Summary
I. Outline of the ProjectCountry: Afghanistan

Project Title: Urban Health System Strengthening
Project
Cooperation Scheme: Technical Cooperation
Total Cost (at the time of evaluation): 380 million yen

Issue/Sector: Health
Division in Charge: Health Division 4, HealthGroup 2, Human Development Department
December 2009 – December 2012 (three Partner Country’s Implementation Organization:
Period of
Ministry of Public Health (MoPH),
Cooperation years)
Record of Discussion (R/D): Kabul Provincial Health Directorate (KPHD)
August 23, 2009
Supporting Organization in Japan: N/A
Related Cooperation Project:
Technical Cooperation “Reproductive Health Project Phase 2”
The World Bank, Japanese Social Development Funds
1. Background of the Project
In Islamic Republic of Afghanistan (hereinafter Afghanistan), provision of basic healthcare services is
one of the urgent priorities. The Government of Afghanistan set Basic Package of Health Services (BPHS)
as minimum requirement of healthcare service in community health centers and contract out to NGOs for its
expansion with financial support from donors, especially in rural areas to improve the health indicators
which used to be worse than those of urban areas. As a result, the coverage of BPHS accounts for 85% of
the population (as of 2008). On the other hand, urban areas including Kabul city have specific problems
such as high population density and mobility of the population, considerable disparity among households,
and growing urban poor including internal displaced people. Moreover, shortage of budget and little
assistance for healthcare in urban areas leads moral hazard of the staff due to delay in paying salary andshortage of equipment and medicines. As a result, healthcare facilities cannot deliver appropriate services.
Accordingly, JICA and the Ministry of Public Health (hereinafter “MoPH”) had agreed to implement atechnical cooperation project, “Urban Health System Strengthening Project (Hereinafter refer to as the
Project)” in 2009 to develop an urban health system model to resolve urban-specific challenges, and theWorld Bank would finance for the trial of the model via Japanese Social Development Funds (hereinafterreferred to as “JSDF”).

2. Project Overview
The Project has been conducted based on the PDM version 0 and 1 signed in June 2009 and September
2011 respectively. The summary of the Project is described below.
(1) Overall Goal
Urban health services are effectively and efficiently provided in Kabul.
(2) Project Purpose
The urban health system is strengthened in Kabul.
(3) Outputs
1) Interventions strengthening Urban Health System based on the results of the situation analysis are
examined.
2) Management capacity (planning and budgeting, monitoring and evaluation, data collection andanalysis) of the Kabul Provincial Health Directorate (KPHD) is strengthened.
(4) Inputs- Japanese side:
Short-term Experts 25 persons(The total number of man-months was 79.7 at the time of the Terminal Evaluation)
Equipment Medical equipment, essential drugs, and medical supplies for CHC etc
Operational cost in Afghanistan 59,412 thousand yen (up to March 2012)- Afghan Side:Counterparts 40 persons (MoPH: 19, KPHD: 21)
Land and Facilities Project office (in KPHD)

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II. Evaluation Team
Members of Ms. Hiroe ONO
EvaluationTeam
Ms. Aya KAGOTA
Ms. Miki KOBAYASHITeam Leader

Cooperation Planning

Evaluation Analysis

Director, Health Division 4, Health
Group
2,
Human
Development
Department, JICA
Staff, Health Division 4, Health Group2, Human Development Department,
JICA
Non-Profit
Organization
HANDS(worked only in Japan)
Type of Evaluation:
Terminal Evaluation

