SUMMARY OF TERMINAL EVALUATION
1. Outline of the ProjectCountry: People’s Republic of China(hereinafter referred to as ‘China’)

Project title: Project for
Vaccine-Preventable Diseases

Issue/ Sector: Health

Cooperation scheme: Technical Cooperation Project

Division in charge: JICA China OfficeTotal Cost: (As of June 2011) 565 million JPY

Period of
Cooperation

Partner Organization:-Ministry of Health of People’s Republic of China-Chinese Center for Disease Control and Prevention (CCDC)-Provincial Health Offices and Provincial CDCs in three provinces
and two autonomous regions (Jiangxi, Sichuan, Gansu, Ningxia andXinjiang)

Dec. 2006- Dec. 2011
(Five years)

Surveillance

andControlfor

Supporting Organization:-National Center for Global Health and Medicine (NCGM)-National Institute of Infectious Disease (NIID)
1-1 Background of the Project
Government of People’s Republic of China (hereinafter referred to as Chinese government) has implemented the
Expanded Programme on Immunization (EPI) since 1978 and the program has greatly contributed to control theinfectious disease such as poliomyelitis (polio), measles, hepatitis B and Japanese encephalitis. Regarding with polio,
Japanese government has particularly contributed to capacity development of concerned personnel and establishmentof system for EPI through Grant Aid and Technical Cooperation, coordinating with World Health Organization (WHO)and United Nations Children's Fund (UNICEF). As a result, Chinese government accomplished to declare theeradication of polio from China in 2000.
Currently, however, there has been magnified a economical gap between rural and urban area in China, and as
for infection control, the potential risk of the epidemic for infectious disease is increasing because of a lack of capacity
in surveillance and systems concerned with EPI. Moreover, the elimination of measles and the control of hepatitis B by
2012, and the maintenance of polio-free status were agreed on the ministerial level meeting of the WHO Regional
Office for the Western Pacific (WPRO) held in 2005. Chinese government is facing with the improvement of theservices of EPI particularly in rural areas toward the achievement of these goals. In response to above, the Project for
Surveillance and Control for Vaccine-Preventable Diseases has been launched in December 2006 which lasts for five
years in cooperation with MOH, CCDC and provincial CDC, which is based on the earlier outputs of the cooperationthat Japanese government had implemented in the past.
The project purpose is to improve the quality of the immunization services and the level of surveillance in rural
areas. In the implementation of the Project, the following five outputs were planned to achieve the project purpose infive Midwestern provinces and autonomous regions; 1) strengthening of surveillances, 2) improvement of the functionof laboratory diagnosis of CDC, 3) establishment of the coordinating system among organizations concerned with EPI,
4) improvement of the EPI services and 5) strengthening of the education of advocacy regarding EPI. Based on the
result of the Mid-term Review in March 2009, the Project has started to concentrate more on the activities related to themeasles elimination by considering the priority in achieving the project purpose.
Regarding measles, despite the coverage of vaccination has reached more than 95%, the trend of the decrease of
the incidence has not yet confirmed and outbreaks has occurred periodically. Against the issue above, the Projectassessed that one of the reasons causing this issue was difficulties for people including the floating population andethnic minority groups in access to the EPI services. Therefore, the Project has focused on the support for “thechecking-up of immunization record and supplemental immunization of the children who missed routine immunizationi(hereinafter referred as to “the checking-up of immunization record and supplemental immunization”)” after the
Mid-term Review, and the Project has worked for developing and trial of the school teachers’ manual for the
implementation of the checking-up of immunization record and supplemental immunization, implementing andmonitoring of the training for the checking-up of immunization record and supplemental immunization and promoting
the awareness of them including the EPI services. Through the activities mentioned above, the Project has made efforts
to promote coordinating among the organizations such education sector (Bureau of Education, Primary Schools andKindergartens), and to introduce the Training Cycle Management. Also, the Project has strengthened cross-sectoraladministrative capacity and has established its system to minimize the harmful influence which is caused by many
vertical programs in critical settings.
1-2 Project Overview(1) Overall Goal: The health for children is improved in the five target provinces and autonomous regions through thecontrol of diseases associated to the Project.
(2) Project Purpose: The level of surveillance and the quality of immunization service is improved in the five target
provinces and autonomous regions in the Project.
(3) Outputs：
1） Field surveillance, including regular monitoring, monitoring and supervision, and reporting system, isstrengthened.
2） Network for polio laboratories is strengthened, diagnostic level of measles laboratories at each level is improved,and cooperation to Japanese encephalitis laboratories is maintained.
3） The system for linkage and communication with other organizations related to EPI is established.
4） Immunization services are improved.
5） The activities for education and advocacy related to immunization are enhanced.
(4) Input (at the point of Terminal Evaluation) ( Total Cost: 565 million JPY)
Japan:
Long-term Experts
6 persons
Provision of Equipment
9,224,468 CNY1
Total 43 persons
Short-term Experts
Cost for Activities
9,323,779 CNY
Trainings in Japan
45 persons
Cost for Equipment
401,340 CNY
China:Counterparts
144 persons
Local Cost
180,205,900 CNY
Project Office in CCDC was provided by the Chinese side.
2. Review Team
Members

