilities and buying equipment, and widely fluctuates every year (the highest amount allocated was 6.82 million Egyptian pounds (144 million yen) in 1997/98, and the lowest was 1.89 million Egyptian pounds (39.9 million yen ) in 1995/96). According to the director of the hospital, the hospital receives donations and additional allocations from the government, and is able to buy expensive medical equipment such as CT scanners.
During the project, equipment whose spare pieces were difficult to obtain were replaced with the ones that could be purchased locally. It was confirmed that such exchanges and updates has been continued even after the completion of the project.
*1 Double outlet right ventricle (DORV), transposition of great arteries (TGA), Tetralogy of fallot (TOF), ventricular septal defect (VSD), atrial septal defect (ASD), and pulmonary stenosis (PS)
*2 Including Phase I (1983-89)
3-2 Factors that Promoted the Realization of Effects (1) Factors Concerning the Planning
N/A (2) Factors Concerning the Implementation Process
Thanks to the strong commitment of political leaders, the government has continued to emphasize policies to improve pediatric health and medicine since the 1980s. Stable budget allocations and additional aid from aid donors have also helped to ensure the project impact. 3-3 Factors that Impeded the Realization of Effects (1) Factors Concerning to the Planning
N/A
(2) Factors concerning to the Implementation Process
The direct cause behind the discontinuation of in-service education is that training rooms was converted to operating rooms due to increasing number of patients. Moreover, there is no in-service education system since no funds were allocated for training and trainers. Low level of awareness was observed toward the importance of in-house education for nurses, while the hospital placed its focus largely on providing routine medical services. 3-4 Conclusion The project focused on the outcomes in the field of pediatric health diseases, and these outcomes were sustained and enhanced after the project implementation. Twenty items were examined in this ex-post evaluation and it was found that three of them were enhanced, 11 of them were sustained, three of them decreased or disappeared, and the remaining three items are not confirmed through the study. Generally speaking, while individual skills, facilities, and equipment were well sustained, those activities which need joint effort by different sections of the hospital, such as record keeping and management systems, either showed weak sustainability or could not be evaluated due to lack of baseline information and monitoring data. 3-5 Recommendations In order to enhance the project outcome and contribute to the achievement of the overall goal, the CUPH should (1) strengthen its educational function as a central institution for pediatrics, (2) thoroughly control in-hospital infections, and (3) promote the digitalization of records. For (1), it is important to make a larger impact on both the CUPH staff and the staff from the Ministry of Health and Population. For (2), this issue must be planned as an individual project, and must include the following three components:, information system management, equipment maintenance, and staff training. For (3), utilization of existing computers and information must be maximized, and therefore software updating, computer training of staff members, and establishment of intranet within the hospital will be necessary. 3-6 Lessons Learned The Phase 2 project boosted sustainability because the equipment maintenance and spare parts replacement can now be done locally. In selecting equipment, the type and specification should be thoroughly investigated and considered with an understanding of local conditions, or only purchase the minimum amount in the early stages of the cooperation, and gradually build them up in keeping with the local conditions. 3-7 Follow-up Situation While medical service in the field of pediatrics has improved to a satisfactory level, emergency care system was not organized well. Hence, JICA implemented “The Pediatric Emergency Care Project in Egypt” from 1999 to 2002 |
