The Summary of Terminal Evaluation
I. Outline of the ProjectCountry：Indonesia

Project title：The Project for Ensuring Maternaland Child Health Service with MCH Handbook
Phase II
Issue/Sector：Health Sector
Cooperation scheme ： Technical Cooperation
Project
Division in charge ： Human Development Total cost：Approximately 304 million yen
Dept., Reproductive Health Division(R/D): October 1, 2006
PartnerCountry’s
Implementing– September 30, 2009
Period ofOrganization：Ministry of Health of the Indonesian
Cooperation
Government
Supporting Organization in Japan：
Related Cooperation：
１ Background of the Project
The general condition of medical health in Indonesia has improved significantly over the past 30
years. The condition of maternal and child health (MCH) has also improved likewise. For example,
the infant mortality rate (IMR) has gradually improved—from 145 to 1000 cases in 1967 to 35 in
2003. The maternal mortality ratio (MMR) has also improved to 307 to 100,000 cases in 2001.
Nevertheless, both figures show seriousness of the medical health condition in comparison with thoseof neighboring ASEAN countries. Such a high figure of MMR can be attributed to Three (3)Delay—detection, transportation, and cure—as well as lack of basic knowledge about pregnancy anddelivery by mothers and their family members.
In order to improve the above-mentioned serious condition, Japan International Cooperation
Agency (JICA) has cooperated to Indonesia with emphasis on MCH in medical health cooperation.
In the Project-Type Technical Cooperation on “Family Planning and Maternal and Child Health(FP/MCH)” (1989-1994), the MCH Handbook was developed and experimented. In the Project-Type
Technical Cooperation for “Ensuring the Quality of Maternal and Child Health Services through MCH
Handbook” (1998-2003), the MCH Handbook was introduced as a tool to improve MCH condition
through health awareness and behavior changes. During this period, the MCH Handbook was
expanded to various regions of Indonesia. As a result of the Ministerial Decree Number
284/Menkes/SK/III/ 2004 on the MCH Handbook issued in 2004 and de-concentration special fund by
the Ministry of Health as well as commitment from local governments, the procurement of MCH
handbooks was prospected to cover 62.4% of pregnant women in 2006. It can be said quantitative
expansion of MCH Handbooks makes a steady progress.
Challenges remain in sustainability of the MCH Handbook both quantitatively and qualitatively.
On the one hand, although high procurement rate was achieved, it is still necessary to facilitate local
governments, who are primarily responsible to deliver medical and health services to their residents
under decentralization, to procure and deliver a larger number of the Handbooks. Also, in order toachieve broader usage of the Handbook, it needs to seek opportunities to collaborate with the birth
registration system or a health insurance system as well as to facilitate medical professionalorganizations to utilize the MCH Handbook. On the other hand, in terms of quality of MCH
Handbook usage, it needs to promote more effective utilization. Challenges are such as development
of better utilization of MCH Handbooks, institutionalization of the Handbook into relevant medical
health systems, mainstreaming the Handbook as an integrating tool for MCH services, anddevelopment of orientation to health personnel.
In order to entangle with the above-mentioned challenges, the technical cooperation project for“Ensuring the Quality of Maternal and Child Health Services through MCH Handbook Phase II”(hereinafter referred to “the Project”) was launched under the cooperation between the Ministry of
Health in Indonesia and JICA. This project aims that the MCH Handbook functions as a tool tointegrate MCH services and a system to sustain MCH services with MCH Handbooks is strengthened.

２ Project Overview（１）Overall Goal
1. MCH services with MCH Handbook become available at every health facility.
2. All pregnant women and children under five years old have their own health record.
（２）Project Purpose
MCH Handbook functions as a tool to integrate MCH services and a system to sustain MCH
services with MCH Handbook is strengthened.
（３）Outputs
1. Accessibility to MCH Handbook by community people is increased.
2. The system of orientation on MCH Handbook for relevant health personnel is strengthened.
3. The system of monitoring and reporting on MCH Handbook is strengthened.
4. Models for better utilization of MCH Handbook are developed.
5. Results of survey and evaluation of MCH Handbook on improvement of MCH are reflectedin MOH’s policy making and implementation process.
