Summary of the Terminal Evaluation Results
1. Outline of the ProjectCountry: Cambodia

Project title: Strengthening Human Resources Development
System of co-medicals in Cambodia

Issue/Sector: Health, Health System

Cooperation scheme: Technical Cooperation

Division

Total cost (as of Jan 2015):

incharge:Human

250 million yen

Development Department, JICA
Period of Cooperation: 22nd June, 2010st

– 21 June, 2015

Partner Country’s Implementing Organisations:
Human Resources Development Department (HRDD),
MOH,

National

Maternal

and

Child

HealthCenter(NMCHC)Japanese Cooperating Organisation(s): National Center for
Global Health and Medicine
Related Cooperation:･Project for Human Resource Development of Co-medicals
1-1 Background of the ProjectTechnical cooperation in the field of Co-medical education system was started as "Project for Human
Resources Development for Co-Medicals", from 2003 to 2010. The project contributed to develop
regulations on the "School approval criteria" and "guidelines for approved schools"; and provided
reference books to the schools for co medicals (Nurse, Laboratory technician, Physiotherapy andRadiology) with short refresher courses for school teachers in Cambodia. However, some issues still
remain, i.e. lack of systematic mechanism for capacity building of teaching staff, insufficientregulations for controlling the quality of health professionals, and difficulties in harmonization andalignment among partners on pre-service and in-service training needs.
Based on the lessons learned from the previous project, "Project for Human Recourses Development
System of Co-medicals" was launched in June 2010 as taking position of phase 2 of the previous projectdescribed above. The project has two main pillars with the focus on nursing and midwifery. One issupporting to develop a regulatory framework for health professionals, another is developing overseas
bachelor bridging course at Saint Louis Collage in Thailand and dispatching Cambodian nursing school
teachers and clinical trainers to the course.
Approaching to an end of the Project in June 2015, a Terminal Evaluation Team (the Team) was
dispatched to review the progress and the achievement and to discuss and agree on the countermeasure
to solve the challenges if any.
1-2 Project Overview(1) Overall Goal: Quality co-medicals are produced through the human resource development system(2) Project Purpose: The educational basis for quality co-medicals (mainly nursing/midwifery humanresources) is improved by enhancement of HRDD management capacity(3) Outputs:xi

1. Drafts for Nursing Regulations are prepared.
2. Draft for Midwifery Regulations is prepared.
3. Quality of education by nursing and midwifery teachers with core team of bachelor holder isimproved.
(4) Inputs (as of Jan 2015)
Japanese side:･Japanese experts
Long-term: 3 persons; Short-term: total 31 persons (34.5MM),
・ Training in Japan: total 6 participants・ Overseas Activity Cost: USD 830,841 (i.e. 209,225USD in Cambodia, 552,628USD in
Thailand)・ Equipment: worth USD29,444 (for Office PCs and antivirus and office software, stabilizers
etc.)
Cambodian side:・ Assignment of C/P: 9 personnel (8 from MOH, 1 from NMCHC)・ Project Office: office space within MOH
Office facilities: meeting room, electricity, water, desks and chairs, printer, security andwhite board
2. Outline of the Terminal Evaluation Team
Evaluation
Team

1. Team Leader, Mr. Tomoya Yoshida, Director, Health Group 2, Human
Development Department, Japan International Cooperation Agency (JICA)
2. Technical Advisor, Dr. Hidechika Akashi, Director, Department of Global Network
and Partnership, Bureau of International Medical Cooperation, National Center for
Global Health and Medicine (NCGM)
3. Cooperation Planning, Ms. Kyoko Sakurai, Health Group 2, Human Development
Department, Japan International Cooperation Agency (JICA)
4. Evaluation Analysis, Ms. Yuko Tanaka, Consultant, Tekizaitekisho LLC.

PeriodJanuary 7, 2015 – January 23, 2015

Type of Evaluation: Terminal Evaluation

3. Summary of Terminal Evaluation Results
3-1 Achievements(1) Likelihood of Achieving the Project Purpose
Project Purpose: The educational basis for quality co-medicals (mainly nursing/midwifery humanresources) is improved by enhancement of HRDD management capacity.
At the time of Mid-term Review (March 2013), the probability of achieving the Project Purpose by theend of the Project was considered to be high. As for the indicator 1 “National Nursing Licensing
System” was considered to be “in the process of achieving” because i) National Exit Exam is
implemented with the endorsement from the Government, ii) responsible institution was about to be
finalized, iii) Sub-decree for nursing regulation is at the final stage before approval. However, duringxii