Evaluation 8 – 19 Sep. 2011
PeriodIII. Results of Evaluation
1. Project Performance(1) Outputs
The Outputs have not been completely achieved up to date. As for Output 1, the effectiveness of theinterventions will be examined. The Output 2 has been achieved through various trainings.
Output 1: Interventions strengthening Urban Health System based on the results of the situational
analysis are examined.
Indicator 1: At least one intervention1 provides evidence to support Urban Health System strengthening
MoPH and JICA, both ensured that the interventions support strengthening of urban health systems in
Kabul. The activities as CHCwD started in May, 2012. It also took time for decision if the MoPH and
KPHD would be responsible for JSDF fund management. Training for Community Health Worker (CHW)
started in June, 2012. At the time of the Terminal Evaluation, effectiveness of the three interventions for
Urban Health System strengthening has not been examined. It will be examined in September and October,2012
Output 2: Management capacity (planning and budgeting, monitoring and evaluation, data collection
and analysis) of the KPHD is strengthened.
Indicator 2-1:. Proportion of KPHD staff trained
The trainings for KPHD staff mainly on management related topics have been organized in the second andthird year of the implantation although there is delay from the original schedule of these trainings. The
implementation had been delayed because the Project formulated training plan after conducting theadditional survey on the capacity of KPHD based on the changed direction of urban health model. In
addition, On the Job Trainings (OJTs) have been conducted through team approach and collaborative
approach in daily work. The number of participants of organized training sessions is totally 335. Since thetotal number of KPHD staff is 52 as of September 2012, the average number of the training for each staff
member is 6.4 times.
Indicator 2-2: The number of submitted reports of new initiatives which are reviewed by the RH taskforce
meeting.
The Provincial Public Health Coordination Committee (PHCC) meeting is scheduled every month. Since
the Project implementation started in December, 2009, the PHCC was organized every month.
Indicator 2-3: Submission rate of reports and proportion of timely-submitted reports to MoPH
The submission rate of activity reports from the KPHD to the MoPH has shown progress since the Project
started (95.8% in JFY2010, 44.4% in JFY2011, and 100% in JFY2012 (up to June)).
(2) Project Purpose
Project Purpose: The urban health system is strengthened in Kabul
The project purpose was partially achieved at the time of the Terminal Evaluation. There is a great
improvement of indicator 1, and indicator 2 is under examination.

1

Following the PDM (ver.1), the Project focuses on interventions in three fields to strengthen the urban healthsystem, 1) Improving Maternal and Child Health (MCH) service at Comprehensive Health Center (CHC) with
Delivery (CHCwD), 2) Expanding immunization coverage using PPP, and 3) Piloting Community Health Workers(CHWs) for CBHC in urban Kabul.

xIndicator 1: Proportion of monitoring and evaluation (M&E) visits implemented as planned.
Regarding available data in the KPHD, planned monitoring visits were conducted as shown in the following
table. Even though the result in Apr. 2011 to March 2012 showed the decline of implementation, M&E
activities in 2012 have been fully conducted according to the plan.
The number of
The proportion of
The number of
implemented asplanned M&E visits actually conducted
M&E visits
planned (%)
Apr. 2010 – Mar 2011
24
23
95.8
Apr. 2011 – Mar. 2012
133
59
44.4
Apr. 2012- Aug.2012
116
116
100.0
Indicator 2: No. of female and under fine children visited out-patient department of Urban-BPHS facilities.
Data to examine the effects of the interventions are being collected.
2. Summary of Evaluation Results(1) Relevance: high(i) Relevance in respect of policy of Afghanistan
The health sector is part of the “economic and social development” which is one of the three “pillars”
defined by Afghanistan National Development Strategy (ANDS) and expansion of basic health service is
one of the priorities. As already mentioned, BPHS has been expanded in collaboration with other donors
especially in rural areas. As a result, the coverage of BPHS in the country has increased to 85%. On theother hand, the coverage of basic health services is not enough in urban areas of Kabul. The project focuseson improvement of basic health services through development of urban health model suitable for the urban
situation. Therefore, the project is relevant in respect of policy of Afghanistan.
(ii) Relevance in respect of policy of Japan
International community agreed six prioritized area including health sector for reconstruction of Afghanistan at
the International Conference on Reconstruction Assistance to Afghanistan held in Tokyo in January 2002.
Thereafter, the Government of Japan (GOJ) has supported health sector as one of their priority area. GOJ
announced its continuous support at Tokyo Conference on Afghanistan in July 2012 towards sustainable andself-reliant development focusing on the agricultural sector, infrastructure development and human resource
development, as well as education and health/medical care. Therefore, the project is relevant in respect ofpolicy of Japan.
(iii) Relevance in consistency with the needs of the recipient country
Major donors have supported delivery of BPHS by contracting out to NGOs in rural areas of Afghanistan.
On the other hand, urban areas have not been supported because of better health indicators compared tothose of rural areas. However, the urban areas face particular health problems such as large population, highdensity and mobility of the population, economic disparity, and growing urban poor including internal
displaced people. Considering the situation, it is relevant that the Project aims to strengthen urban healthsystem in Kabul.
(iv) Relevance in respect of the project design
The project consists of two components: 1) examining the valid interventions to strengthen urban healthsystem and 2) strengthening of management capacity of KPHD. As these two aspects are crucial to achieve
the project purpose, the project design is relevant. Selection of the three interventions in the PDM (ver.1) isalso considered relevant because they are formulated based on the needs identified through the situational
analysis conducted from the end of 2009 to 2010. Also the interventions are considered feasible as they canbe implemented during the Project period.
(2) Effectiveness: moderate(i) Achievement of the Project Purpose
The project purpose was achieved partially at the time of the Terminal Evaluation due to a short
implementation period of the three interventions. Indicator 1 of “monitoring and evaluation (M&E) visits
implemented as planned” has been achieved.
(ii) Causal relationship between Outputs and Project Purpose
The current version of PDM (ver.1) includes two Outputs. The Output 1 should contribute to theachievement of the Project Purpose through verifying effective measures which will improve some aspectsxi