LeaderInfection
Control

Dr. Hiroshi YOSHIKURA

EPI
Administration

Dr. Tamotsu NAKASA

Cooperation
Planning
Coordinator

Mr. Ryotaro ODA

Deputy Resident Representative, JICA China OfficeDirector, the Department of Disease Control,
the Ministry of Health, China
Councilor, Pharmaceutical and Food Safety Bureau,
Food Safety Department, Ministry of Health, Laborand Welfare
Director, Expert Dispatch Services Center,
Department of International Medical Cooperation,
National Center for Global Health and Medicine
Program Officer, JICA China Office

Dr. LIU Ran
Ms. Michiko FUJIMOTO

National Staff (Health Sector), JICA China OfficeSenior Consultant, Fujita Planning Co., Ltd.

Memberfrom
Chinese side

Evaluation
Analysis

1

Ms. Kazuko KURASHINA
Dr. LI Quan-Le

1 CNY was converted to 14.4856JPY in JICA regulated rate as of June 2011.
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Period of Evaluation

May 29th- June 28th, 2011

Type of Evaluation: Terminal Evaluation

3. Results of Review
3-1. Verification of Performance(1) Achievement of Outputs
1) Output 1: Field surveillance, including regular monitoring, monitoring and supervision, and reporting system, isstrengthened.
In the first half of the project period, trainings related to polio Acute Flaccid Paralysis (AFP) surveillance,
measles surveillance and hepatitis B surveillance were carried out. It is confirmed that field surveillance which is
obligated to the CDC at each level by MOH was implemented appropriately judging the result of the review by WHO.
In the latter half of the project period, the support to the checking-up of immunization record and supplemental
immunization has been implemented. The pilot provinces and autonomous regions have recognized the checking-up of
immunization record and supplemental immunization as a part of field surveillances. Moreover, the information inschools regarding epidemic of infectious disease such as measles has come to be reported immediately to the healthorganizations due to the strengthening of the coordination between the educational department and the healthdepartment. In addition to the fact that the checking-up of immunization record and supplemental immunization is apart of surveillance, it also strengthened the coordination between the schools and the health department including
CDCs and clinics as a platform in implementing surveillance. Therefore, trainings and surveillances mentioned above
are implemented appropriately in terms of both quality and quantity.
2)

Output 2: Network for polio laboratories is strengthened, diagnostic level of measles laboratories at each level isimproved, and cooperation to Japanese encephalitis laboratories is maintained.
Since Mid-term Review, total 9 members from CCDC and provincial CDCs participated to the training courses
held in NIID in Japan to strengthen the function of measles and polio laboratory; 3 persons to “learning techniques forlaboratory diagnosis of polio eradication”, 3 persons to “learning laboratory diagnostic techniques for the global controlof vaccine-preventable diseases including polio”, and 3 persons to “inspect and acquire measles virus genetic testing
technology”. After joining the training courses, the participants provide their gained knowledge and skills to theircolleagues in the CDCs they belong to or staff in the lower branch of the organizations through the routine trainings.
Thus, the outputs of the trainings have been expanded to the personnel not concerned with the Project directly. In
addition to the outputs mentioned as below, the functionality of laboratories has been steadily improved. The reasonsare as follows; 1) the result of annual WHO accreditation of province laboratories for polio and measles reached toregulated standard in the project period, 2) the result of WHO proficiency test of province laboratories for polio alsoreached to more than 95%. Also, laboratory equipment provided from Japan under the Project are used properly, it was
confirmed that equipment provision has contributed to improve diagnostic techniques relating the Project. Regarding
the cooperation with laboratory in the field of Japanese encephalitis, it was confirmed at the Mid-term Review that theoutputs were achieved at the satisfactory level which has been maintained until the point of the Terminal evaluation.
3)

