Asia
1. Outline of the ProjectCountry:

Project title:

Mongolia

Maternal and Child Health Project

Issue/Sector:

Cooperation scheme:

Health/Medical Care

Project-type Technical Cooperation

Division in charge:

Total cost:

First Medical Cooperation Division,
Medical Cooperation Department

Period of Cooperation

1 October 1997 - 30 September Partner Country's Implementing Organization:
2002
Ministry of Health, Social and Welfare (MOHSW)

Supporting Organization in Japan:
Health and Welfare Department of Chiba Prefecture, Chiba
Serum Institute ,Toho University, International University of Health and Welfare

Related Cooperation:
1-1 Background of the Project
In Mongolia, the Expanded Programme on Immunization (EPI) was initiated based on existing immunization activities starting
since as early in the 1960s. Vaccine procurement, with assistance from international organizations, assured high immunization
coverage. In the meantime, Iodine Deficiency Disorder was acknowledged as a serious problem in Mongolia. According to theresults of a national survey on goiter in 1992 conducted by the government with the assistance of U.N. Children's Fund(UNICEF), the rate of hypertrophied thyroid gland caused by IDD in students and women of the childbearing age at the capital,Ulaanbaatar, was over 40%, and many intellectual developmental disorders and stillbirths that might have been caused by IDD
were observed. Therefore, it was necessary to take urgent countermeasures such as dissemination of iodized salt. The
government also joined the "World Summit for Children" held by the United Nations in September 1990, where the "National
Action Plan for Development of Children in Mongolia" was developed in May 1993, and actively promoted were EPI and IDD
countermeasures in a plan under strong instruction by the government.
Under these circumstances, the government of Mongolia requested from the government of Japan to launch a project-type
technical cooperation on IDD and EPI countermeasures to reduce IDD and accomplish self-management of EPI for maternaland child health and primary health care (PHC) as a part of the program.

1-2 Project Overview
The project implemented training to the staff of the Ministry of Health, Social and Welfare (MOHSW) for purposes such as
fostering the staff, epidemiology study, laboratory development (study room) and enhancement of diagnosis techniques,development of cold chain and logistics (low temperature logistics by refrigeration), and diffusion activities, aiming at the self
management of EPI and bringing IDD under control in Mongolia.
[EPI](1) Overall Goal
To promote maternal and child health in Mongolia.
(2) Project Purpose
To strengthen the prevention system for EPI target diseases in Mongolia.

(3) Outputs
1) Immunization coverage rate is increased in towns and villages.
2) Surveillance system on EPI targeted diseases is improved.
3) Cold chain logistics is improved.
4) Medical workers improve their techniques on EPI.
5) Mongolian people raise their consciousness and increase knowledge on EPI.
[IDD](1) Overall Goal
To promote maternal and child health in Mongolia.
(2) Project Purpose
IDD is brought under control in Mongolia.
(3) Outputs
1) Monitoring system is established for IDD elimination.
2) Salteries at project sites (target areas) manufacture appropriate iodized salt.
3) Iodized salt is disseminated at project sites (target areas).
4) Mongolian people increase their knowledge, attitude and actions to the importance of using iodized salt.
(4) Inputs
Japanese side:
Long-term Experts

6Equipment

165 million yenShort-term Experts

23

Trainees received

13

Local Cost70 million yen

Mongolian Side:Counterparts for EPI

31

Local Cost for EPI

1.12 million US dollar (approximately 149 million yen)Counterparts for IDD

10

Local Cost for IDD

51.94 million tugrik (approximately 6 million yen)

Land and Facilities

2. Evaluation Team
Members of Evaluation
Team

Team Leader/General: Kiyomichi FUJISAKI, Managing Director, Medical Cooperation
Department, JICAIDD Sector: Chieri YAMADA, Professor, School of Health Sciences, Hirosaki University
EPI Sector: Hiromu YOSHIDA, Senior Researcher, National Institute of Infectious Diseases
Evaluation Analysis: Keiko NAMIKI, System Science Consultants Inc.
Cooperation Planning : Kiyoka TAKEUCHI, First Medical Cooperation Division, MedicalCooperation Department , JICA