of urban health care. The achievement of Output 2 on the management capacity of KPHD would contributeto the achievement of the project purpose.
(iii)Assumption
The Important assumption for realization of Project Purpose is “The equipment and medicines through
JSDF will be procured timely”. The disbursement of JSDF was delayed since the change of policy for UHM
implementation caused the delay of writing proposal to JSDF. In addition, even though the proposal wasapproved by JSDF for operation of three interventions, it took time to prepare implementation systemamong MoPH and KPHD. Thus, the important assumption of the Project was failed. However the Project
has provided some of the medicine to lessen the negative influence.
(3) Efficiency: moderate
Shortage and high turnover of human resources of the MoPH and KPHD caused difficulty in assignment of
the Afghanistan counterparts. As well as there were insufficient appointment of the health staffs forprovision of 24 hour delivery services in spite of efforts by KPHD and MoPH. These facts affected theefficiency in the aspect of human resources.
In terms of Japanese expert team, dispatches of Japanese experts were not necessarily appropriate as fortiming and expertise. For example, the expert of health policy assigned to the Project stayed in Afghanistan
for less than thirty days in the first year of the Project’s implementation when the UHM was discussed andproduced. In addition, due to security reason, not more than two Japanese experts have been permitted tostay in Afghanistan at a time since 2011 by JICA restriction. This arrangement resulted in the difficulties for
assigning experts with proper expertise in right timing.
(4) Impact: moderate(i) Possibility of Achievement of Overall Goals
The possibility is uncertain at the time of the Terminal Evaluation. After analyzing the effectiveness ofinterventions, the Project will prepare “Recommendation on Sustainable Measures for Strengthening of
Urban Health System and Expansion to the Urban Cities of the Country.” With the strong commitment for
improvement of urban health system, it will possibly contribute to effective and efficient service provisionin urban area if the recommendation is incorporated into the other urban health projects of MoPH including
System Enhancement for Health Action in Transition Project (SEHAT) by World Bank and EU planned tostart from 2013 to 2018.
(ii) Positive impact
The Project had an activity in collaboration with Reproductive Health Project Phase 2 (RHP2),
implemented by Reproductive Health Directorate (RHD) of MoPH and JICA, after discussion among RHP2
(RHD/JICA), MoPH, KPHD and the Project. The RHP2 supported conducting training of Basic Emergency
Obstetric and Newborn Care (BEmONC) for 22 skilled birth attendants who would work in the target
CHCwD. Although this kind of collaboration between the two projects was not planned when the Project
was commenced, the collaboration contributed to increase efficiency and also enhanced the relation
between KPHD and RHD.
(5) Sustainability: moderate(i) Institutional Sustainability
Management capacity of KPHD has improved through various trainings. Also, KPHD has contracted withtechnical assistants under a project funded by JSDF to support daily activities of KPHD. These would
reinforce institutional sustainability.
(ii) Financial Sustainability
MoPH does not have enough financial resources for programs and projects. The resources from donors are
crucial to ensure financial sustainability of urban health related activities. The JSDF finances the KUHP todeliver BPHS for US$ 3,500,280 from September 2011 to September 2013. In addition, the World Bank andEC are in preparation of SEHAT which includes component of urban health.
(iii) Sustainability of the interventions
The Project plans to propose the stakeholders “Recommendation on Sustainable Measures forStrengthening of Urban Health System and Expansion to the Other Urban Cities of the Country” after
examining the effectiveness of the interventions. A draft of the Recommendation has been produced at theend of August. The final version of the Recommendation is planned to be presented in November afterxii

