Evaluation Summary
1.

Outline of the ProjectCountry: The
Indonesia

Republicof Project Title: the Project for Enhancement
Competency through In-Service Training

Issue/Sector: Healthcare
medical treatment

and Cooperation Scheme: Technical Cooperation Projectof

Nursing

Health Team 3, Health Group 2, Total Cost： 430 million JPY（Sum of the total cost from JFY
HumanDevelopment 2012 to JFY 2016 and estimation for JFY 2017 as of July 2017）
Department
Period of (R/D):
The Board for Development and Empowerment of Human
Cooperatio 15/10/2012-14/10/2 Resources for Health, the Ministry of Healthn
Directorate General for Health Services, the Ministry of Health,017
the Ministry of Health
University of Indonesia, Padjajaran University, Airlangga
University, North Sumatera University, Hassanuddin University
Supporting Organization in Japan: N/A
Other Related Projects: N/A
1-1 Background of the Project
In recent years in the Republic of Indonesia (hereinafter referred to as sIndonesia”ndonesia years in
the Republic of Indonesia (hereinafter referred to as stry of Healthf Heac growth and improvement of
the quality and quantity of health service delivery. Meanwhile, emerging problems such as widening
regional gaps, transition of disease structure, aging society, declining family involvement in care, andincreasing role of private sector in health and medical service provision and training health personnel
are coming to the surface; therefore, a new regime needs to be developed in order to address theseissues. Given the fact that the nursing staff plays a significant role in the health and medical service
provision, the Government of Indonesia (hereinafter referred to as “GOI”) has commenced politicalefforts for the enhancement of nursing competency through the introduction of nursing registration
renewal system as well as the reinforcement of in-service training. However, in-service training inIndonesia has usually focused on nurturing specialists in each professional discipline, andsystematized training was not necessarily sufficient.
On the other hand, under the rapid globalization of health workforces, it is a common recognition
that the GOI calls for urgent attention to enhance competencies of nurses to the global standardso
level. The Government of Japan has started receiving Indonesian candidates for nurses and care
workers from 2008 on the basis of the Japan-Indonesia Economic Partnership Agreement. In thiscontext, the Japan International Cooperation Agency (hereinafter referred to as “JICA”), on the basisof the request from the GOI, commenced a five-year technical cooperation project entitled “TheProject for Enhancement of Nursing Competency through In-service Training” (hereinafter referred
to as “the Project”) from October 2012 with the Board for Development and Empowerment of
Human Resources for Health (hereinafter referred to as “BPPSDMK”), the Ministry of Health(hereinafter referred to as “MOH”) as a principal counterpart organization of the Indonesian side.
1-2 Project Overview（1）Overall Goal
In-service training system for enhancement of nursing competency is disseminated in other areas
in Indonesia.
（2）Project Purpose
In-service training system for enhancement of nursing competency is strengthened in target areas.

1（3）Outputs
1）Career Development Ladder System (hereinafter referred to as 'the Ladder System') is introducedin pilot hospitals which are approved by the Ministry of Health.
2）In-service training program of targeted subjects is strengthened in order to be accredited astraining(s) which can receive credits for nurse registration renewal.
3）The results of Output 1 and 2 are shared with other institutions which conduct in-service training
for nurse.
（4）Input（as of the evaluation）
the Japanese Side– Dispatch of JICA Experts: Long-term Experts: a total of 4 persons, 95.5 M/M (Chief
Advisor/Nursing Administration and project coordinators) (1 for predecessor and 1 forsuccessor, respectively), Short-term Experts: a total of 37 persons (Nursing Administration,
Ladder System, Disaster Nursing, Critical Care, Emergency Nursing), a total of 14.7 M/M,
and Project Consultation Mission: a total of 17 persons, a total of 9.3 M/M– Employment of Local Staff: Six (6) staff members in total: 2 in Jakarta, 1 in Makassar, 1 inMedan, 1 in Surabaya, and 1 in Bandung– Provision of Equipment: Simulators for skill practices, etc., Emergo Train System (ETC) for
the table-top simulation training system of Emergency and disaster medicines– Training in Japan: Total number: 130 persons (40 for Ladder System, 7 for Disaster Nursing(H.E.L.P.), 43 for curriculum development in Emergency Nursing, Critical Care and DisasterNursing, and 40 for curriculum development in Geriatric Nursing, Total days: 163 days
– Meeting Package: costs for a total of 83 meetings / seminars /assessment / trainings
the Indonesian Side
– Allocation of Counterpart Personnel: Project Director: a total of 2 persons (1 forpredecessor and 1 for successor), Project Managers: a total of 6 persons (2 persons at thesame time and 4 was replaced), Secretary: 2 persons, and Other counterpart personnel: a totalof 83 persons– Facilities, Equipment and Materials: A project office room in the BPPSDMK, the MOH
with utility costs, furniture and internet facility, and Office spaces in 5 Universities withutility costs, furniture and internet facility– Local Costs: A total of 83 meetings/seminars/assessment activities/trainings, All travelling
costs including allowance for Indonesian personnel except for study trip to the Fatmawati
Hospital, Printing costs for the draft guidelines for the Ladder System, documents forworkshop (partially), draft documents for curriculum and modules (partially)2.

