Summary of Terminal Evaluation
I. Outline of the ProjectCountry: Islamic Republic of Afghanistan

Project title: Reproductive Health Project Phase 2

Issue/Sector: HealthCooperation scheme: Technical Cooperation

Division in charge: Health Team 4, HealthGroup 2, Human Development Department

Total cost : approximately 350 million yen(R/D): From May 10, 2010 to May 9, 2015
(5 years)

Partner Country’s Implementing Organization:
Reproductive Health Directorate of Ministry of Public HealthSupporting Organizations in Japan: Nothing Particular
Related Cooperation: Technical Cooperation Project"Urban Health System Strengthening Project"

1-1 Background of the ProjectThe Government of Japan resumed its support to Islamic Republic of Afghanistan (hereinafter referred toas "Afghanistan") subsequent to the High-level Officers' Meeting on Reconstruction Support for Afghanistan
in November 2001 and the Meeting on Reconstruction Support for Afghanistan in January 2002. Afterwards
in August 2002, JICA dispatched a basic study team, which established and agreed with the Ministry of Public
Health (MoPH) on the following four priority issues as targets for JICA's cooperation strategy in health sector:(1) Improvement in women's health, (2) Measures to protect children from preventable diseases, (3) Infectious
disease control, particularly tuberculosis, and (4) Strengthening of MoPH's implementation and management
capacity in order to provide effective health services. Subsequently, The Reproductive Health Project Phase
I was implemented from September 2004 to September 2009, to improve the capacity of reproductive health(RH) officers and RH service providers to provide necessary services.
However, further improvement of management capacity of RHD and RH officers in provinces wasregarded necessary to develop and implement the RH related programs, and to monitor the activities for
efficient and effective RH services. Eventually Reproductive Health Project Phase II (hereinafter referred toas "the Project") was requested by the Government of Afghanistan for further reinforcement of administrative
management capacity of RHD and Provincial Reproductive Health Officers (PRHOs). The Project aims at
improvement of RHD's management skills for the RH programs as the Project Purpose or the main objectiveof the Project. To achieve that Project Purpose, four pillars of Outputs were set, improvement of a) policy
formulation, b) activity coordination, c) M&E capacity and d) in-service training management, which were
the result of the revision of Project Design Matrix (PDM) in 2011.
1-2 Project Overview(1) Overall Goal
The quality of RH services is enhanced.
(1) Project Purpose
RHD manages the RH program more effectively and efficiently.

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(2) Outputs
1. RHD’s capacities for policy formulation are strengthened.
2. RHD’s capacities to coordinate RH-related activities are strengthened.
3. RHD and PRHO’s capacities for M&E of the RH Program are strengthened.
4.	RHD and PRHOs’ comprehensive capacities to manage in-service training for RH service providers arestrengthened.
(3) Inputs
Japanese side:
JICA Expert: Two (2) long-term and one (1) short-term experts; Four (4) local consultants
Group training in Japan: Eleven (11) Persons (Training and dialogue programms)
Provision of equipment: Equipment was provided for emergency obstetrics at 5 hospitals and technicaltrainings and training management at regional training centers.
Overseas activity cost: 124.8 million yen
Afghan side:
Counterpart: 19 persons (RHD); 30 PRHOs
Local Cost: Personnel costs, Electricity and heating expenses
Provision of land and facilities: Office space for Japanese experts and local consultants; Meeting Rooms
2. Evaluation Team
Members ofEvaluation
Team

Mr. Shigeki
FUKUDATeam Leader

Senior Deputy Resident Representative, JICA
Afghanistan Office

Dr. Yoshihito
KASHIWAZAKI

Evaluation Analysis

Consultant, A&M Consultant

Dr. Zabihullah
Rahmani

Cooperation Planning

Program Officer, JICA Afghanistan Office

Mr. Chigiru
YAMASHITA

Cooperation Planning

Assistant Resident Representative, JICA
Afghanistan Office

Mr. Yukihiro
KONDO

Evaluation Planning

Health Team 4, Health Group 2, Human
Development Department, JICAPeriod of Evaluation

From November 20, 2014 toFebruary 10, 2015

Type of Evaluation: Terminal evaluation

3. Results of Evaluation
3-1 Achievement(Output)
The activities for Outputs 1 and 2 have mostly been completed and a part of the activities (such as Activities
1-4, 2-1 and 2-2) are supposed to continue as routine work of RHD. For Outputs 3 and 4, the discussion,
revision and endorsement steps to formulate the guidelines had taken a considerable long time, which resulted
in the delay of implementation of the M&E activities and in-service trainings. Nevertheless, they have beencommenced partially and are expected to accelerate towards the completion of the Project.