6. The capacity of MOH and relevant local governments to effectively share the experiences ofimproving MCH services with MCH Handbook is strengthened.
（４）Inputs
Japanese side：
Long-term Expert: 3 experts (Total 5 experts)
Equipment:
2,408,000 Yen
Short-term Expert: 3 experts (Total 5 experts)
Local cost:
96,835,000 Yen
Trainees received: 35 trainees (As of Aug. 09)
Others:Indonesian’s Side：Counterpart:
14 officials Equipment
Land and Facilities
Local Cost
OthersII. Evaluation Team
Members of Team Leader: Tomoko TAKEUCHI, Director of Reproductive Health Division, Human
Evaluation
Development Department, JICA
Team
Maternal and Child Health: Yasuhide NAKAMURA, Professor, Graduate School of
Human Science, Osaka University
Maternal and Child Health: Yoshiko FUJIWARA, Ex-JICA expert to Indonesia as MCH
AdvisorEvaluation Planning: Jotaro TATEYAMA, Representative, JICA Indonesia OfficeEvaluation Planning / Maternal and Child Health: Shoko SATO, Special Advisor
Reproductive Health Division, Human Development Department, JICA
Evaluation Analysis: Tatsuya NISHIDA, Senior Consultant, KD Tech, Inc.
Period ofFrom July 12, 2009 to August 15, 2009
Type of Evaluation ： Terminal
Evaluation
Evaluation

3. Results of Evaluation
3-1. Project Performance
Overall Goal: (1) MCH services with MCH HB become available at every health facility.
(2) All pregnant women and children under five years old have their own health record.
It is too early to state conclusively on the progress of the Overall Goal at this stage, partly because
the Evaluation Team was able to collect the data on indicators of the overall goal only in a limited
manner, and partly because the achievement of an Overall Goal is expected to appear in several
years after the end of the Project.
Project Purpose: MCH HB functions as a tool to integrate MCH services and a system to sustain
MCH services with MCH HB is strengthened.
It will be partly achieved by the end of the Project. On the one hand, it is concluded that models forbetter utilization of MCH Handbooks developed by the Project have already been reflected in MOH’s
policy (the second verifiable indicator in the Project Design Matrix (PDM)2). On the other hand, theProject is not likely to reach the goal of giving 80% of pregnant women antenatal services using MCH
Handbooks by September 2009 (the first verifiable indicator in PDM2).
Output 1: Accessibility to MCH HB by community people is increased.
Among the four verifiable indicators, all except one (1-3) have been achieved or will be achieved by
the end of the Project.
Output 2: The system of orientation on MCH HB for relevant health personnel is strengthened.
All of the three verifiable indicators have been achieved.
Output 3: The system of monitoring and reporting on MCH HB is strengthened.
It has been achieved since Ministry of Health already started nationally monitoring distribution rate of
MCH handbooks.
Output 4: Models for better utilization of MCH HB are developed.
It has been achieved since all five model activities utilizing MCH Handbook were already developed.
Output 5: Results of survey and evaluation of MCH HB on improvement of MCH are reflected in MOH’s
policy making and implementation process.
All of the three verifiable indicators have been achieved or will be achieved by the end of the Project.
Output 6: The capacity of MOH and relevant local governments to effectively share the experiences ofimproving MCH services with MCH HB is strengthened.
All of the three verifiable indicators have been achieved.

3-2. Summary of Evaluation Results(1) Relevance
The improvement in MCH remains to be an imminent issue to be resolved, because Indonesia’s
IMR and MMR are higher than those of other ASEAN countries. Therefore, providing assistance forthe improvement in MCH in Indonesia is still valid. Also, the Project has been very much consistent
with both major national development plans of Indonesia and the Japanese aid program, both of which
explicitly give a high priority to the improvement in MCH.
The Project’s strategy of enhancing the use of the MCH Handbook both quantitatively andqualitatively has been appropriate because it has contributed to integrating various MCH services aswell as to enhancing the sustainability of MCH services with a MCH Handbook.