Terminal Evaluation Team

Members

Mr. Tomoya
YOSHIDA

LeaderDirector, Health Team 3, Health Group 2, Human
Development Department, JICA

Prof. Yayoi
Technical Advisor
President, Japanese Red Cross Kyushu
TAMURA(Nursing Education) International College of Nursing
Prof. Yoko
Technical Advisor
Dean, National College of Nursing, Japan
HAMAMOTO (Nursing Education)
Ms. Sachiko
KUNO
Dr. Yoichi
INOUE

Cooperation Planning Associate Expert, Health Team 3, Health Group 2,
Human Development Department, JICA
Evaluation Analysis Senior Consultant, Consulting Division, Japan
Development Service Co., Ltd.

2

Period of 10/Jul/2017 – 29/Jul/2017
Evaluation
3. Summary of Evaluation Results
3-1 Achievements（1）Output 1

Study Type: Terminal Evaluation

The concept and the procedures for the introduction of the Ladder System was disseminated to over
100 hospitals under the umbrella of the MOH through the National Seminar following the
distribution of the provisional version of the National Guidelines in 2013, and the JICA experts
continued related project activities directly with the local counterpart personnel. Though the levelof progress of the introduction of the Ladder System in each hospital, 8 out of 9 target hospitals
performed the competency assessment for certifying PK levels of nursing staffs, and subsequent
planning and implementing CPD training in light of the PK levels.
On the other hand, the Project was supposed to conduct monitoring and evaluation of the Ladder
System operated in accordance with the novel Guidelines; following those processes, the Project
was also supposed to perform further revision of the Guidelines by the end of the project period.
However, the Joint Terminal Evaluation Team observed crucial problems in the practical operationof the Ladder System in hospitals as well as the effective operation of CPD training by utilizing the
System; in particular, the overlapping of the indicators for the evaluation of nursing competencies
in the Ladder System with that for the determination of the Clinical Privileges under the Credentials
for nurses, as well as the mismatching of nursing competency (PK level) with existing in-housetraining programs at each hospital.
At the time of the interview session with the MOH, it is inferred that the National Guidelines of theLadder System is under the final inspection at the legal section of the MOH via the signing by thehealth minister, and is anticipated to be published very soon. However, the said problems regarding
the practical operation of the Ladder System simultaneously with the Credentials will take place inother hospitals and make it difficult to apply the Ladder System nationwide at current conditions.
Therefore, it is suggested for the BPPSDMK of the MOH to commence the prompt actions fordiscussing practical countermeasures among relevant parties such as counterpart universities andhospitals.
For these reasons, it is deemed that the achievement level of the Output 1 is intermediate as of thetime of the Terminal Evaluation.
（2）Output 2
Two working groups, consisting of the participants of the Training in Japan, took initiative for thedeveloping work of the curriculums of Emergency Nursing, Critical Care and Disaster Nursing(Group for Output 2A) and Geriatric Nursing (Group for Output 2B) with the technical advices of
the JICA experts as needed basis. The Project has completed the developing work of the curriculumwith training modules for each topic in general. As for the Disaster Nursing and Geriatric Nursing,the MOH conducted TOTs and nurtured a total of 60 trainers in each subject in various areas ofIndonesia as of the time of the Terminal Evaluation. Since the costs for the implementation of TOT
were borne by the MOH in consideration of sustainability, the TOT for Critical Care has not been
conducted due to the budget constraints as of the time of the Terminal Evaluation. The MOH isplanning to conduct the TOT of Critical Care in August 2018 using the next year’s budget. The
curriculum and the training modules for basic geriatric nursing were certified as a National
Standards by the MOH. The working groups for other topics are supposed to move forward for
acquiring the certification of the curriculums as National Standards by taking necessary procedures
such as the verification of them by trial-based training, followed by the revision work as needed.
Meanwhile, the Indonesian counterpart personnel indicated the intention to maintain the working
groups by any means and continue to develop and/or revise curriculums in consort with related
nursing associations even after the end of the project period; therefore, it is expected that theverification of the training effects on the knowledge and skills of nursing staffs will be performed infuture by the Indonesian counterparts to a certain extent.