Output 3: The system for linkage and communication with other organizations related to EPI is established.
“Five-provinces meeting” has been conducted annually or biannually in the Project. The meeting gave theopportunities for the counterparts in each province to share and exchange experiences regarding the EPI activities, andto make it better to analyze the current state and situation for themselves. As a result, EPI activities have been improved
through the meeting. In addition, experts attended nation-wide and international conferences such as “EPI advisorygroup meeting”, “Anti-measles nation-wide meeting”, “Interagency Coordinating Committee”. Through the attendanceof the meetings, the communicating and coordinating system with the internal/international organization such as WHO
and UNICEF has been strengthened.

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4)

Output 4: Immunization services are improved.
In the latter half of the project period, the Project mainly supported to the activities of checking-up of
immunization record and supplemental immunization at the pilot districts; two pilot districts were selected in eachprovince. It aimed at raising the coverage of immunization. In 2009, the Project supported for three provinces and two
autonomous regions to give the official notice on carrying out the checking-up of immunization record andsupplemental immunization which indicates mission, procedures and responsibilities for the each concernedorganization. Moreover, the Project developed “teachers’ manual of the checking-up of immunization record andsupplemental immunization” for teachers in kindergartens and primary schools. To introduce the official notice and themanual at the pilot districts, the Project conducted trainings of trainers and participatory trainings for the personnel on
the field of both health and education together to reinforce their knowledge and skills. The total number of training
participants reached to 12,969 in targeted provinces.
After carrying out above project activities, the coordinating system between the health department and theeducation department was tightened, and the responsibility of each department on the checking-up of immunization
record and supplemental immunization of the incomplete immunization children was clarified. As a result, thechecking-up of immunization record were carried out with less error. Currently, almost 100% of the children who areentering schools in pilot districts have received the checking-up of immunization record. Compared with the coveragerate of supplemental immunization at whole provinces to which the pilot district belong, the coverage of pilot districts
has increased. Especially, the coverage of supplemental immunization for measles has increased (whole provinces:
89.05%, pilot districts: 96.8%). Though quality of the checking-up of immunization record and supplemental
immunization has been improved in the pilot districts as described above, the effects of the pilot districts have not been
fully disseminated to other districts at the point of the Terminal Evaluation. Also, the study for the Terminal Evaluation
revealed the problems to be improved in implementation of the checking-up of immunization record and supplemental
immunization, such as the procedure and the method of following-up.
In addition to the project activities listed above, the trainings to strengthen the epidemiological administration on
EPI were conducted in Japan. The participants of the trainings have worked on the project activities as leading
personnel and have contributed producing the outputs of the Project.
Also, the equipment concerned with cold chain provided from Japan was effectively used in the project sites.
Particularly, the supplemental provision of the refrigerators and vaccine carriers was carried out timely and urgently,
when the disaster of an avalanche of rocks and earth occurred at Zhouqu district in Gansu Province in August 2010. It
prevented outbreak of infectious diseases in the stricken area.
5)

Output 5: The activities for education and advocacy related to immunization are enhanced.
Each CDC at three provinces and two autonomous regions developed posters and goods for advocacy regarding
the checking-up of immunization record and supplemental immunization of the incomplete immunization children.
And also, CDCs utilized communication tools such as commercials on TV and short messages of mobile phones, so as
to advocate the checking-up of immunization record and supplemental immunization to ordinary people. On the other
hand, teachers and the rural doctors who were educated through the training conducted as activity of Output 4, came tosend parents the information about the checking-up of immunization record and supplemental immunization. In
response to the activities mentioned above, it was confirmed on site survey in the Terminal Evaluation that the parentsin every pilot district got to be more cooperative with the checking-up of immunization record and supplemental
immunization, compared with before launching of the Project.