Selecting MOH, professional organizations, as a target group has been appropriate, because
MOH is the major policy planner while professional organizations are major stakeholders indeveloping policies and building an institution on the MCH Handbook policy.
Japan is the appropriate country which should provide Indonesia with assistance on the MCH
Handbook, considering Japan’s unsurpassed advantage of promoting the MCH Handbook over any
other countries, the MCH Handbook’s advantages over growth cards, and JICA’s long experiences andknow-how in Indonesia.
(2) Effectiveness
The Project has been partially effective. This is because the Project has not been able to reach its
target indicator 1 under Project Purpose of providing at least 80% of pregnant with antenatal services
using the MCH Handbook by September 2009, although the Project reached its target indicator 2 of
the Project Purpose of reflecting models for better utilization of MCH Handbooks in MOH’s policy.

Regarding the cause and effect relationship between the Outputs and the Project Purpose stipulated
in the Project Design Matrix (PDM)2, as the Project developed model activities for effective
utilization of MCH Handbook (Output 4), these model activities were adopted into policies of Ministryof Health. Furthermore, the rate of pregnant with antenatal services using the MCH Handbook was
logically supposed to increase as the types and number of medical institutions where MCH Handbook
is available increase (Output 1) as well as trainings are expanded to those who work at institutions
where MCH Handbook is newly introduced (Output 2). However, time was not enough to produce
achievement of the Project Purpose after achieving these Outputs.
Meanwhile, since the available copies of MCH handbooks have increased from 2006 (58%) to 2008
(78.8%) and also the Indonesian government already provided 56% of all the estimated pregnant
women with antenatal care with a MCH Handbook in 2008, it is expected that the Indonesian
government will achieve the Project Purpose in a coming few years.
(3) Efficiency
The Project is implemented sufficiently efficiently. As mentioned before, among 19 indicators for the
Output, all except one (1-3) have been achieved or will be achieved by the end of the Project.
Regarding activities for producing the Output, progress of the Project activities was relatively slow.
However, the delay was recovered by the third year of the Project so that all planned activities wereconducted. In other words, the planned activities were enough to produce the expected Outputs. In
addition, the Project efficiently managed its activities by hiring local consultants or experts with local
experience and also by mobilizing Japanese long-term and short-term expert who had experience indeveloping the MCH Handbook in Indonesia.
（４）Impact
It is early to state conclusively when the Overall Goal will be achieved because it takes a few more
year to achieve the Project Purpose. Nevertheless, after the Project Purpose is achieved, as long as
Ministry of Health continues their policy to improve maternal and child health by utilizing MCH
Handbook as well as Directorate General of Public Health keeps exercising leadership to otherdirectorate generals and other institutions related to MCH Handbook, it is expected that the Overall
Goals will be achieved in near future. Regarding unanticipated impacts, the Evaluation Team observedsome unanticipated positive impacts such as improving the knowledge of MCH of other members thanmothers and empowering a community. On the other hand, the Team did not observe any unanticipatednegative consequence generated by the Project until now.
（５）Sustainability
Effects of the Project are expected to be sustainable in terms of policy, organization andtechnology, while the financial and human resource sustainability is still uncertain. Note in particularthat local self-reliance is a key for sustaining effects of the Project.
The Team finds that the Indonesian side has developed and improved the organizational andpolicy sustainability of its effects by incorporating the MOH Handbook in various existing healthprograms through decrees, guidelines and manuals and also by firmly committing itself to the use of
the MCH Handbook. Furthermore, the Project has successfully integrated the use of a MCH
Handbook in the study and work of midwifes and nurses through the cooperation with IBI and PPNI.
The Team finds it likely for the Indonesian side to sustain effects of the Project technically, too.
The Project has developed technical capacity of MOH to plan, implement, review and revise the MCH
Handbook through Project activities. Also, the Project has trained a number of MOH officials,
Provincial and District Health Officials, medical service providers so that the Indonesian side has now
possessed sufficient technical capacity on the promotion of the MCH Handbook utilization at alllevels.