3For these reasons, the achievement level of the Output 2 is deemed to be appropriate at the time of
the Terminal Evaluation.
（3）Output 3
A variety of activities for the dissemination of the achievements of the Project have been done
during the 1st half of the project period through the dissemination seminars of the National
Guidelines, the Annual Assembly of Specialized Hospitals and the Training of Trainers held in
various parts of Indonesia. In addition, the Project, especially following the time of the Mid-term
Review, has held seminars and workshops for the dissemination of the training curriculum withtraining modules geared not only to health professionals but also to master’s and undergraduate
students in neighboring places to the project sites; indeed, the sum total of the participants was over
4,000.
Meanwhile, the Project, at the initiative of the MOH, is planning to hold the National Seminar
geared to approx. 100 flagship hospitals in August 2017, and to share the achievements, findings
and experiences gained through the 5-year project.
For these reasons, the achievement level of the Output 3 is deemed to generally be appropriate at
the time of the Terminal Evaluation（4）Project Purpose
The Project, under the Output 1, has established a foundation of the Ladder System from thetechnical point of view through the project activities at 9 target hospitals; whereas, several crucial
problems regarding the practical operation on the ground are remained in relation to thesimultaneous operation with the Credentials. Meanwhile, the Project, under the Output 2, has beenworking on the development of curriculums and training modules for the said 4 prioritized themesin Indonesia, resulted in the development of cross-organizational networks. Concerning the Output
3, some experiences and achievements have already been shared with non-targeted areas of the
Project.
In summary, several problems especially for the practical operation of the Ladder System in
hospitals; therefore, it is necessary for the Indonesian counterparts including the target hospitals to
re-examine the original concept and ideal operation of the Ladder System. As has been described,
the Project did not reach at the initially-envisaged achievement level; however, the foundation of
the in-service training system for the reinforcement of nursing competency (the Project Purpose)
was established from the technical point of view.
For these reasons, the achievement level of the Project Purpose is deemed to be moderate at thetime of the Terminal Evaluation．
3-2 Summary of Evaluation Results（1）RelevanceThe relevance of the Project is generally maintainedWith regard to the consistency of the Project Purpose with the Indonesian Health Policies, the needsof the target groups, and Japan’s aid policies that were confirmed at the Ex-ante Evaluation of the
Project, there has not been any alteration of the Indonesian health policies since then as well as theneeds of the target group. The Team can therefore conclude that there has not been any change that
may have undermined the relevance of the Project, and therefore the consistencies have been
maintained at the time of the Terminal Evaluation.
Meanwhile, Indonesia, likewise Japan, has experienced many disasters such as earthquakes andtsunami, and population aging is advancing rapidly in recent years. Under these circumstances, theMOH stated in an interview session that they put priorities in the enhancement of knowledge andclinical skills of nursing staffs especially in disaster nursing as well as geriatric nursing, and also
attach importance to the revision and/or development of curriculums with training modules asmeans for realizing the said end. The Project has been assisting the Indonesian side to revise or4