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(2) Achievement of Project Purpose: The level of surveillance and the quality of immunization service is improvedin the five target provinces and autonomous regions in the Project.
The reported coverage rates of immunization for polio, measles, and hepatitis B have been maintained at highcoverage rate. Also, the surveillances regarding polio and measles have been properly conducted as the WHO
reviewed. The implementation of the checking-up of immunization record and supplemental immunization of theincomplete immunization children made the coverage of supplemental immunization on polio, measles, Japanese
encephalitis and hepatitis B increased. Therefore, it is highly expected to achieve the project purpose until the end of
the project period. The respective reported coverage rate for target diseases are shown as follows.
*Polio(2010): Jiangxi 99.81%, Sichuan 99.33%, Gansu 99.80%, Ningxia 99.56%, Xinjiang 99.41%*Measles (2010): Jiangxi 99.70%, Sichuan 99.03%, Gansu 99.55%, Ningxia 99.46%, Xinjiang 95.99%*Hepatitis B(2010, Immunization within 24 hours of birth): Jiangxi 95.40%, Sichuan 87.71%, Gansu 93.05%, Ningxia
95.92%, Xinjiang 86.30%*Hepatitis B(2010, Completed case for immunization 3 times): Jiangxi 99.86%, Sichuan 99.33%, Gansu 99.80%,
Ningxia 99.52%, Xinjiang 99.27%(3) Prospect of Overall Goal: The health for children is improved in the five target provinces and autonomous regions
through the control of diseases associated to the Project.
Currently, significant outputs were generated in nationwide through a series of EPI activities under the guidanceof the Ministry of Health in China. Although the polio-free is maintained at the point of the Terminal evaluation in May
2011, it is necessary to strengthen the prevention of the imported infection by wild polio virus because the major
outbreak of polio occurred in neighboring Tajikistan in 2010. Incidence of measles have been reduced to the lowest
level in history, however it has not been eliminated yet. The infection of hepatitis B has been adequately controlledcurrently, and especially, the prevalence rate of hepatitis B antigen for children under five years has reduced below 1%.
Infection of Japanese encephalitis is well controlled. Judged based on the situation mentioned above, EPI-related
infectious diseases in the target provinces are controlled effectively, and it is expected that the standard of health forchildren is improved.

3-2. Summary of Evaluation Results(1) Relevance
Considering the policies related with the EPI in China and WPRO and the consistency with the Japanese ODA
strategy, the relevance of the Project is high. Policies for EPI strengthening are indicated in “11th five-year plan(2006-2010)” and “Health sector reform (2009-),” and polio-free, elimination of measles and control of hepatitis B
which are all targeted I the Project are set as regional common purpose in WPRO region.
(2) Effectiveness
Effectiveness of the project is high. Regarding the strengthening of the field surveillance and the functionality oflaboratory, the Project executed the dispatch of experts and equipment provision in the first half, and the trainings inJapan in the latter half of the project period. Also, Ministry of Health in China has strengthened the management
system for disease control from the aspect of administration. The system regulates that administrative organization at
upper level provides technical guidance and monitoring to the organization at lower level. On the other hand, thecooperation for the checking-up of immunization record and supplemental immunization in the latter half of the project
period strengthened the coordination between health department and education department. And it clarified the work
procedure and the responsibility of the personnel concerned with the activities. In addition, the development of thevteachers’ manual and the provision of the training for teachers and rural doctors made the checking-up of immunization
record and supplemental immunization to be executed more precisely at the pilot sites. The teachers increased theirawareness that the immunization is important of health care for children in school due to strengthening of thecoordination between health department and education department. Then, the teachers began to send information about
health care including the immunization more than before the Project. The parents also increased their awareness of theimportance of immunization for their children. Currently, people’s awareness of health has risen by economic
development in China. These things mentioned above generated synergic effect, and the supplemental immunization
has been promoted for incomplete immunization children. As a result, it is considered that the effect of the Projectcontributed to the reduction of incidence of infectious disease such as measles. Therefore, it is judged that outputs wereenough to achieve project purpose and there are no significant influences of external conditions.
However, it was found out that the process of the checking-up of immunization record and supplemental
immunization and the recording method of the activities were rather complicated and it prevented the teachers fromfollowing up of supplemental immunization smoothly. To execute the checking-up of immunization record andsupplemental immunization more precisely, it is necessary for the Project to verify the process, to clarify the problem
and to improve them.
(3) Efficiency
Since lack of communication between Japanese side and Chinese side partially affected the efficiency, efficiencyof the Project is evaluated as moderate. Although project activities were selected through the mid-term review, activities
have been implementer enough to produce each output and inputs, timing of activities, qualities and quantities were all
relatively satisfactory. However, to achieve the Project Purpose, it is necessary to disseminate the outputs of the Projectat the pilot districts to other districts in each province. The project team should pay attention to better communicationeach other for smooth implementation of the project activities. The equipment provision directly contributed to thestrengthening of the epidemic surveillance and the functionality of laboratories. The project activities were
implemented smoothly utilizing the equipment. Therefore, it is judged that the input is appropriate to produce theoutputs in the Project.
In the latter half of the project period, the dispatch of short-term experts and trainings in Japan were executed for thecooperation in the field of laboratory. However, the preparation and follow-up of activities above did not much involve
long-term experts in the project office. If the trainings in Japan were coordinated in cooperation with the project office,the efficiency of the Project is considered to be more increased.
(4) Impact
The Project has supported EPI activities focused on the elimination of measles which is one of national healthplan in China. In latter half of the Project, the supplemental immunization has been enhanced at the pilot districts andcontributed to the control of epidemic of concerned diseases to a certain degree. At the time of the Terminal Evaluation,
the effect mentioned above in the pilot districts has just begun to be disseminated to a few other districts partly in someprovinces and autonomous regions. It was observed that incidence of measles, hepatitis B, polio and Japanese
encephalitis which are set as indicators of overall goal, have been effectively controlled and it is expected to beachieved if children’s health keep improving by disseminating project effects.
As for positive impacts, the Project conducted trainings of trainers and participatory trainings for the personnel
on the field of both health and education together to reinforce their knowledge and skill on the checking-up of
immunization record and supplemental immunization of the incomplete immunization children. The coordinating
system between health department and education department was reinforced and the expansion of EPI activities waspromoted through the coordination between both departments. And the coordination system enhanced not only thevi

