Summary
1. Outline of the ProjectCountry: Myanmar
Project Title: The Project for Primary Health Care for Mothers and Children
Issue/Sector: Healthcare and medical care
Cooperation Scheme: Development Partnership Program
Division in Charge: Reproductive Health Team, 4th Group (Health II), Human
Development Department, JICA
Total cost (as of the time of evaluation): 180.797 million Japanese yen
Period of Cooperation (Duration):
July 1, 2002-June 30, 2005
Partner Country’s Implementing Organization: Department of Health, Ministry ofHealth (MOH/DOH), DOH in Nyaung-Oo, Meiktila and Pakokku Townships
Supporting Organization in Japan: Association of Medical Doctors of Asia (AMDA)
Related Cooperation: None in particular
1-1 Background of the Project
The mortality rate of infants in Myanmar is 110 out of 1,000 births. Primary HealthCare (PHC) is one of the important tasks that must be addressed in order to cope withproblems such as illness caused by nutritional deficiencies and unsanitary water, lack ofbasic knowledge on healthcare, defects in basic healthcare service and inadequate
health post.
In the middle area of Myanmar called the “Dry Zone,” which is the region
covered by this project, annual precipitation is limited to around 500-600mm. It is said
that it is the region wherein economic development is notably lagging behind inMyanmar, because of this climatic environment. Respiratory diseases and skin diseases
are frequently found. There are also many cases of waterborne infectious disease suchas diarrhea and dysentery due to lack of drinking water and water for daily life; andhealthcare and sanitation conditions are poor. Accessibility to healthcare and medicalcare facilities is low, and in many cases healthcare service are insufficient. Due to a lackof communication and means of conveyance, transportation to emergency medical carefacilities is also a significant problem. For the poor, food shortage and lack of nutritional
knowledge among mothers in particular are also problems.
The Association of Medical Doctors of Asia (AMDA), to which this project is consigned,
had implemented the “Primary Health Care Project” in collaboration with the UNDP

and WHO from 1997 in the Dry Zone. It also implemented the “Mother and Child
Health Care Project,” a Development Welfare Assistance Program by JICA, from 1999
in the Meiktila Township. Achievements by AMDA are highly regarded by the national
government of Myanmar, and the AMDA is expected to further develop its pastachievements through this Development Partnership Program.
(1) Implementing agencies
Association of Medical Doctors of Asia (AMDA)(2) Project duration
3 years (July 1, 2002–June 30, 2005)(3) Budget size
180.797 million Japanese yen(4) Targeted area
Five villages each from Nyaung-Oo and Meiktila Townships in the Mandalay Division
and Pakokku Township in the Magway Division; targeted to 100,000 people in total
1-2 Project Overview(1) Overall Goal
To reduce maternal and child mortality in the targeted area
(2) Project Purpose
To improve and enhance the health conditions of mothers and children in the targetedarea(3) Project Outputs
1. Qualities of and opportunities for available healthcare services increase in thetargeted area.
2. Nutritional conditions of mothers and children and the environmental sanitation
improve.
3. Knowledge and skills of health personnel engaged in MCH services are enhanced.
(4) Project Inputs (as of this terminal evaluation)
1) Japanese side:
Long-term experts

4 personsShort-term experts

8 personsNo. of trainees received in Japan none
Equipment supply

35.256 million yen

Local cost

49.711 million yen

Others (training cost)

3.476 million yen

2) Myanmar Side:
Health personnel allocation

92 persons

Procurement of land and facility for the Project
Manpower of residents offered for construction work