develop curriculums and teaching modules for the prioritized topics such as disaster nursing andgeriatric nursing, and also to nurture health personnel to be trainers. For these reasons, the Project
has been assisting the counterparts in accordance the needs from Indonesia.
Japan Country Assistance Policy for the Republic of Indonesia (issued in April 2012 and effective
as of July 2017), on the other hand, states that Japan focuses on improvement of Indonesian’s
capacity to cope with global and regional challenges as one of the key strategies of cooperation; theProject aim, which is to strengthen competencies of nurses to the global standards’ level under
rapid globalization of health workforces is consistent with the Japanese Government’s policy.
（2）EffectivenessThe effectiveness of the Project is considered to be moderate.
The Project is aiming to strengthen the in-service training system that meet the policies ofcompetency raising of nurses as well as situations and environments of hospitals in Indonesia. To
this end, the Indonesian organizations took initiative to project activities for the strengthening of theLadder System as well as the development of training curriculum with materials following theTraining in Japan. Further, policymaker(s), research and education institutes and medical facilities
conducted these activities in tandem; especially, the pilot hospitals have a variety of backdrops suchas the size, history, type (governmental, university or private). Since the Project is operated undersuch circumstances and conditions, it is deemed that the Project has accomplished to presented a“system”ystemals have a variety of backdrice training with high applicability and feasibility.
Having said that, as was described in the Achievement of the Project Purpose section, though thedevelopment of curriculums and training modules under the Output 2 has made a good progressincluding its unionization, several crucial agendas, which are continuously struggled by theIndonesian side even after the end of the project period, are remained in the Ladder System (Output1), and consequently, the Ladder System cannot be applied in non-targeted areas as of now (Output
3). For these reasons, it is deemed that the Project Purpose will have not been achieved by the endof the project period.
As just described, the Project has been running with strong ownership of the Indonesianorganizations despite of many challenges and obstacles. It is difficult to estimate the possibility of
the achievement of the project Purpose at this point due to several uncertainties like the budget forthe project activities; however, it is anticipated to some extent that the establishment of in-service
training system with high applicability and feasibility as well as the reinforcement of institutional
function can be attained by the end of the project period given that the project activities progresses
as planned.
（3）Efficiency
Since the progress of research activities have partially been impaired by some internal and external
factors, the efficiency of the Project is deemed to be moderate.
The Project has commenced in October 2012; however, the arrival of the Chief Adviser of the
Project (JICA expert) was 11 months after the commencement of the Project. Eventually, full-scale
operation was commenced thereafter. The baseline survey was supposed to be conducted at very
beginning of the project period; nevertheless, preparatory work for the survey was practicallycommenced after the arrival of the Chief Advisor due to various reasons. Finally, the field survey of
was started in January 2014 via the determination of the contents of investigation and subsequent
approval process in the MOH. Moreover, there were several problems in an outsourcing contractorof the field survey, resulting in ineffective baseline survey. As for the endline survey, likewise,
several crucial problems such as the improper conditions for the survey as well as insufficient
analyses, data interpretations and discussions were found in the endline survey; therefore, theresults of the survey were not used as objective evidences for verifying the effect of theintroduction of the Ladder System.
Especially in the 1st half of the project period, the Indonesian side has been exerting strong financial