activities of the checking-up of immunization record and supplemental immunization, but also other activities on publichealth due to sharing various information. As a result, the coordinating and collaborating system between different
departments were reinforced to improve health issue. At Nanfeng district in Jiangxi Province, the coordinating system
between EPI department and Maternal and Child Health department in District Health Office was constructed tightly,
and they have collaborated to integrate the three kinds of medical records; ‘immunization record’, ‘pregnancy healthrecord’ and ‘child health record’ respectively, to ‘maternal and child health handbook’. The importance of
immunization has been recognized in the project sites and it is expected that synergistic effect to interest of perinatal
health increases.
(5) Sustainability
The works to improve the activities in laboratory and surveillance are implemented as routine activities of the
CDC in provinces and autonomous province, and sustainability is relatively high. Regarding the checking-up of
immunization record, with regard to the aspect of policy, system and implementation skill, sustainability is high at thepilot districts. The provinces and autonomous regions is revising the plan for the checking-up of immunization record,
and they are preparing to disseminate the process of the checking-up of immunization record conducted by the Projectutilizing teachers’ manual for the checking-up of immunization record and supplemental immunization issued by the
Project. The counterparts in pilot districts have already acquired the knowledge and skill to provide the training.
Moreover, it is essential for administration of the both education and health in higher level such as provincial level andprefectural level than country level to collaborate each other practically to disseminate the outcomes of the Project to all
countries in target provinces and autonomous regions. To enhance the organizational sustainability of the Project, it isdesirable to strengthen cross-sectoral collaboration such as health and education sectors with the higher levelgovernment agencies’ understanding and commitment to the activities of the checking-up of immunization record.
Also, as for budged aspect of the sustainability, it is necessary for the CDCs at each level to secure the budget for the
training of the checking-up of immunization record and make the training implementation efficient since the Project
has spent the implementation costs of training so far.

3-3. Factors promoting effect of the Project
Since the commencement of the Project, the Chinese government has significantly increased the importance ofthe policies related to the vaccination. In 2008, the Ministry of Health stipulated the responsibility of the CDC at alllevels. With the development of the system, it is specified that the CDC at higher levels provide technical guidance andmonitoring to the CDC at lower level. The reform of public health sector is underway after the issue of ‘Restructuring
health and pharmaceutical system’ in 2009 and it has been promoted to strengthen public health services including the
EPI. Thus, the Chinese government has enhanced management system regarding disease control on its own and it has
been contributed greatly to improving the immunization services.