However, too frequent personnel transfer at MOH, provincial and district governments, and theuncertainty on how to share the financial cost of printing and distributing MCH Handbooks among thecentral, provincial, district and city governments might threaten the sustainability of the Project.
In particular, self-reliance by local government as well as communities is crucial for the effectsof the Project to continue after the completion of the Project. The Project has observed the steadyprogress of self-reliance of such local governments and communities as those in West Sumatra, West
Nusa Tenggara and East Java. However, efforts of self-reliance such as securing budget for printing
handbooks or conducting trainings are still needed to be enhanced and expanded..

3-3. Factors that promoted realization of effects(1) Factors concerning to Planning
The Project’s strategy of enhancing the use of the MCH Handbook both quantitatively andqualitatively has contributed to integrating various MCH services. In particular, selecting local
governments, medical staffs and mothers and children under five years as a target group of model activities
has enabled to develop a MCH Handbook policy and build a MCH Handbook institution, which could beapplied and expanded to all of the pregnant women, babies and infants in Indonesia.
(2) Factors concerning to the Implementation Process
The Indonesian side has taken a leadership in hosting and holding numerous seminars,
workshops, and other kinds of training on the promotion of MCH services with MCH Handbooks withand without supports of the Project. Also, Minister of Health has shown a strong commitment toimproving MCH with the use of MCH Handbook, and many counterparts and stakeholders worked
effectively through coordination mechanisms to significantly contribute to the progress of the Project.
The Japanese side, especially Japanese experts, provided necessary assistance to the Indonesian side ina timely manner.
3-4. Factors that impeded realization of effects(1) Factors concerning to Planning
The Team did not observe any factor concerning to Planning, which potentially impeded
realization of effects.
(2) Factors concerning to the Implementation Process
Some of project activities such as printing and distributing MCH Handbooks, implementing
model activities, holding national review meetings and others were delayed and postponed in the firstand second years of the Project period because budget allocations to MOH were substantially cut andalso because it took time to coordinate among parties concerned more than expected. There was acase in which the venue for holding a Third Country Training Program, which had been scheduled totake place in West Sumatra in the second year, changed and took place in West Java due to an
earthquake in the year.
However, the Project had overcome these delays and postponements until the third year.
Consequently, the Team did not find evidence that the delays and postponements had negatively
affected the Project since most effects of the Project has become visible until now.
3-5. Conclusion
The Team concludes that the Project has made tremendous progress and achieved almost all of
Outputs and a part of the Project Purpose while the progress in the Overall Goal remains yet to be seen.
In particular, The Project has been valid due to its consistency with the Indonesian national
development plans and Japanese aid program, its appropriate target selection and implementation strategy,
large needs for the improvement in MCH, outstanding Japanese expertise and experience in promoting the
MCH Handbook.
The Project has also been partially effective since the Project has not been able to reach its target ofproviding at least 80% of pregnant with antenatal services using the MCH Handbook. However, thistarget goal is expected to be fulfilled in the near future, because the Project has been going in the right
direction.
The Team considers that the Project is sufficiently efficient due to a very high level of ownership on
the Indonesian side, effective coordination mechanisms developed in the Project, and the mobilization of
local resources, experiences and knowledge.
With regard to impacts of the Project, some target indicators of the Overall Goal remains yet to beobserved and studied further. However, the Team observes some unanticipated positive impacts such as
the improvement in husbands’ MCH knowledge and a sign of community empowerment.
Effects of the Project are expected to be sustainable in terms of policy, organization and technology
because of the strong organizational and institutional commitments shown by MOH, while the financial andhuman resource sustainability could be uncertain due to too frequent personnel shifts and uncertain
financial burden-sharing of printing MCH Handbooks among the central and local governments. In
particular, local self-reliance is crucial for the effects of the Project to continue after the completion of the
Project.

3-6. Recommendations(1) Secure the budget for printing and distribution of MCH Handbook through advocacy(1)-1 The optimal balance of cost sharing between the national and local level
It is recommended that the Indonesian side implement measures to share the financial burdens ofprinting and distributing MCH Handbooks appropriately among MOH, provincial, district and city healthoffices. It is important to respect and to promote the local government’s effort to secure necessary amountof MCH Handbook on their own account.