the preliminary consultation for draft Sub-decree with the Council of Ministers, the lawyers pointed outthat there were some discrepancies between the draft Sub-decree and existing law(s) and regulations,and that a law is required to support the licensing system. Therefore, a new Law on health professionals
was identified as crucial step before proceeding to the approval of draft Sub-decree.
Overall, the level of achievement of the Project Purpose, it is considered to be partly achieved. As ismentioned earlier, indicator 1 is not achieved while the rest of the indicators are either mostly achievedor close to be achieved. In order to fulfill the indicator 1, drafting of regulations is set in PDM (asOutput 1 and 2), and these outputs are complemented by several external conditions. The second
external condition “Responsible organization for licensing and registration is decided promptly” isagreed but it has to wait till the enactment of new law, while the third external condition “Draft ofnursing regulations (licensing) are approved and issued by the relevant level of authorities of thegovernment” would not be fulfilled by the end of the Project. On the other hand, the first external factor“The National Exit Exam is implemented as planned” is already fulfilled; however the Evaluation Teamnotes that there are several more important steps to examine and reach to agreement among relevant
stakeholders (MOH and 5 professional councils) in order to be able to initiate a National Licensing
System in Cambodia. These important steps were not clearly addressed within the current PDM as partof the Project activities, and with some influence of implementing structure it was very difficult for the
Project to bring forward each process leading to National Licensing System.
(2) Level of Achievements: Outputs
Output 1: Drafts for Nursing Regulations are prepared.
Support for regulatory development for National Licensing System became more important issue for
Cambodia after the initiation of the Project, so in response to strong request from Cambodian side theProject agreed to modify its scope by shifting more focus from training of existing and new teachers
onto strengthening regulatory framework through development of regulations relating to National
Licensing System. The modified content of Output 1 was officially agreed during the consultative
mission in Dec 2011 as to develop drafts for nursing regulations. At the beginning of the Project,legislative support at higher level (i.e. Law level) was also discussed within MOH, however considering
the project scope such as cooperation time and implementing structure the Project decided to focus at
Sub-decree and Prakas level.
During the development process of draft Sub-decree, not only HRDD but also related departments(such as Legislative Department and Hospital Service Department of MOH) as well as HealthProfessions Councils were also involved as technical working group and consultative working groupmembers. During the drafting process, core counterpart members were also given opportunities to learn
about licensing and registration system in other countries (especially in Japan and in Thailand) throughtraining courses in Japan and technical exchange meetings.
Since then, it took a long time to determine the highest responsible body for management ofregistration and licensing system. Recommendation from working group and consultative group to havethe Minister of Health to issue the license within transitional period of 5 years because the process forxiiilicensing application is not developed yet in Cambodia. Recommendation was also made to establish a
National Board to assist development process for licensing system and work together for the quality ofeducation and health professional.
The final draft of “Sub-decree for Nursing Regulation” was submitted to the Minister of Health inFebruary 2014, however during the preliminary consultative meeting with lawyers of Council of
Ministers, lawyers pointed out that there are duplications with the existing law and suggested that theamendment of existing law8 or development of new law would be necessary in order to bring further
the process of approval of the draft Sub-decree. Based on the agreement in JCC September 2014, atechnical working group was formed to develop a draft for amendment, as a result of a series of
discussion within the working group and consultation meeting among senior members of MOH and
Health Professions Councils, a new Law on health professionals was agreed to be developed.
Output 2: Draft for Midwifery Regulations is prepared.
The component of drafting midwifery regulation was not started at the time of mid-term review(March, 2013) and the Japanese side suggested to exclude this component out of the scope of the
Project. However, as a result of discussion in JCC, both sides agreed to keep this component within the
Project scope. On the other hand, HRDD, being in charge of many tasks such as accreditation of private
schools and management of national exams, does not have further human capacities to take up role ofregulatory development in this component, director of NMCHC was appointed as an additionalcounterpart to be responsible for the drafting of midwifery regulations based on the amendment of R/D
in May 2014. The technical working group was formed in December 2014 and the group is now at the
preparation stage for drafting midwifery regulations. The expected timelines for the working group is tofinish the first draft by the end of February, followed by revision of the draft by April. The Project aims
to submit the final draft to Minister of Health around May 20159. Nevertheless, in order to proceed withthe approval process of draft Sub-decree, Law on health professionals mentioned earlier need to be
developed as well. In addition, contents of the draft Sub-decree need to be revised so that it iscompatible with the new law on health professional once it is drafted.
Overall, the level of achievement of Output 2 at the time of terminal evaluation is still limited.
However, the Project has recently taken up activities to start a drafting process with technical working
group members so it is expected that the draft will be developed according to the planned timelines
mentioned above.
Output 3: Quality of education by nursing and midwifery teachers with core team of bachelor holder isimproved.
The original project design (PDM ver.1) placed more focus on strengthening the education system ofteachers, and the focus was shifted to the support for regulatory framework of National Licensing
89

Law on Management of Medical, Paramedical, and Medical Aide Profession
According to the interview with Director of NMCHC on 9 Jan 2015.