Approx. 450 persons

2. Evaluation Team Overview
Members of the evaluation team(Area in charge: name, title)
Leader: Toru Rikimaru (Senior advisor, JICA)
Project evaluation: Kazuhiro Tanaka (Program Officer, AMDA)
Evaluation planning: Yukichi Usui (Reproductive Health Team, Human Development
Department, JICA)
Evaluation Period
From May 29, 2005 to June 9, 2005
Evaluation type: Terminal evaluation
3. Overview of Evaluation Results
3-1 Achievements(1) Project Purpose Achievements
As for the project purpose, namely “to maintain and improve the healthconditions of mothers and children in the targeted area,” although the valid data wasunavailable for the health conditions of mothers, an environment was established inwhich the cooperation between the residents and health administration would help toimprove the health conditions of mothers and children. In addition, judging from thefollowing four indexes, the purpose was generally achieved.
1) Incidence of diarrhea decreased among children during the project period.
2) Cases of children’s malnutrition decreased due to the implementation of the feeding
program.
3) Mothers’ knowledge on nutrition, healthcare and sanitary practices improved due tothe implementation of health education activities.
4) Access to quality medical services at the community level increased.
(2) Output Achievements
1) Output 1: Qualities of and opportunities for available healthcare services increase.

Qualities of and opportunities for healthcare services have significantlyincreased, such as the access to primary healthcare centers becoming about 9 times
greater, through activities such as the improvement of the medical care environment
through the establishment/renovation of medical/health facilities and the provision ofmedical equipments, the collaborative mobile clinic activities and the increasing
opportunities for emergency transportation of patients.
2) Output 2: Nutritional conditions of mothers and children and the environmental
sanitation improve.
A total of 2,435 undernourished children participated in the feeding program in
the targeted area, and 56% of them recovered to the standard level. However, thenutritional status of the mothers could not be determined due to unavailability of valid
data. Also, enhanced knowledge on nutrition and healthcare/sanitary and behavioral
changes (including the diffusion of toilet constructions) among local residents wereconfirmed through the survey by implementing organization and interviews in thisevaluation. The fact that voluntary health education activities are carried out bymothers’ groups that were formed through this project is largely contributing to theachievement of this output.
3) Output 3: Knowledge and skills of health personnel engaged in MCH services areenhanced.
A total of 577 health personnel participated in training courses implemented
under this project (training course for midwives, traditional medicine training course
and training on the use of medical equipment). It was confirmed through the follow-up
survey, by implementing organization and interviews in this evaluation, that those whoparticipated in the training courses utilized the knowledge and skills obtained throughthe courses in providing healthcare services.
3-2 Summary of Evaluation Results(1) Relevance
According to the “National Health Plan (2001-2006)” developed by Myanmar’s
Ministry of Health, community healthcare is one of the top priorities. In order toimprove the level of community healthcare, it is important to broaden opportunities toreceive health services at the primary level and to improve nutritional status and thesanitary environment in the communities. The promotion of healthcare activities under
the initiative of residents also accords with the concept of “Human Security,” which
JICA adopts. Furthermore, it was confirmed through interviews at the time ofevaluation that the need for quality health services is high in the targeted area.
Therefore, the relevance of this project is high.
(2) EffectivenessAs already mentioned in 3-1 (1) above, although the valid data was unavailable