From the viewpoint of cost-effectiveness and optimal use of the limited resources, it is important toavoid the overlapping expenditure for printing various kinds of health record cards for mothers andchildren. It should be streamlined to MCH Handbook as it includes the most comprehensive contents ofboth record-keeping and health information.
(1)-2 Advocacy for policy-makers at local level
In order to ensure the funding at the local level, it is essential to strengthen advocacy activities
targeting on representatives in the legislature at the provincial and district levels. Fund raising from NGOs
and private entities could be one of the options at the local level to increase the budget for printing anddistributing the MCH Handbook. It is recommended for Indonesian side to explore the possible funding
sources as much as possible.
(2) Strengthen the monitoring system for the MCH Handbook
The monitoring system for the MCH Handbook should be further improved. The Indonesian sidedeveloped and started monitoring the MCH Handbook from 2008. However, some data on the MCH
Handbook utilization, particularly the distribution rate, are still incomplete. The accurate data obtained
from the monitoring activity will be a strong evidence for advocacy for various levels. Therefore,
reviewing and improving the current monitoring system would be of a help.
(3) Continue and strengthen the collaboration and partnership(3)-1 Collaboration within the health sector
The Evaluation Team confirmed that the MCH Handbook is functioned as a tool to integrate MCH
services in many places. Most of these cases are in preventive care including Posyandu and pubic healthcenters. There are room for further improvement of involving other actors in health sector such as bothpublic and private hospitals。For the functional referral system and continuum of care, the linkage between
preventive care and clinical service is crucial.
(3)-2 Partnership with other ministries
Further cooperation with other ministries could enhance the current MCH Handbook system. For
example, It is efficient to work with Ministry of Home Affairs (MOHA) in order to advocate MCH
activities with MCH Handbook at the local level because they are influential to the local government interms of planning and budgeting. The topic of “MCH service with MCH Handbook” should be included as
one of the contents in professional education such as medical and nursing education by cooperating with
Ministry of National Education (MONE).
Linkage with early birth registration and MCH Handbook is another issue to be considered.
Increasing the number of early birth registration is one of the national priorities. The MCH Handbook
could be a useful tool for this goal though the close collaboration among related authorities is further
needed.
It is recommended that MOH maintain contacts with relevant ministries and deepen theirunderstanding that the MCH Handbook would be beneficial to programs of their ministries as well.
(4) Maintain the institutional memory related to MCH Handbook(4)-1 Prevent the interruption of services due to the personnel shifts
The frequent change of personnel has been a challenge during the Project implementation period.
The Team would like to propose that actions should be taken to develop an institutional memory at both thecentral and local governments in Indonesia that skills, knowledge and experience, which were obtained
through the Project, not be lost due to frequent personnel shifts.
The Project developed various technical guidelines and standard operation procedures such as how to
use the MCH Handbook at different settings, training materials for health professionals and volunteers andso forth. However, the Team believes that the individuals who contributed to its development and weretrained based on these materials are important assets.

(4)-2 Maintain the institutional memory of MCH Handbook experience
As mentioned in the Section 1 of Introduction, both Indonesian and Japanese sides shared a relatively
long cooperation experiences related MCH Handbook in this country, starting from its development inearly 1990, nationwide expansion, institutionalization by the Ministerial Decree and improvement of thequality of MCH service with MCH Handbook. The rich lessons learned have been accumulated during thisprocess. Both Indonesian and Japanese sides should maintain and utilize this knowledge and network as
institutional memory.

3-7. Lessons Learned(1) Project management involving multiple stakeholders
The unique characteristic of this Project is involvement of large number of stakeholders at the centrallevel. In addition to the wide geographical coverage, the implementation partners vary from the central,provincial, district level to the community.
