Asia
I. Outline of the ProjectCountry: The Lao People's Democratic Republic
Project title: Project for the Improvement of Sethathirath Hospital (SH)
Issue/Sector: HealthCooperation scheme: Project-type Technical Cooperation
Division in charge: Health Personnel Development Team Group III (Health I), Human Development Department
Total cost: 545 million Japanese Yen
Period of Cooperation(R/D):
1998.12.18(Extension):(F/U):(E/N)(Grant Aid)
Partner Country's Implementing Organization: Ministry of Health. Lao PDR, Public Health Department of Vientiane
Municipality, Sethathirath Hospital
Supporting Organization in Japan: Faculty of Medicine. University of the Ryukyus, Okinawa Medical Association, Okinawa
Prefecture
Related Cooperation:

1 Background of the Project
Sethathirath Hospital (SH) is a general hospital officially equipped with 175 beds and 290 staff, including 75 doctors. It is a core
medical hospital in northern Laos, as well as a site for the training and education of medical personnel. Since the building andfacilities were too old to provide Lao citizens with adequate medical services, the New SH was built with the assistance of theGovernment of Japan. At the same time, the Lao Government requested Japanese technical cooperation for the upgrading of
medical services at SH. In response, the project for the improvement of SH was commenced as a five-year program in October
1999.

2 Project Overview(1) Overall Goal
1.The SH's output, such as its medical record system, computerization of patient's records, therapeutic meals, training for
medical staff in district hospitals, produced through the Project is used by other hospitals in Lao PDR.
2. No. of patients received diagnosis or treatment within Lao PDR is increased.
3. No. of laboratory tests requested to SH is increased.
4. Technical exchange activities with hospitals in neighboring countries are implemented.

(2) Project Purpose
Medical service and training capability of Sethathirath Hospital (SH) are improved.

(3) Outputs
1. Clinical skill and knowledge in the following fields are improved :1-1. Internal Medicine field (infectious disease, hematology, endocrinology)
1-2. Gastro intestinal (GI) endoscopic field

1-3. Pediatric field (especially neonatal care)
1-4. X-ray field (includes CT scanner, ultrasonography)
1-5. Obstetrics and Gynecology (OBGY) field(perinatal care, high risk pregnancy, oncology)
1-6. General Surgery field(particularly oncological diagnosis & therapy)
1-7. Other clinical fields (such as Emergency, ICU, Anesthesia, Ophthalmology, Dental care)
2. Skill and knowledge of Laboratory at SH are improved
3. Skill and knowledge of Pharmacy at SH are improved
4. Skill and knowledge of Nursing field at SH are improved
5. Functions in Hospital Administration at SH are improved
6. Medical equipment and facilities can work on request at SH
7. Dietary service at SH is improved
8. Functions of training system for post-graduated doctors are improved at SH
9. Referral system between local health facilities in 3 Provinces (all district hospitals in Vientiane Municipality, Central and main
district hospitals in other 2 Provinces) and SH is improved.
9-1. Skill and knowledge on Primary Medical Care (PMC) of medical staff at local health facilities are improved.
9-2. Health education toward people are promoted.
9-3. Introduction and transportation system for patients from local health facilities is improved.

(4) Input
Japanese side:
Long-term Experts:

15

Equipment:

146,000,000 YenShort-term Experts:

31

Local cost:

approx. 30 million Yen

Trainees received:

18

Lao Side:Counterpart:

120

Local Cost:

approx. 6,800 US$

II. Evaluation teamMembers of Evaluation Team:
Team Leader:
Akira HASHIZUME, Executive Technical Advisor to the Director General, Human Development Department, Japan
International Cooperation Agency
General Medicine:
Tadashi NISHIMAKI, Professor, Faculty of Medicine, Organ-oriented Medicine, Division of Digestive and General Surgery,
University of the Ryukyus
Community Health:
Hiroyuki NAKANO, Chief, Division of Pediatrics, Department of International Cooperation, St. Mary's HospitalEvaluation Planning:
Yuko KATSUNO, Health Personnel Development Team Group III (Health I), Human Development Department, Japan
International Cooperation Agency
Evaluation Analysis:
Akira MATSUMOTO, Manager, Consulting Department, TAC International Inc.