Period of Evaluation

1 June 2002 - 19 June 2002

Type of Evaluation:
Terminal Evaluation

3. Results of Evaluation
3-1 Summary of Evaluation Results[EPI](1) RelevanceThe project is in line with the "National Action Plan for Development of Children in Mongolia" settled by the government ofMongolia and the contents of the plan and study methods were appropriately settled in conformity with the national standards
which were established in collaboration with international organizations (WHO, UNICEF).
(2) EffectivenessThe originally settled purpose covered too broad area, and its correction was difficult at mid-term mission (project consultationteam). Therefore, as the EPI activities were consisted from three items of (1) vaccination, (2) cold chain development, and (3)enhancement of surveillance system, the accomplishment was measured not by the original purpose but by narrowing down
actual activities. It was evaluated that the basic techniques based on the WHO standards were transferred to the counterparts.
(3) Efficiency
The inputs from the Japanese side and training of the counterparts were appropriately implemented as scheduled. The
Mongolian side had provided facilities and assigned counterparts to implement the project. However, for the latter part of theproject, the long-term experts were not dispatched from the Japanese side, and the activities by the short-term experts werealso not implemented continuously. The human resources from the Mongolian side were limited and the counterparts had othertasks for other international institutions so their activities were limited. However, the budget, equipment and the personnel
allocated for the project were efficiently utilized for the activities, which led to a certain result.
(4) Impact
The overall goal; to promote maternal and child health in Mongolia, is somehow related with the effects that EPI gave tomaternal and child health care, but it will take a long time for the effects to be realized. As for other positive impacts, theevaluation study identified the followings: the transferred techniques in the center of Mongolia expanded to local areas, anddevelopment of methods utilized by the experts at the laboratories (inspector method by hands) motivated some engineers toreview their inspection methods proactively.
(5) Sustainability
As for the organizational sustainability, the Ministry of Health (MOH) and National Center for Communicable Diseases (NCCD)
developed an organizational system and cooperation system as the health care administrative agency and an implementing
organization with expertise respectively. Under the project, cold chain and diagnosis laboratory were established, and theinformation, education and communication (IEC) activities on EPI led to a high vaccination rate, over 95%. Quality ofsurveillance still needs some improvements in terms of its accuracy, and the percentage of expenditure by the Mongolian
government is very low and depends on financial aid provided by the aid organizations. However, a vaccination fund wasestablished under the New Vaccination Law enacted in 2001. Therefore, it is evaluated that the high vaccination rate can be
maintained as long as the vaccine is supplied continuously.
[IDD](1) RelevanceThe project is the same as EPI, in line with the "National Action Plan for Development of Children in Mongolia" settled by thegovernment of Mongolia. Based on the results of a national survey on goiter in 1992 conducted by the government with theassistance of U.N. Children's Fund (UNICEF), it became clear that there was an urgent need to take countermeasures to IDD
such as dissemination of iodized salt. The relevance of the project to the needs was high.
(2) EffectivenessThe disease rate of goiter was lowered from the 40% level to the 20% level nationally. The dissemination project on iodized salt
was developed for the parents, teachers and students, and the recognition rate of the salt reached to be 95%. Thedissemination rate of iodized salt in urban areas was improved to 80%. However, in rural areas, people recognized theimportance of ionized salt but could not buy them because of financial difficulties, and so the dissemination rate was still low.
Therefore, as for the original project purpose at national level it was difficult, but in the target area where activities wereimplemented the expected effects was obtained, which indicated that the accomplishment rate was high. In the meantime, thechange of jurisdiction on the iodized salt industry from MOH to the Ministry of Food and Agriculture (MOFA) and the change ofcounterparts resulting from the change of government in the middle of the project interfered with the activities and lowered theaccomplishment rate of the project purpose.
(3) Efficiency
Generally, the inputs from the Japanese side were appropriately implemented. Similarly, the Mongolian side provided a certain
levels of input, but because the counterparts hold the post of the counterpart with the other donors concurrently, there was atime restraint for them to cope with the project activities. In addition, there was financial difficulty as well as the ripple effects ofthe change of government, which resulted in the hampering of project implementation such as insufficient maintenance of thefacilities. However, the allocated budget, equipment and personnel were efficiently utilized for the activities, which led to acertain result.
(4) Impact
The overall goal; to promote maternal and child health in Mongolia, is somehow related with the effects that IDD Elimination
Program gave to maternal and child health care, but it will take a long time for the effects to be realized. As for some positive
impacts, development of the methods utilized by the experts at laboratories (inspector method by hands) motivated someengineers to review their inspection methods proactively. On the other hand, there were also some negative effects observed
such as cheaper iodized salt was imported from neighboring countries including Russia, and the domestic production of the salt
was limited.
(5) Sustainability
As for organizational aspects, the Ministry of Health (MOH) and National Center for Communicable Diseases (NCCD)
developed an organizational system and cooperation system as the health care administrative agency and an implementingorganization respectively. However, as the population of Mongolia is small, it is extremely difficult to assure the humanresources. As for the financial aspect, as the government of Mongolia is constantly short of funds, the country tends to rely on
aid from other donors. However, the IDD Elimination Program itself does not require huge amounts of money, so there would be
no huge financial problem if activities are continuously implemented in an appropriate scale. The counterparts have acquired thetechniques of analysis and inspection methods and become able to implement accurate inspection and diagnosis bythemselves, therefore, a reliable monitoring system has been established to some degree. However as there will be no problem
in following the existing methods, the counterparts have not reached the level to develop new ideas proactively and to conduct
IEC activities, planning, implementation and evaluation.