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System during the consultative mission in December 2011. The component for nursing and midwifery
teachers education was modified and integrated into one of the outputs (Output 3), i.e. improved qualityof education for nursing and midwifery teachers through upgrading academic qualification of teachersand preceptors hence forming a “core team of bachelor holder”. As of January 2015, 13 teachers and 19
preceptors (27 nurses, 5 midwives, total 32) have been sent to take a bridging course in SLC Thailand
developed by the Project with its technical and financial support10. The SLC course has more focus(about 2/3 of total teaching hours) on clinical training in order to enforce the clinical experience ofteachers11.
As for the level of achievement, it is considered that Output 3 is mostly achieved. Most of the SLC
graduates interviewed during the terminal evaluation study are either continuing to be in a position ofteaching students (as preceptors or teachers) or providing some advice for other colleagues who arepreceptors or teachers.
3-2 Results as per Five Evaluation Criteria(1) RelevanceThe relevance of the Project remains high for the following reasons:

The Project design is in line with national policies of Cambodia, namely “Cambodia Health Strategic
Plan 2008-2015” and “Second National Health Workforce Development Plan 2006-2015”, both ofwhich elaborate the needs of improvement of human recourses for health.



The Project is consistent with priority areas for Japan’s Assistance Policy for Cambodia (April2012). The Project is located under the development program for “Strengthen Health System”,
under the priority area (development subject) of “Enhancement of Health and Medical Care”.

The requirement from ASEAN Economic Community (AEC) for mutual recognition arrangement isanother factor to enhance relevance of the Project approach to urgently develop a National
Licensing System.

(2) EffectivenessThe effectiveness of the Project is considered to be moderate for the following reasons:The possibility of achieving the Project Purpose “The educational basis for quality co-medicals(mainly nursing/midwifery human resources) is improved by enhancement of HRDD management
capacity.” by the end of the Project is considered to be moderate in terms of achievement of
indicators. Achievement of indicator 1 of the Project Purpose is affected by some of the external
conditions specified in PDM (ver.3), in addition a Law on health professionals turned out to benecessary in order to start a National Licensing System.

Regarding the logical relationship between Outputs and indicator 1 of the Project Purpose, draftingof nursing/midwifery regulations (Outputs 1 and 2) is not sufficient for starting National Licensing
System.

10
11

Including those who are currently studying in SLC; they are expected to complete their study in February 2015.
In Cambodia at least three years of clinical experience is required for teachers, however number of teachers cannot fulfil thisrequirement （according to the questionnaire and personal communications with JICA experts in January 2015）.

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

Besides the achievement of indicators, Output 1, 2 and 3 contributed to the enhancement of HRDD
management capacity especially through the experience of developing the nursing/midwifery
regulations, as well as monitoring and follow-up of BSN bridging course. Therefore, Output 1, 2
and 3 contributed to the improvement of educational basis.

The effectiveness of the Project would increase if nursing/midwifery regulations drafted by the
Project (Output 1 and 2) are approved and enacted by MOH. In order to start a National Licensing
System MOH also decided to develop a Law on health professionals, therefore it is hoped that thedrafting and approval process of this law would go smoothly and effectively.

(3) Efficiency
Overall, the level of efficiency of the Project is considered to be intermediately high for the following
reasons:Some inhibiting factors affected efficient implementation of the Project activities. These include;
delay of decision making within MOH and a general election affected the progress of the Project. In
addition, it was not until the last moment of the Project cooperation period that a new law isrequired to support Sub-decrees for Nursing/Midwifery Regulations developed by the Project.

Regarding the bridging course in SLC Thailand, all of 32 students12 successfully completed the
BSN course and returned to their respective schools and teaching hospitals. Upon returning to
Cambodia, SLC graduates continue to be involved in educational activities to share theirexperiences to their colleagues and students in schools and teaching hospitals.