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Output 1: RHD’s capacities for policy formulation are strengthened.
The indicator was partially achieved because M&E based on the revised guideline has just been initiatedlately. With the support of the Project and other partners, RHD completed the revision of National RH Policy
and Strategy in 2012 after two-year-long efforts, and subsequently revised the related guidelines as well. RHD
has started to implement monitoring activities (Activity 1-4) based on the revised Strategy and guidelines.
Output 2: RHD’s capacities to coordinate RH-related activities are strengthened.
The two indicators are considered achieved as the RH-related meetings and initiatives have increased
significantly although their exact numbers were not presented. The coordination capacity of RHD has
significantly been strengthened through the Project activities. When the Project was initiated, the capacity ofRHD was not enough to coordinate inter-directorate meeting, however now, the large-scale conferences withthe partners can be managed by RHD with minutes writing. Through the coordination, RHD is now able toinvolve other directorates, partners, and other institutions in RH program and activities.
Output 3: RHD and PRHO’s capacities for M&E of the RH Program are strengthened.
The both indicators haven't been achieved mainly due to delay of endorsement of M&E guideline. However,
RHD has finally developed the guideline, indicators and tools for M&E based on the revised RH Policy andStrategy, and have started M&E activities under the new guidelines in 2014. OJT on report writing for RHD
permanent staff is in progress for integrated feedback. A Five-day tutorial class was given to 5 staff of RHD,
followed by OJT imposing an assignment to the staff. The progress is slow due to the overload of their routine
work but the training will be completed in due course. On the other hand, National RH Workshop was held
only once in 2012 and needs to be organized by the end of the Project.
Output 4: RHD and PRHOs’ comprehensive capacities to manage in-service training for RH service
providers are strengthened.
This output is hard to achieve during the Project period judged from the indicator. The In-Service Training(IST) Guide (National IST guideline and tools) was finally compiled lately and accordingly the planning andimplementation of IST were delayed. It is expected the remaining activities (planning and implementation ofIST) are commenced by the completion of the Project and continued afterwards.
(Project Purpose) RHD manages the RH program more effectively and efficiently.
Project Purpose is partially achieved.
The Activities related to Outputs 1 and 2 have mostly been completed although a part of them (Activities
1-4, 2-1 and 2-2) should be sustained onwards. For Outputs 3 and 4 the scheduled Activities have partially beencompleted. Especially in terms of in-service training, the formulation of the guidelines needed comprehensive
operational steps, which have taken a certain amount of time and resulted in delay of its commencement.
For the Indicators, 1 and 2 have been achieved while 3 & 4 are incomplete due to delayed endorsementof the related documents (i.e., M&E and IST guidelines, and IST plans). However, the M&E and ISTs arecurrently under the planning process for achievement of the Project Purpose.
Indicator 1) Based on the results of M&E, the RH strategy and planning document are reviewed
periodically and revised by RHD when necessary.
Based on AMS 2010, the National RH Policy and Strategy 2012-2016 was revised and promulgated.
Subsequently, RH national guidelines have been reviewed and revised based on the revised RH Policy andStrategy by the Project and other partners. The reports from the M&E mission teams also played major role in
the revision process of all the RH strategy and planning documents.