commitment to the Project, and it is considered that ideal cost sharing is realized from the5viewpoint of sustainability. Having said that, the principle of the cost share was maintained
following the time of the Mid-term Review, especially after the dissolution of the BUK in
December 2015, the limitation of the budget for the project activities became more severe, andsome important project activities were also subject to significant delay. For instance, the TOT of
Critical Care was postponed for several times and has not been implemented as of the time of the
Terminal Evaluation. Under the circumstances, the Project had assisted a part of activity costs of
the Indonesian side as special exception (not for the TOT of Critical Care).
Meanwhile, a total of 130 Indonesian counterpart personnel participated trainings in Japan in thetheme of Ladder System, in-service training system, curriculum development focusing on threesubjects as follows: Disaster Nursing (H.E.L.P.); Critical Care; Emergency Nursing; and GeriatricNursing, as of the time of the Terminal Evaluation. After coming back from the Training in Japan,
the participants took initiative to promote the project activities with indirect support from JICA
experts in accordance with the plan of actions developed by them. Thus, the knowledge andtechniques are not only used as a basis as well as a starting point for the project activities inIndonesia but also used for CPD trainings at the target hospitals. The instruments and equipment
provided by the Project such as simulators have been used for the trainings effectively.
（4）Impact
The following positive as well as negative impacts are confirmed and/or expected by the
implementation of the Project.
The Team observed that nursing competency assessment was performed on the basis of two similarevaluation processes of the Ladder System and the Credentials in the target hospitals. Though some
hospitals managed to run the two evaluation processes efficiently by simplifying the procedures,
other hospitals are suffering from the increased work burden. It is confirmed that the Minister’s
decree of the Ladder System is anticipated to be published very soon, all hospital in Indonesia will
be obliged to take the evaluation process of the Ladder System on top of that of the Credentials,
that is to say, the Ladder System cannot be promoted to distribute to non-targeted areas unless someeffective countermeasures are taken.
On the other hand, as for the development of curriculums and training modules, through TOT of
Critical Care has not been done as of the time of the Terminal Evaluation, the verification work ofother topics such as Disaster Nursing and Geriatric Nursing moved forward steadily to acquire thecertification as National Standards from the MOH. It is unlikely for the curriculum and the modules
to be certified by the end of the project period; however, each working group presented an inintention to maintain the network by any means. Thus, it is anticipated that the activities for theacquisition of the certifications will be maintained even after the end of the project period.
As was just described above, the development of curriculums and training modules is anticipated tobe continued or even enhanced by themselves and it is anticipated the benefits are also be
distributed nationwide in future. In contrast, several problems were found in the Ladder Systemfrom the political and organizational aspects; thus, prompt actions should be taken by theIndonesian side to address the issue for the steady achievement of the Overall Goal in approx. 3
years following the termination of the Project.
On top of that, several positive impacts of the Project are observed or expected as follows: 1)
Influences on Nursing Education at Universities; and 2) Preparatory actions for the establishment of
the Geriatric Nursing Association. Nevertheless, it was confirmed that some of target hospitals
encountered increased workload for operation the Ladder System on top of the Credentials. Thiscan be regarded as a negative impact of the Project.
（5）Sustainability
Several crucial problems are observed for self-sustainability as well as self-deployment of thebenefits provided by the Project at the time of the Terminal Evaluation.
It is highly anticipated that political significance of the reinforcement of nursing competency inIndonesia will be sustained even after the end of the project period. However, two similar