Period of Evaluation:
29 May 2004 - 13 June 2004

Type of Evaluation:
Terminal Evaluation

III. Results of Evaluation
1 Summary of Evaluation Results(1) Relevance
The Project is relevant to the national policy of Lao PDR and the project purposes are in line with the goals of SH. In light of theincreased numbers of inpatients and outpatients treated at SH, the Project also seems to be relevant to the needs ofbeneficiaries.

(2) EffectivenessThrough the careful studies and discussions, the evaluation team ranked the achievements of nine (9) Outputs based on three(3) levels of criteria (A, B and C).
The three (3) levels of criteria were provided by the results of the following judgments:
A= The indicators were generally relevant and the Outputs of Activities were well achieved.
B= The indicators were generally relevant but the Outputs of Activities were not adequately achieved or satisfied.
C= The indicators were not generally relevant and the Outputs of Activities were not adequately achieved.
Using the above criteria, the nine (9) outputs were ranked as follows.
Level A: 1 Clinical Field, 2 Laboratory Field, 3 Pharmacy Field, and 6 Medical Equipment.
Level B: 4 Nursing, 5 Administration, and 9 Referral System.
Level C: 7 Dietary Service and 8 Training System for Postdoctoral Fellows.
The evaluation team concluded that, with the exception of a few Activities, the targets of the Project Purpose and Outputs aregenerally relevant. The Project Purpose and Outputs are expected to be satisfactory, even though some of the Activity Outputs
have not been achieved to the same degree as the corresponding indicators.

(3) Efficiency(Efficiency of Human Resource Inputs)
The dispatch of long-term experts was efficiently executed and relevant, and the advice from the Japanese experts wasappropriate and kind. Several setbacks affected the Activities of the Project, however. These included a change in the planning,a delay in the dispatch, and a shortening of the dispatch period for the short-term experts.

(Efficiency of Equipment Inputs)
All the machinery and equipment were appropriately provided after long-term experts imparted their advice. The long-term
experts accurately estimated the appropriate types of equipment (level, etc.), the appropriate quantities, and the capacity of thecounterparts.

(Efficiency of Budgetary Inputs)
The budgetary inputs provided have met the requirements of the Project Outputs. The SH staff have understood the cost
sharing scheme, which attempts to secure budget and improve revenues. The Project implementation has been deemed tohave been efficiently managed.

(Efficiency of Training Inputs)
Eighteen (18) trainees were received in Japan, all of whom are now working at SH. The training in Japan has been useful not
only for technical improvement, but also for the acquisition of knowledge in medical ethics, clinical treatment, and patient care.
Furthermore, the materials and samples in Japan have been amply utilized for reference and practice. As an added merit, those
who have received training can become trainers in their sections.

(4) Impact
SH has been transformed into a new hospital equipped with modern medical equipment. In the process it has also gained agood reputation among both patients and the public in Vientiane. This, in fact, has been the biggest impact of the Project.
It is magnificent that the success of the Project has not come at the expense of other hospitals and services offered in Lao PDR.
Government budget has not been allocated exclusively to the Project or reduced at other hospitals.
No accurate data has been obtained on the numbers of patients treated in Laos before and after the project. It can beconfirmed, however, that the CT scanner and other new devices introduced under the Project have influenced the flow ofpatients.
The SH laboratory section has received a growing number of orders and commissions from other hospitals and privatecompanies, and SH is expected to function as a reference center in Vientiane.
The SH now offers full-time training for staff from the district hospitals year round. The system is very effective and a model
method for strengthening the referral system.
The nursing section still operates by a two-shift rotation system. This seems to be the standard for a "modern hospital."
Hospital systems enabling efficient consultation with a great number of patients are almost established at SH.

(5) Sustainability(Institutional Sustainability)
As one of the three biggest hospitals in Laos, SH will continue to function as a referral hospital for the regional hospitals inVientiane. As such, the Lao government is expected to continuously support SH.
SH has its share of outstanding talent, skill, and knowledge in medical care, but a considerable gap between the "top talent" andyoung generation needs to be bridged.
The Project has steadily strengthened the hospital. However, the official addition of the new function of "University Hospital"
raises questions about its function as a "General Hospital." It is important to continuously strengthen the medical functions anddevelop human resources to shoulder the new hospital function.