(4) Impact
Impact is a viewpoint that asks “whether expected or unexpected long-term effects are brought about
as a result of the Project”. Overall Goal, which is expected to be achieved within three to five years
after the Project completion, is one of the expected impacts of the Project.
As for the level of achievement of Overall Goal “Quality co-medicals are produced through the humanresources development system”, it is still premature to examine to what extent the outcome of the
Project could contribute to fulfill the Overall Goal. MOH is still in the preparatory phase in terms ofsetting up a National Licensing System, therefore it is hoped that the Overall Goal “quality ofco-medicals are produced” will be fulfilled once National Licensing system is set up in Cambodia.
As for another impact besides the Overall Goal, following are reported as potential impact of the
Project.
Core members of professional councils were also involved in some project activities such as working
groups, training seminars and technical exchanges. This contributed to enhance knowledge of
Health Professions Council members.



One SLC graduate was assigned to HRDD and this will contribute to the human resource
development in nursing and midwifery in the future.



12Self-support group “BSN-GG” including SLC graduates was formulated during the Project. This

Including batch 4 who will complete their studies in February 2015.

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may be a potential platform for continuous knowledge sharing, which could lead to the formation ofan academic society in the future.
(5) Sustainability
1) Policy aspects
The sustainability of the Project from policy aspects is considered to be high for the following reasons:

Development of human resources for health is likely to remain one of the priority areas of healthsectors in Cambodia. MOH is now preparing “Cambodia Health Strategic Plan (HSP)” and “Second
National Health Workforce Development Plan (HWFDP)” for the next phase starting from 2016,and human resources for health is one of the 6 priority areas of HWFDP.



Law on health professionals is now in a preparatory phase within MOH. Once this Law isestablished and related regulations (including Sub-decrees of Nursing/Midwifery Regulations) areenacted, it will reinforce the sustainability of the effects of the Project.

2) Institutional and financial aspects
In terms of organizational and financial aspects, sustainability is moderately assured.


In terms of National Licensing System, responsible organization for licensing is agreed to be the
Minister of Health and it will be transferred to Health Professions Councils in about 5 years’ time.
Technical working group also suggested establishing a national board to assist development process
for licensing system. The institutional arrangement will be officially documented either in Law on
health professionals or in related regulations.

Regarding BSN bridging course in Thailand (SLC), there is no financial or institutional arrangement
within MOH to continue sending teachers/preceptors to SLC after the Project. On the other hand,in-country bridging course was supported by WHO/Ausaid during Feb 2013 – Dec 2014, andrecently Korean government (through KOICA) started to support in-country bridging course inpartnership with UHS during Jan 2015-Dec 201613.

3) Technical aspects
The sustainability of the Project from technical aspects is considered to be intermediately high for thefollowing reasons:

During the process of regulatory development, key stakeholders from MOH and Health Professions
Councils participated in working groups, technical exchange meetings, and trainings. Some of themwere also involved in the drafting of Nursing/Midwifery Regulations. Through these activities
counterpart members enhanced their knowledge and experiences of regulatory development in
National Licensing System.



22 SLC graduates among 26 returned are in position to improve teaching –learning activities atschool (i.e. working group mentioned above, technical bureau staff) and at hospital (ie head or vicehead nurse at ward, member of nursing department).

13

According to the information collected by JICA Cambodia Office, the total budget is USD 1 million, and KOICA provides bothtechnical and financial support, covering 40 candidates from bridging course.

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

Course syllabi on two subjects were developed to standardize quality of education. However, course
syllabus on clinical practice at hospitals is not developed.

(6) Factors that promoted/ inhibited realization of effects
1) Promoting factors:Japanese Supporting Group provides technical advices especially on drafting nursing regulations andschool accreditation regulation.

Regular monitoring made by HRDD officials to SLC enhanced understanding of HRDD to recognize
this bridging course within the wider context of human resource development program (and not
merely JICA’s scholarship program).



Bridging course in Thailand is an effective input from the Project for providing opportunities toteachers and preceptors to learn about some fundamental issues of nursing practice such as nursing
care in hospitals, health centers and communities. It also provides opportunities to learn fromprofessors from Thailand in foreign language (English).

Strong management capacity of some of the counterpart members. They had a chance to learn
experiences from other countries in terms of school accreditation system, national exam, licensing
and registration system (its framework, operation, role of public administration etc.)

Among the SLC graduates, 1) all return to their original institution/hospital upon completing theirstudy in Thailand, and 2) They can count in support and understanding from their bosses.