consultation with the stakeholders. It is crucial to build consensus and commitment of those stakeholders
especially MoPH, World Bank and EU to ensure sustainability and further expansion by including theactivities in JSDF’s Urban Health Project and SEHAT.
Moreover, the Project make efforts to assure sustainability; the three interventions have been implemented
with capacity building of KPHD, existing facilities are utilized for implementation, improve anenvironment for CHC activities by obtaining understanding of their family and community. These factors
contribute operational sustainability of the interventions.
3. Factors promoting better sustainability(1) Factors concerning to Planning- Feasible activities are planned in revision of PDM based on the results of the situation analysis and withconsideration of the remaining of the Project period.
(2) Factors concerning to the Implementation Process- PDM was revised to shift the direction of the Project due to the change of implementation policy of UHM.
- In addition to the technical assistance by the Project, technical assistants funded by JSDF also contributethe enhancement of capacity of KPHD and its sustainability.
4. Factors inhibiting better sustainability and impact(1) Factors concerning to Planning
No specific factor is observed.
(2) Factors concerning to the Implementation Process- The Project had to undertake a full review of its plan due to the change of direction of planned UHM
implementation by KPHD and MoPH.
- The Project was designed to develop UHM and work out the Model on trial basis by utilizing JSDF. However,the JSDF funded activities were delayed because of the late submission of the proposal and preparation of theimplementation system among KPHD and MoPH. Therefore, the Project supported the activities until JSDF
disbursement.
- Worsening security situation influenced project implementation. The Project’s office needed to move out from
MoPH to JICA’s premises which sometimes caused difficulty of communication among KPHD, MoPH and the
Project. Additionally, not more than two Japanese experts have been permitted to stay in Afghanistan at atime since 2011 as JICA restriction. This arrangement resulted in the difficulties for assigning experts withproper expertise by right timing.
5. Conclusion
The Project met difficulties in the implementation. Especially, the direction change on UHM required thechange of the Project design itself. There were also external conditions which had negative influence on theimplementation such as security. As a result, the implementation process was not necessarily smooth. The
revision of PDM in September, 2011 was one of the efforts by the Project to change track of the direction
and accelerate implementation. The implementation period of the three interventions was relatively shortand many activities are still underway. On the other hand, the capacity of KPHD is enhanced throughvarious trainings. The outcome of the Project including achievement of Project Purpose is limited at thetime of the Terminal Evaluation.
After the Terminal Evaluation, the Project proposed “Recommendation on sustaining implementation of theinterventions for urban health system strengthening and expansion to the country” to present direction forimprovement of urban health services to other areas of Kabul. It is important that the recommendation isshared and discussed with the stakeholders including the MoPH, World Bank, EU for further improvementof urban health system.
6. Recommendation
The Project is recommended to start consultation as soon as possible on the proposed “Recommendation on
Sustainable Measures for Strengthening of Urban Health System and Expansion to the Other Urban Citiesof the Country” with stakeholders such as the MoPH, World Bank and EU to elaborate more feasible andeffective contents. The final version of the recommendation should be agreed at the Joint Coordination
Committee (JCC) in November, 2012.
It should be taken into account that the Recommendation was produced based on the survey andxiiiexperiences of three kinds of interventions in Kabul. It is recommendable to first expand recommended
activities from the current target areas to other areas of Kabul. In case of expansion to other cities in the
country as the next step, it would be necessary to conduct assessment on the situation of those cities andreflect the situation and needs of those cities.
7. Lessons Learned
Coordination with stakeholders including the approval by the country’s authority and consensus building
require time and efforts. Especially for an innovative project like the Project, coordination and collaboration
among stakeholders including different departments within the MoPH, KPHD and donors are important,and time for coordination should be taken into account in to the implementation period.
Understanding of the family members is important for sustainability of the activities that involve women.
The Project designed CHW activities to involve women among the community as CHW. However, one of
the CHCs met resistance by the family and community members at the beginning of CHWs activities
because it is not common that women participate in activities in the community. Thus the Project advocatedthe community to obtain understanding for the activities by women.

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