for the health conditions of mothers, the project purpose is considered to have beenachieved, in general. The achievement of the project purpose is also considered to beclosely connected with the achievement of project outputs. The achievements of project
outputs are generating a synergic effect, such as the fact that the connection betweenhealth administration and residents was enhanced through the implementation ofmobile clinic services, or voluntary activities in the community, such as self-help
healthcare groups including mothers commenced/were promoted. These factors are
considered to have contributed to the achievement of the project purpose. Therefore,
this project is judged to have been highly effective.
(3) Efficiency
Input for this project is considered to be reasonable in light of the achievementof the project purpose. Project activities are carried out according to the plannedschedule, so the timings of the inputs were also appropriate. Therefore, this project isconsidered to have been efficient. All the health facilities have been constructed orrenovated in accordance with the standard of Myanmar’s Ministry of Health. Medicalequipments and tools were suitable in terms of quality and quantity for the level ofrespective facilities. The project utilized the local resources and procured goods fromlocal companies, considering the cost-effectiveness and the convenience of maintenance.
However, expected utilization was not confirmed for some of the inputs, such as thenewly constructed station hospital and some the tractors provided.
(4) Impact
Although it was too early at the time of this final evaluation to judge the extent
of the achievement of the project in terms of the overall goal, “to reduce maternal andchild mortality in the targeted area” in the long term, it is expected to contribute to theattainment of the overall goal in terms of the improved health awareness in thecommunity and increased opportunities to receive medical services at the primary level.
Also, through the organization of community groups, such as mother self-help groups,
the project made a positive impact, such as the empowerment and unity of thecommunities. As for the spreading effect of the project to non-targeted areas, facts suchas the residents of non-targeted areas visiting the mobile clinic were confirmed.
(5) Sustainability
Although the sustainability was not considered to be enough at the beginningof the project, based on the results of the interim evaluation by the implementingorganization, the project put emphasis on ensuring sustainability by adopting aparticipatory approach for implementing activities in the latter half of the project
period.
The collaborative mobile clinic activities at primary levels are sustainable withthe cooperation of basic healthcare personnel and the community residents. However,regarding the feeding program, it is financially difficult to sustain activities that are
similar to those implemented under the project. The sustainability of the transportationof emergency patients depends on whether the tractors can be used to generate enoughincome for maintenance. Although the activities are considered to be sustained in many
villages, there are some villages that are finding it difficult to do so. Activities such as
nutrition and health education by self-help groups including mothers are sustainable if
the initiative of the communities is maintained. The sustainability of station hospitals
completely depends on the availability of medical doctors.
Thus, the sustainability of this project differs by activities. It is difficult toevaluate at the moment, and will depend heavily on the level of community
empowerment and the cooperation of healthcare personnel.
3-3 Factors Contributed in the Production of Effect(1) PlanningIt was effective for an NGO with past achievements in the targeted area toimplement this project under the scheme of the Development Partnership Program.
(2) Implementation Process
One thing that contributed to the production of the effect of this project is thefact that the implementing organization implemented interim evaluation by itself,
recognized the problems given in 3-4 (1) below, and took countermeasures thereof.
3-4 Problems and Factors that Raised Problems(1) Planning