3-2 Factors that promoted realization of effects(1) Factors Concerning the Planning
N/A.
(2) Factors concerning the Implementation Process
1) The project did not introduce existing inspection methods which were expensive by experts, but introduced sustainable
methods in a flexible manner in Mongolia. It was possible to carry out the project activities efficiently, because the adjustment
with other international institutions with different systems was made successfully and avoided the overlap with the activities
conducted by other institutions.
2) The project was the first trial to make the MOHSW the counterpart organization and was promoted in harmony with relatedorganizations, which made it possible to implement the activities in rural areas.

3-3 Factors that impeded realization of effects(1) Factors Concerning the PlanningAppropriate correction was not made during the project although the project purpose was too ambitious at the planning stage. It
was necessary to set the target of the project at a realizable level and to set the purposes more specifically. As the EPI and IDD
were put into one project, the long-term experts had to cover the areas which they were not specialized in, which restricted theactual activities of the project.
(2) Factors concerning the Implementation Process
As the counterparts also worked for other organizations as counterparts, they could not give enough time, and so technicaltransfer was difficult. The change of counterparts caused by the change of government meant that the counterparts who took
over the former counterparts had to start working on the activities without enough understanding about the project-type technicalcooperation. Therefore, they were dependent on the Japanese experts, and the Japanese experts had to implement those
activities which were supposed to be taken care of by the Mongolian side.

3-4 Conclusion[EPI]
It was not enough just to try to increase the vaccination rate at some districts only, but it was necessary to continuously try toraise the vaccination rate in wide areas. Therefore, it was difficult to implement narrowed down activities within the projectframework, and the effects could not be evaluated highly even though the activities was very well conducted. Fundamentally, it
is not possible that the budget of the Mongolian government could cover the EPI activities, and it is difficult for the project to becontinued with sustainability by the Mongolian side.
[IDD]
In huge areas with weak fundamental development, the five-year cooperation period was too short for national development ofthe IDD Elimination Program; therefore, the project activities should be developed by narrowing down the target. However, thecontents of the activities implemented was not so complicated compared with the EPI, therefore, the project has a higher
possibility to be continued by the Mongolian side with sustainability.

3-5 Recommendations(1) As for EPI, it is necessary for MOHSW to establish a vaccine fund or to collaborate with international aid organizations tocontinuously assure vaccine provision. It is also necessary to assure financial resources to establish a maintenance andmanagement system for the cold chain.
As the commencement of the instructor's retraining course was delayed more than planned, it is necessary to plan, develop andimplement the course again.
(2) It is necessary to enhance the management section by the personnel who are in charge of the nutrition program at MOH tograsp all the activities of IDD Elimination Program. It is also an urgent task that the government of Mongolia assures sufficientbudget to implement the IDD activities continuously after the termination of the project.

3-6 Lessons Learned(1) To prevent divergence between purpose and activities, from the planning stage, it is necessary to strive to set an attainabletarget and to recruit and assure the staff (experts and counterparts) as planned.
(2) Counterparts might have financial difficulties and shortage of human resources; therefore, it is necessary to develop a
feasible plan that considers the actual condition of the country.
(3) It is sometimes necessary to implement a drastic reform at the mid-evaluation because the change at the mid-evaluation
may have strong impacts on the final results.

3-7 Follow-up Situation
N/A.