3-4. Factors inhibiting the effect of the Project
Project has supported the activities regarding the checking-up of immunization record and supplemental
immunization at the latter stage of the Project. This activity was to be implemented in two pilot countries in each of theprovinces and autonomous regions, and implementation of activities would be carried out based on detailed discussion
between Japanese Experts and C/P in provinces and autonomous regions and the in-depth instruction by JapaneseExperts. However, the Japanese Experts and personnel concerned with CCDC could not communicate enough, and it
has been difficult for Japanese Experts to communicate with the C/P in provinces and autonomous regions smoothly,vii

which resulted in having an influence on efficiency of the Project.

3-5. Conclusion
Outputs and progress toward the goal of the Project has reached satisfactory levels, as described above
considering the fact that relevance and effectiveness are high, with positive impacts and sustainability. Judging the
progress steadily improving the quality of immunization services and surveillance in the project provinces, theachievements of the Project are sufficient and the Project may be terminated as planned. The checking-up of
immunization record and supplemental immunization of the incomplete immunization children, in particular, has
contributed to the outputs of the Project in the pilot districts, and it has led to effective control of preventable diseases
such as measles. In addition, through the above activities, the platform for the coordination between the healthdepartment and education department toward health issues has been enhanced. The teachers’ manual for the
checking-up of immunization record and supplemental immunization was issued and the method of implementation of
the training for the method and procedure was improved on the platform. Also the foundation of the dissemination tooutside of the pilot districts has been developed. Summarizing up the experience, knowledge and challenges gained
through activities of the Project, the prospect is high that the children's health as overall will be improved.

3-6. Recommendation(1) The enhancement of the effectiveness of the checking-up of immunization record and supplemental immunizationof the incomplete immunization children (for CCDC, Provincial CDCs)
1) To implement the process of the checking-up of immunization record and supplemental immunizationsmoothly, it is necessary to clarify the responsibilities of education department and health department in eachstage of the works. It is better to identify that parents have responsibility for submission of proof ofchildren’s immunization history, education department has responsibility for checking-up of immunization
record and health department has the responsibility for the supplemental immunization. Also it is desirable
that related departments work together if needed.
2) It is necessary to clarify the responsibility of the parents. Also, it is necessary to strengthen the activities foradvocacy and education to make the parents’ decision easy regarding the vaccination. Also, it is desirable toannounce vaccination record or substitute certification as necessary items for the admission to parents prior
to recruitment of new students into kindergarten and primary school. It is necessary to announce that
supplemental vaccination is must for children if there is not any certification to identify children’svaccination history.
3) To monitor the progress of the checking-up of immunization record and supplemental immunization, it isnecessary to identify to evaluation method including the verifiable indicators, means and timing ofverification. Utilizing the evaluation method, the evaluation should be carried out constantly. It is desirable
to determine the cause of incomplete immunization children based on the result of the evaluation, and to
improve the activities against each problem.
(2) The dissemination of the outputs of the Project at pilot districts to other districts (for MOH and CCDC, Provincial
Health Offices and CDCs)
1) It is necessary that the CDCs of provinces and autonomous regions disseminates the model of thechecking-up of immunization record and supplemental immunization of the incomplete immunization
children which the Project has implemented to outside of pilot districts in the rest of the project period.

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2)

3)

It is desirable that the government of national, provincial and autonomous regions level take it consideration
disseminating the approach and method of the activities regarding the checking-up of immunization recordand supplemental immunization all over China.
In order to promote the activities mentioned above, national government needs to commit to the taking
leadership for the concerned activities. In addition, national and provincial governments need to secure thecost for the dissemination.

(3) Utilization of the platform through collaboration among departments (for CCDC, Jiangxi CDC, Nanfeng CDC)
The promotion of the coordination among departments implemented by the Project, such as the workshop on
participation and the introduction of the Project Cycle Management training formulated the platform to work, and it
can be utilized for the implementing the projects concerned to nutrition and maternal and child health. It has great
potential to contribute to the improvement of the child health in China. In fact, the Project has had impact on thematernal and child health. The CDC and the Department of Health is proceeding the integration of the‘immunization record’, ‘pregnancy health record’ and ‘child health record’ to ‘maternal and child health handbook’ atNanfeng District in Jiangxi Province. As the result, the community’s concern to EPI has increased and parents havecome to recognize the importance of the ‘immunization record’. The ‘maternal and child health handbook’ isexpected to promote the concern to perinatal health to have much to do with child health. The handbook has not been
distributed yet, and it is desirable that related organization should distribute the handbooks, consider the evaluation
method of the outputs, and monitor the outputs and impacts of the Project in the rest of the project period.

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