2) Inhibiting factors:
The delay of decision making within MOH and a general election (July 2013) affected the progressof the Project in submitting or bringing draft Sub-decree to the preliminary consultation withlawyers of the Council of Ministers. This resulted in the delay of recognizing the necessity foramending or establishing a Law on health professionals. (See section 3.2.2 for details).

Within the Project design (PDM ver.3), indicator 1 of the Project Purpose (National Licensing
System is started) cannot be achieved by achieving Outputs (1 and 2) and fulfillment of external
conditions only. Activities on development of implementation capacity for National Licensing
System were necessary, or either modification of Project indicator was necessary.

3-3 Conclusion
According to the Project design, this Project aims to enhance “the educational basis for quality
co-medicals” by improving management capacity of HRDD (see PDM ver.3). Two kinds of mid-termgoals are set as “Outputs”, and these are i) To draft Nursing/Midwifery Regulations and ii) To improve
quality of nursing/midwifery teachers. As for Output level, Output 1 and 3 are considered to be mostly
achieved, while the level of achievement of Output 2 is still limited at the time of terminal evaluation.
However, the progress of Output 2 is still on track, and it is expected to be achieved by the end of the
Project (June 2015). The Project Purpose is considered to be “partly achieved”, instead it will take atleast few more years before the National Licensing System can actually be implemented (indicator 1 of
the Project Purpose).

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In terms of five evaluation criteria, relevance is considered to be remained high, effectiveness ismoderate and efficiency is considered to be intermediately high. It is still premature to examine thelevel of achievement of Overall Goal of the Project, because the “human resource development system”
including National Licensing System is not yet started. Overall Goal shall be verified when the Law on
health professionals is established and the National Licensing System is started. In terms ofsustainability, it is considered to be high from the policy aspect, moderately assured from theorganizational and financial aspects, and intermediately high from technical aspects.
3-4 Recommendations and Lessons learned
3-4-1 Recommendations
On the ground of the results of the study summarised above, the Mid-term Review Team has made thefollowing recommendations to the Project.
1. By the end of the project, MOH should draft the new Law on health professionals. On drafting theLaw, MOH is recommended to check the consistency in the contents of the Law and draft nursing
and midwifery Sub-decrees.
2. It is recommended that MOH should take prompt actions towards making and getting approval of
the new Law on health professionals, so that the draft sub-decrees on nursing and midwifery
regulations do not get stuck in pending status.
3. As recommended by the mid-term review team of the Project in March 2013, it is necessary for
MOH to state the responsible organization of licensing and registration of health professionals inthe draft Law or Sub-decrees.
4. The Project is recommended to take necessary steps for approval and enactment of the draft joint
Prakas on the School Accreditation. HRDD is recommended to conduct regular monitoring of
public and private schools for ensuring the implementation of the joint Prakas, once it is enacted.
5. The inventory list of laws and regulations developed by the Project proved to be very useful for thenational and local health administration bodies. Therefore, it is recommended that the legislative
department of MOH establish and maintain mechanism to manage, update and disseminate theinventory list, and MOH allocate the annual budget for the operation.
6. MOH is strongly recommended to make a mid to long term strategy and action plan specifically fornursing and midwifery human resource development in Cambodia Health Workforce Development
Plan 2016-2020. It should include development plan for the teaching professionals at nursing
schools and preceptors in hospitals including overseas and in-country bridging courses.
7. Project is recommended to set the target number for the indicator of the Overall Goal “# of certified

xixnurse/midwife under the new system increases” specified in PDM (ver.3).
8. MOH and nursing/midwifery schools are recommended to develop syllabi of all subjects including
clinical practice syllabus. SLC graduates from hospitals and schools can be utilized in this process.
9. The project is recommended to hold seminars for dissemination on 1) Joint Prakas on school
accreditation among officers from private and public health professional schools 2) professional
development of nurses through BSN bridging course among nurses on International Nursing Day.
3-4-2 Lessons learned
1. At the initial stage of any projects aiming to develop health sector laws and/or regulations, theproject should create the inventory list on the related laws and regulations to promote understandingof MOH on entire laws and regulations on health, if they do not have the list.
2. Within PDM, achievement of outputs and fulfilment of external conditions should be directly linked
to achievement of the project purpose.
3. The scope of projects aiming to develop health sector laws and/or regulations should be limited toformulation of the draft laws and/or regulations because enactment of laws and/or regulations ishard to achieve only by the project inputs.
4. Conducting educational program outside the country where education environment is advanced iseffective in fostering potential leaders at the early stage of the development of the sector.

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