(Financial Sustainability)
Judging from the security in cost sharing and establishment of revolving funds at SH, the hospital appears to be on the rightpath towards self-finance. However, there is still room for improvement in the financial management capacity of the institution
and the definition of a clear strategy.

(Technical Sustainability)
SH is deemed technically sustainable. The counterparts have gained high abilities in diagnostic and therapeutic methods andtheir system for outpatient care.
No obstacles are foreseen in the maintenance and repair of expensive machinery and high-tech equipment such as CTscanners. This is because SH has contracted out the repair and maintenance functions.
Excluding those who have been transferred for study or service elsewhere, almost all of the counterparts have been allocatedand stayed in SH. Thus, human resource management is expected to be stably maintained.

2. Factors that promoted realization of effects(1) Factors concerning to Planning
The Project has been running in line with the hospital construction granted by Japan. The timing seems to be good. The Project
has been able to support the new hospital management and system.

(2) Factors concerning to the Implementation Process
SH initiated a useful technical exchange with hospitals in Thailand and Vietnam. This exchange focused on training in fields not
sufficiently covered by the Japanese experts. Other factors such as the language barrier, training locations, and technical andeconomic points also had positive effects.

3. Factors that impeded realization of effects(1) Factors concerning to Planning
N/A(2) Factors concerning to the Implementation Process
The Project activities were impeded by delays in the delivery of the equipment and a change in the procurement method for theCT scanner.
The shortage of hospital staff and the two-shift rotation in the nursing section still need to be tackled.

4. Conclusion
Based on the finding of the evaluation, both the Japanese and Lao sides discussed and confirmed that the Project would
achieve the Project Purpose during the project period. This Project has transformed SH into an excellent general hospital in Lao
PDR and strengthened its reputation accordingly. The counterparts have acquired almost all of the necessary skills andknowledge and improved their capabilities in medical services and training. However, efforts in some areas will have to besustained through the end of the project period to ensure adequate acquisition of skills. The Project has established a basic
technical and financial foundation. Institutional sustainability will henceforth be required for the ongoing enhancement of theroles of SH, including its roles as a teaching and referral hospital.

5. Recommendations
The Team recommended the Project respond to the following challenges.
(1) The condition of On the Job Training (OJT) for nurses has been prepared by introducing the two-shift rotation for nurses.
Senior nurses including six (6) nurses who will finish higher education in July 2004, they should plan OJT program for juniornurses.
(2) Hospital administration in SH has been well managed through frequent evaluations and instructions by Japanese experts.
However, the number of qualified administration staff should be increased, because the shortage of manpower precludes thehospital management smoothly. Also, after the completion of current Project, it is necessary to improve the self-evaluation
system such as regular checking sheets introduced into maintenance section in April 2004.
(3) Hospital dietary services have not been provided due to the external assumptions. Alternatively, a system of dietary therapy
should be upgraded.
(4) Training for post-graduated doctors has no been systematically implemented. The training system is a basic component forSH as a "teaching" hospital. Therefore, as a pre-required condition, it is essential to record patient's data, and to secure theeasy access and the availability of data.
(5) It is important to feed back patient's information for referring hospitals. The feed-back will contribute to the development ofmutual confidence. Consequently, it is necessary to clarify and resolve the problem of low reply-rates to the referring hospitals.

6. Lessons Learned(1) Technical cooperation including training with neighboring countries was valuable for the activities of the Project.
(2) English group study was effective to upgrade communication skill for smooth implementation of technical transfer.
(3) The monitoring sheet was effective to promote the smooth project activities. In additions, it should be flexibly modified
according to the change of situation and easier utilization by both sides of the experts and counterparts.
(4) Through the activities of the Project, the partnership between SH and University of the Ryukyus has been strengthened. By
the deepening of the partnership, it is meaningful for SH to grade up toward university hospital.