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Indicator 2) RHD is involved in policy planning and research protocol making related to RH.
RHD revised the National RH Policy and Strategy as well as several guidelines (MNH, M&NDR andPCPNC) under support of the Project and other RH partners.
Indicator 3) M&E (including M&S) is conducted by PRHO according to the M&E guideline in 80% of34 provinces.
RHD is leading the M&E activities and have already visited 12 provinces. The M&E will be taken over by
the PRHOs once the translation of the guideline is completed.
Indicator 4) 90% of public primary health care facilities have skilled birth attendants who have been
trained according to the RHD’s in-service training guidelines.
This indicator is not expected to be achieved during the Project Period as the remaining time is pressing.
In-service trainings according to the National RH IST Strategy haven't been commenced yet.
3-2 Factors that promoted the implementation of the Projecti) Since the Phase 1 the Project has been always playing roles as supporter for the C/Ps at the center of theProject activities, which have developed the institutional capacity of RHD. This approach is the characteristicsof the Project.
ii) As a result of utilizing the capacity of local consultants, the Project could implement the Project activities
smoothly even under the security conditions which limit the activities of the Japanese expert.
iii) The cooperation with other RH partners facilitated the Project activities through cost sharing for workshops
and task sharing for various working groups.
3-3 Factors that hindered the implementation of the Project
The biggest hindering factor is the security in Afghanistan. Especially, the security conditions at theprovincial levels significantly affect the activities such as M&E and IST. In relation to the security conditions,limitation of activities by Japanese experts is also another hindering factor for the Project. Nevertheless, JICA
has tried to compensate the absence of expert by increased allocation of the local consultants and the trainings
in Japan.
3-4 Summary of Evaluation Results(1) Relevance: Very high
The maternal mortality ratio in Afghanistan was 460 per 100,000 live births in 2010 (WHO) and required
much improvement, therefore, the Project utterly addresses the needs of the Afghan people. In addition, oneof the target indicators in the Afghan Millennium Development Goals is 50% reduction of maternal mortality
ratio by 2015 and 75% reduction by 2020 compared with the ratio in 2002, which is in line with Afghanistan
National Development Strategy. Furthermore, maternal and child health including RH is an important subsector in health sector cooperation of Japan.
(2) Effectiveness: Moderate
In order to achieve the Project Purpose, there are four pillars of aspects in improvement of RHD's capacities;
1) policy formulation, 2) activity coordination, 3) M&E capacity and 4) in-service training management. Eachone of these pillars forms Outputs in the PDM and is well balanced to achieve the Project Purpose. While apart of the scheduled Activities for Outputs 3 and 4 hasn't been achieved yet, Activities for Outputs 1 and 2
have mostly been completed. Especially for the latter, a number of activities such as holding or coordinatingx

various workshops have been carried out and contributed to enhancement of RHD capacity. For example,
the document formulation work led to capacity building of RHD and its management skills has drasticallyimproved. Consequently, RHD leads the taskforce meetings and all the RH-related initiatives become in linewith the Policy and Strategy revised by the Project. Coordination in the RH area is important because many
partners have high interests and commitment in the area and they have their own projects or programs.
(3) Efficiency: Moderate
Transfer and resignation of the RHD staff are frequent, which negatively affect accumulation of knowledge
and know-how in the institution. Only about 20 PRHOs had been assigned in 34 provinces for a long time
(PRHOs are expected to play important roles in implementation of M&E and IST), which negatively affected
the Project activities especially regarding Outputs 3 & 4. In addition, long-term experts haven't been allocatedas planned since the activity of the Japanese expert in Afghanistan was limited due to the security restraint.
(4) Impact:
It's still too early to conclude the prospects for achieving the Overall Goal, however, one of the Indicators(Indicator 1) shows a good sign for the health seeking behavior of the mothers. Accordingly, commencement
and continuation of the Project activities especially IST under the new guideline (Output 4) for midwives tobe skilled birth attendants is expected for achievement of the Overall Goal.
(5) Sustainability: Moderate
In terms of the political aspect the sustainability of the Project is considered to be secured. For theinstitutional and technical capacities of RHD appear to be well developed through the Project, however, thekey activities on M&E and IST under the new guidelines are still remaining. Some unstable factor that affects
the sustainability has still been acknowledged such as the financial condition of MoPH since operational costs
for RH related projects have largely been dependent on the international partners.
3-5 Conclusion
The Activities related to Outputs 1 and 2 have mostly been completed although a part of them (Activities
1-4, 2-1 and 2-2) should be sustained onwards. For Outputs 3 and 4 the scheduled Activities have only partiallybeen completed due to delayed endorsement of the related documents (i.e., M&E and IST guidelines and ISTplans). Currently the Project is making an effort to achieve the Project Purpose and expected to accelerate theactivities on M&E and ISTs. Under the unstable security conditions, the Project has made constant efforts toproduce outcomes side by side with RHD.
3-6 Recommendations
1.	
RHD is expected to maintain operative coordination with the RH related partners for sustainable
implementation of the RH programs, especially PRHO workshop and Maternal and Newborn Death
Review (M&NDR) related activities.
2.	MoPH should conduct M&E activity and IST based on the new guideline. The Project Activities behindthe schedule, i.e. translation of M&E guidelines and, M&E activities (Output 3), and development of ISTplans, and implementation of ISTs (Output 4), should be accelerated.

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3.	RHD is advised to enforce the National RH Policy and Strategy (2012-2016) assuredly and to monitor therelated activities constantly in order to maximize the operation on reproductive health.
4.	MoPH is expected to make further efforts to assign the remaining four (4) PRHOs in order to operate M&Eand IST activities smoothly.

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