6evaluation processes, the competency assessment of the Ladder System and the evaluation items for
the Clinical privileges under the Credentials, are simultaneously operated in the project target
hospitals, implying that some of the target hospitals managed to run the processes with an
unexpected burden of work. It is confirmed that the National Guidelines of the Ladder System
will be effective very soon, i.e., the Ladder System is supposed to be operated together with theCredentials, the same problems and/or burden will be induced at every hospital nationwide. It isstrongly suggested that MOH should start immediately to take necessary measures to avoid thesame problems.
For the development of curriculums and training modules supported by the Project, financial
sustainability is secured to a certain level since the funding from the MOH and other relatedorganization is expected to be maintained. For example, funding from the BPPSDMK, the
PUSRENGUN and the YANKES will be allocated to Disaster Nursing working group. For
Geriatric Nursing working group, once the Geriatric Nursing Association is established (as of July
2017, regulation of the society is drafted), activities will be continued by the income frommembership fee and training fee. Meanwhile, once the Minister’s decree for the Ladder System
become effective, all the hospitals in Indonesia are supposed to bear the responsibility for theoperation, including operational costs, of the Ladder System; implying that the financial
sustainability of the Ladder System will be secured.
The Project had developed the National Guidelines of Carrier Ladder Systems for Nurses(provisional version) and the indicators of the competency assessment. Besides, the Team observedthat some target hospitals operate the Ladder System efficiently together with the Credentials, andcreated benefits of the System for CPD as well as professional relocation on the basis of nursing
competency. For these reasons, it is deemed that the Ladder System is established in Indonesia fromthe technical point of view. However, it is strongly suggested that the Project should take measures
to cope with the said operational problems by investigating and reviewing the actual situation of theoperation of the Ladder System in hospitals. As for the development of curriculums and modules,
the working group members have acquired a know-how of the development of curriculums andtraining modules though the project activities enough to continue the said activities independently
even after the end of the project period. Actually, the working group for geriatrics autonomously
progressed the development of the curriculum and modules geared to intermediate level; this can be
regarded as a typical example for explain the technical autonomy of the Indonesian side.
3-3 Factors that promoted the attainment of the Project（1）Concerning the project design
The working group member of the Ladder System participated a study tour at the Fatmawati
Hospital, one of the pilot hospitals of the Project, where the System was operated since 2007. This
experience made them comprehends the Ladder System easily, resulting in smooth introduction ofit.
（2）Concerning the implementation process of the ProjectA professional organization of the PPNI and subordinating HIPGABI and HIPERCCI, as external
supporters of the Project, provided each working group as well as universities with technicalsupport. It is considered that this external support enhanced the efficiency of the Project to a certain
extent.
3-4 Factors that impeded the attainment of the Project（1） Concerning the project design
Both Baseline and Endline surveys were consigned to local consultant enterprises; unfortunately,
the Project found several problems for their performances of the survey and the quality of the reportsuch as the compliance of survey protocol, insufficient data analyses and so on, and the results ofthe surveys could not be used for grasping actual situation and measuring the intervention effect of7the Project, respectively. Thus, it is considered that this has hindered the efficiency of the Project toa certain extent.
（2） Concerning the implementation process of the Project
The curriculums in hospitals existing before the introduction of the Ladder System are not always
specifies the target PK levels, and sometimes, insufficient coordination between the departments
responsible for capacity development of nursing staffs and in-service training as well as insufficientunderstanding the original purpose of the Ladder System happened in the target hospitals, resulted
in the mismatch of PK levels with the contents of the trainings. It is considered that the saidmismatch diminished the efficacy of the Ladder System to some extent; therefore, is also regarded
as a hindering factor against the effectiveness of the Project.
Meanwhile, as has been described, the competency assessment of the Ladder System and theevaluation items for the Clinical Privileges under the Credentials are overlapping in many parts ofevaluation processes, resulted in a unexpected burden in the project target hospitals. As a possible
cause of this burden, the Project could not forecast the likelihood of the occurrence of the burden
for operating two evaluation processes correctly, and any actions were not taken for coordinate thetwo Directorate Generals responsible for the systems. It is considered that this could hindered theeffectiveness of the Project to a certain extent.
3-5 Conclusions
As the result of the persistent efforts of the Project, the curriculums and the training modules weredeveloped for the themes of important health challenges such as disaster nursing and geriatricnursing, and the networks for that purpose were also developed. Meanwhile, it is deemed that thefoundation of the Ladder System with high advantages for effective CPD training as well as
professional relocation was established from the technical perspectives as the National Guidelines
and the indicators for the assessment of nursing competency by the Project. However, several
problems in the Ladder System are observed for more efficient operation in hospitals as of the timeof the Terminal Evaluation.
With regard to the results of based on the five evaluation criteria, it is confirmed that the relevanceof the Project was maintained since the Project has continuously assisted the Indonesian side toaddress the important health challenges in Indonesia. Meanwhile, it is deemed that theeffectiveness, the efficiency and the sustainability of the Project were deemed to be moderate fromthe perspective of practical operation of the Ladder System despite that its technical foundation wasestablished. In order to ensure the steady achievement of the Overall Goal in future (Impact), it isdesired for the Indonesian side to continue the efforts to address the challenges even after the end of
the project period.
3-6 Recommendations（1）It is necessary for hospitals to modify the training contents in light of target PK levels of the
trainees to avoid a mismatch between the contents and PK levels, the Ladder System can exert its
characteristics and advantage effectively. In addition, it is recommended for the target hospitals toreview the existing training courses, which are not supported by the Project, and revise them inconsideration of planning and implementation of CPD on the basis of the Ladder System.
（2）It is important to search effective and efficient operational procedure for better practices of two
systems of Ladder System and Credentials. The BPPSDMK should commence discussions on thestandardized operational procedure as soon as possible to solve the current challenges observed insome hospitals; in particular, the governing system of the Ladder System at the ministry level
especially after the end of the Project as well as the standardization of the operational procedures ofCredentials in harmonized way with Ladder System.
（3）It is recommended that the BPPSDMK will continue to nurture trainers for the trainings that the
project developed and to disseminate in cooperation with stakeholders such as nursing associations