“To how many people the medical service can be provided” was emphasized at
the planning stage, and the perspective of the participation by community residents
who serves as the basis of primary healthcare was not sufficiently incorporated, which
had a negative effect on the sustainability of the project.
(2) Implementation Process
Nothing specifically
3-5 Conclusion
The relevance, effectiveness and efficiency of the project are confirmed. The
project is also producing positive impacts in terms of community empowerment. The
method to promote active participation by health personnel and residents of thecommunity that had been employed in the latter half of the project period wasconsidered to be particularly effective. Upon the implementation of such methods, thepast experiences of the implementing organization in the area in question (or in othercountries) were considered to have been fully utilized. However, ensuring thesustainability of the project is the current challenge. To what extent the effect produced
can be sustained in the future relies largely on the level of the effectiveness ofcommunity organization and the extent of the continuation and the promotion ofactivities under cooperation with health administration.
3-6 Recommendations (Specific Measures, Recommendations and Advices on thisProject)(1) The sustainability of this project largely depends on the empowerment of thecommunities. Therefore, it is encouraged that the community group activities after theend of the project be monitored to ensure sustainability.
(2) Experiences of and lessons learned from the project may serve as a leading model topromote

community

healthcare

intheruralareaofMyanmar.

Therefore,

documentation of the project process is strongly recommended for sharing such
experiences and lessons.
(3) In one station hospital constructed and equipped by this project, the facilities were
not utilized for a long period before a medical doctor was assigned, owing to the absenceof human resources in Myanmar’s Ministry of Health. Therefore, it is recommendedthat the Ministry of Health ensure the adequate assignment of health personnel.
(4) Some tractors provided through the project were defective in terms of performance,durability and maintenance system provided by local companies, and expectedutilization was not confirmed for these inputs during the project period. In the selection
and procurement of machine and equipment, sufficient information on the performanceof items, maintenance system and guarantee system should have been collected andconfirmed.
3-7 Lessons Learned (Matters Helpful for Discovering/Forming Similar Projects Derived
from this Project and Implementation, Operation and Administration Thereof)(1) The participatory approach employed in this project is considered to be effective forthe promotion of PHC on the condition wherein access to medical service is quite
limited.
(2) Through mother groups established in the implementation process of the feeding
program, mothers implemented health education activities as well as obtained
opportunities to communicate and implement voluntary activities. These activities areconsidered to have contributed not only to enhancing mothers’ knowledge but also toenhancing their social empowerment.
(3) The “service-provision activities” carried out especially in the first half of the project
period contributed to promoting the behaviors of community residents to seek healthservices themselves. On the other hand, if the participatory approach had been planned
from the beginning of the project, the sustainability of the project could have beenpromoted further.
(4) The achievements of the purpose and outputs of the project could have been assessedmore accurately if more relevant indicators had been set from the beginning of theproject and the supporting data had been available.
(5) The recovery rate of undernourished children who participated in the feeding
program was not always high. If a more appropriate approach had been employed in thefeeding programs, which were based on a consultation with nutrition experts, theeffectiveness of the program could have been higher.

(6) The project was implemented in the “dry zone” area, where people reside in a severe
natural environment, and the security of household food is quite vulnerable. Therefore,
under such conditions, the significance of the feeding program that supported changes
in mothers’ behaviors and improvement in the nutrition of children was quite high fromthe humanitarian point of view, even if the sustainability of the program itself was not.

Chapter 1: Overview of the Evaluation
1-1 Background and Purpose of Dispatching the Evaluation TeamThe Evaluation Team was dispatched from May 29 to June 8, 2005, upon the completionof “The Project for Primary Health Care for Mothers and Children,” implemented withthe scheduled period from July 1, 2002 to June 30, 2005 in the Union of Myanmar(hereinafter referred to as “Myanmar”). The purpose of the said Evaluation is tounderstand and summarize the project performance, as well as to implement evaluation
based mainly on the five criteria of evaluation, in order to contribute to the futurecooperation of Myanmar and Japan and future collaboration with NGOs.
1-2 Members of the Evaluation Team and Evaluation Period
1-2-1 Members of the Evaluation Team
Area in charge

nametitle

LeaderToru Rikimaru
Senior advisor, JICA
Project evaluation
Kazuhiro Tanaka
Program Officer, AMDA
Evaluation planning
Yukichi Usui
Reproductive Health Team, Human Development Department, JICA
1-2-2 Evaluation Schedule
ScheduleTime

Process Accommodation

May 29 (Sun)
Arrive Yangon
May 30 (Mon)AM
Meeting at JICA Myanmar OfficePMVisit and hold meeting with the Director of Public Health Division, Department ofHealth, Ministry of Health of Myanmar
Visit the Director General of the Department of Health, Ministry of Health
Visit the Director General of the Department of International Affairs, Ministry ofHealth
YangonTraders HotelMay 31 (Tue)AM
Transition (from Yangon to Nyaung Oo)
Visit AMDA Nyaung Oo OfficeTransition (from Nyaung Oo to Pakokku)
Visit AMDA Bangkok Office
Visit Bei Gyi to inspect activities and interview residents
PMVisit KanTaw to inspect activities and interview residents
Transition (from Pakokku to Nyaung Oo)
Visit Let Pan Che Paw RHC (Rural Health Center) and inspect equipments provided
Nyaung Oo
Thante Hotel
June 1 (Wed)
AM
Transition (From Nyaung Oo to Meiktila)
Visit Ahle Ywar Station Hospital, inspection and interview
Visit Meiktila Medical OfficePM
Visit Kyun Khin Gyee to inspect activities and interview residents
Meiktila
Winzin Hotel
June 2 (Wed)
AM
Visit Nyaun Za to inspect activities and interview residentsPMTransition (to Nyaung Oo)
Visit Nyaung Oo District Hospital, Visit DMO (District Medical Officer) and holdmeeting
Inspect the children’s ward of Nyaung Oo District Hospital and hold interviews
Nyaung Oo
Thante Hotel