Under such a complicated circumstance, the Project was implemented successfully because it
focused on generating specific and visible outcomes at the field level. Involving multiple actors contributed
to make a clear division of labor among them and to find a way for effective co-working system. Thesefeatures represent the strength of the Japanese technical cooperation. Close focus on producing visible
outcomes at the field level through practical and close training would be an important lesson learned fromthis Project.
(2) Strong sense of ownership and leadership
Strong ownership and leadership on the counterpart was the key to success of this Project. MOH andlocal health offices such as provincial and district health offices have shown its enthusiasm and capability
to plan, implement and review various kinds of socialization, orientation and training. Consequently, morethan a hundred of these seminars, workshops and meetings were hosted and held by MOH and/or local
health offices with little or no assistance of the Project. This strong ownership and leadership of theIndonesian is particularly noteworthy.
The effectiveness of using the MCH Handbook in integrating and improving MCH services wasrecognized by Indonesian side gradually through the implementation of the Project activities including
developing model practices, joining the counterpart training in Japan and hosting the Third Country
Training Program (TCTP) and In-Country Training Program (ICTP). It is concluded that the process ofdeveloping such an effective tool and package in cooperation with Japanese experts lead them to havestrong sense of ownership.
(3) MCH Handbook as an effective tool to integrate MCH services and to provide continuum of care
[Provider side’s point of view]
The MCH Handbook can be an effective tool for integrating maternal and child health services.
Integrating MCH services through the use of MCH Handbooks is desirable because it helps pregnant
women and mothers keep records of their pregnancy and child’s development comprehensively at the sametime to gain necessary information in a timely manner. The distribution of MCH Handbooks alone,
however, does not automatically guarantee the integration of maternal and child health services. MCH
Handbook can be effective when it is used as a tool to integrate the existing services.
During the course of the Project implementation, more and more attention was directed how to
reduce the neonatal mortality. One of the core values of MCH Handbook is continuity of care. MCH
Handbook is a tool to increase the knowledge and awareness on pregnancy among pregnant women andfamily as well as to increase readiness of delivery. In this connection, the MCH Handbook is still a valid
tool to integrate Maternal, Neonatal and Child Health (MNCH) services when properly implemented.
(4) MCH activity with MCH Handbook: its contribution to increase the awareness on health issues
among community [Demand side/ beneficiary side’s point of view]
The Project showed that providing health information to pregnant women and mothers as well as
health volunteers by using MCH Handbook increased their knowledge on pregnancy and child care. As aresult, some positive behavior changes such as improved nutrition intake and selection of safer delivery
options, meaning the preference change from delivery attended by traditional birth attendant to skilled birthattendant, were observed. The MCH activity with MCH Handbook can’t be sustained without the demand
from the community. This Project is a good example to link the community needs for better health with the

provision of quality service.
(5) Careful consideration to the diversity
A major important lessons learned from the Project was the fact that the Project was successful
because it paid close attention to the diversity of Indonesia. Indonesia is diverse in terms of culture,religion, and ethnicity. It means that a successful model in one area does not automatically lead to a successin other areas. The Project, both the Japanese and Indonesian sides, was sensitive enough to respect thisdiversity. The MOH established the standard contents and the pink color for the cover page as a national
standard, but it is allowed to fine-tune the MCH Handbook in accordance to the culture, religion andethnicity of each locality as far as the basic concept is the same. It made it easier to be accepted by thepeople living there. By creating their own version of MCH Handbook in each area, they also developed
sense of ownership towards the handbook.
(6) Enhanced self-reliance at the community level
From the experience of this Project, the Team concluded that the MCH Handbook is an effective tool
to increase self-reliance at the community level as well. Not only the direct users of the MCH Handbook,the Project did intend to involve the community leaders and religious leaders in introduction of MCH
activities with MCH Handbook. Where community leaders recognize the importance of improving
maternal and child health, some villages started their own activities by using MCH Handbook.
It is concluded that active involvement of community to the Project activities was a timely andappropriate intervention where the government of Indonesia also promotes self-reliance of the community.
The Ministry of Health and local governments could utilize this opportunity fully to promote “MCH
activities with MCH Handbook” by playing a stewardship role to provide appropriate guidance to thecommunity.