8

even after the project period.
（4）It is recommended that the Indonesian side will continue to develop curriculums by utilizing the
networks formed through the working groups formed under the Project especially for the
project-assisted topics (development of a curriculum of advanced level, etc.).
（5）It is recommended for the universities to play a leading role for in-service training in neighboring
hospitals in order to maintain or even enhance the quality of CPD training for nurses; in addition, theuniversities and related hospitals should have practical discussions on the implementation system aswell as its cooperation including affective use of instruments provided by the Project.
（6）The BPPSDMK should continue the efforts for the improvement of CPD program for better
quality of nursing care with an eye on the changing society and its health challenges in Indonesia.
3-7 Lessons Learnt（1） The Mid-term Review Team confirmed that some OVIs stipulated in the PDM needed to berevised to appropriately identify the achievement levels of the Project Purpose and Outputs, andprovided recommendations for modifying the PDM, clarifying some words and terms and thedefinition of "achievement levels," and fostering common understanding between concerned parties.
At the JCC meeting held after the Mid-term Review, however, no discussion took place as to revising
the PDM, while project members on the both Indonesian and Japanese sides were not sufficiently
aware that the OVIs should also be the yardstick by which the Project should manage theachievement levels of the Project Purpose and Outputs. Consequently, it was difficult to evaluate theachievement levels of some Outputs and the Project Purpose at the Terminal Evaluation because they
could not be evaluated using the OVIs stipulated in the PDM.
Here are two major lessons to be learned from the above: (1) it is necessary to establish adequate
understanding between concerned parties as to how JICA projects should be monitored and whatroles the PDM should play as a monitoring tool and (2) it is vital for JICA (office/headquarters) towork, through occasions such as activities of the JCC and Project Consultation Committee in Japan,
to ensure the implementation of all recommendations made based on the Mid-term Review, jointly
held by the Indonesian and Japanese sides. Improving the precision of the PDM at the beginning ofcooperation is also important.
（2）The directorate in charge of Output 1: Ladder System in the Ministry of Health, a majorcounterpart organization in the Project, was dissolved as part of the large-scale restructuring of theministry in December 2015, resulting in 10 months of vacancy.
This restructuring coincided with the stage in which the system was introduced to actual services(hospitals) in accordance with the National Guidelines of the Ladder System (provisional version)and competency assessment indicators, which had been created with the support of the Project.
Following are three possible results of the MOH directorate in charge being vacant that wereidentified at the time of the Terminal Evaluation:①

Monitoring and evaluation as to introduction to services could have been inappropriate;②

It could have been impossible for MOH to identify problems like double standards (Ladder
System and Credentials) in time;③

It could have been impossible to detect it in time when the Ladder System was not used inline with its original characteristics, purposes or effects.

Furthermore, it has also been suggested that the above could cause negative impacts on theachievement levels of Output 1 and the overall Project Purpose.
In this way, a change to the structure of a counterpart organization can significantly affect not
only the implementation of project activities but also the achievement levels of the Outputs andProject Purpose. There has also been evidence to suggest that a major restructuring can hinder
communication between experts and the counterpart. This means that when such is the case, itis necessary to provide the counterpart organization with consultation opportunities etc., for9example by sending a mission from the JICA headquarters to it, in a timely manner, in addition
to doing various on-site coordination work.

10