Evaluation Summary
1. Outline of the ProjectCountry:

Project Title:

Republic of the Philippines

Project for Comprehensive Etiological andEpidemiological Study on Acute Respiratory
Infections in Children: Providing Evidence for thePrevention and Control of Childhood Pneumonia inthe Philippines

Issue/Sector:

Cooperation Scheme:

Healthcare and Medical Treatment

Technical Cooperation Project under the scheme ofScience and Technology Research Partnership for
Sustainable Development: SATREPSDivision In-Charge:

Total Cost (estimated at completion of the

Health Team 3, Health Group 2,Project):Human Development Department

560,000,000 Japanese Yen

Period of(R/D):

Partner Country’s Implementing Organizations:

Cooperation

1 April 2011 - 31 March 2016

Research Institute for Tropical Institution (RITM)(Revised):

Supporting Organization in Japan:

1 April 2011 - 31 March 2017

Tohoku University Graduate School of Medicine

1-1. Background of the Terminal Evaluation
The Republic of the Philippines (hereinafter referred to as “Philippines”) officially requested
to Japan a technical cooperation project under the scheme of the Science and Technology ResearchPartnership for Sustainable Development (hereinafter referred to as “SATREPS”) entitled “TheProject for Comprehensive Etiological and Epidemiological Study on Acute Respiratory Infectionsin Children: Providing Evidence for the Prevention and Control of Childhood Pneumonia in thePhilippines” (hereinafter referred as “the Project”) and Tohoku University Graduate School ofMedicine (hereinafter referred as “Tohoku University”) also submitted the research proposal to theJapan Science Technology Agency (hereinafter referred as “JST”). As a result of discussion
between the Ministry of Education, Culture, Sports, Science and Technology, the Ministry ofForeign Affairs (hereinafter referred as “MOFA”), the JST and the Japan International Cooperation
Agency (hereinafter referred as “JICA”); it adopted the proposal officially and determined to startthe five-year Project from April 2011 to March 2016.
The Project is jointly conducted by the Research Institute for Tropical Medicine (hereinafterreferred to as “RITM”) and Tohoku University to analyze the childhood pneumonia in thePhilippines through etiological studies, disease burden studies, risk factor analysis and present theeffective prevention and treatment by intervention studies. The Project mainly conducted at thefield level in the Philippines where under-five mortality ratio is still highly suspended in 31 per
1,000 live births in the year when the Project had commenced (2011), and pneumonia is top rankedas a death cause in children.
The Project was initially launched from April 2011 to March 2016 for the duration of fiveviii

years, but extended till March 2017 for further one year, because of a disastrous typhoon Yolanda
in November 2013 in the Philippines which severely damaged the Project sites, especially in
Eastern Visayas region. After the establishment of Japan Agency for Medical Research andDevelopment (hereinafter referred as “AMED”) on 1 April 2015, all projects in the field of
Infectious Diseases Control have been transferred from JST to AMED.
1-2. Project Overview(1) Overall GoalMortality due to childhood pneumonia is reduced.
(2) Project Purpose
Etiology, disease burden and risk factors of childhood pneumonia are defined and effective
interventions to reduce mortality due to pneumonia in children are validated.
(3) Outputs
1) Etiology of childhood pneumonia and respiratory infections in the selected sites isdetermined.
2) Disease burden due to childhood pneumonia is measured in the selected sites.
3) Risk factors for severe pneumonia in children are identified.
4) Interventions to reduce mortality due to childhood pneumonia are evaluated.
5) Research outcomes for the reduction of child mortality due to pneumonia are shared with thePhilippines and international relevant organizations for policy recommendations.
(4) Inputs
Japanese Side: Total Amount 560,000,000 Japanese Yen
Japanese Experts (Long-term: Project Coordinator)

3 personsJapanese Experts (Short-term: Researchers)

10 persons

Counterparts Training in Japan

6 persons

Provision of equipment, machinery and materials

110,000,000 Japanese Yen

Operational Expenses

130,000,000 Japanese Yen

Philippines Side:
Assignment of Counterpart Personnel (Researchers)

16 persons

Facilities, Equipment and Materials for the ProjectOperational Expenses for Utilities
2. Evaluation TeamMembers

Japanese SideTeam Leader

Dr. Kaname

Executive Technical Advisor to the Director

KANAIGeneral, Human Development Department,JICAix

Cooperation

Ms. AkikoDeputy Director, Health Team 3, Health Group

Planning

ITO

2, Human Development Department, JICA

Evaluation

Dr. Mahmood

President, Japan Soft Tech Consultants (JUSTAnalysis

Ul ZamanConsultants), Japan

KHAN
Team leader of theProf. Takeshi

Program Supervisor, AMED

Research Study

KURATA

Cooperation

Dr. Yasushi

Deputy Manager, Division of International

Planning of theSHINTANICollaboration, Department of International

Research Study

Affairs, AMEDPhilippines Side
Dr. Anthony P. Calibo

Officer In-Charge (OIC), Division Chief, Children HealthDevelopment, Family Health Office, Department ofHealth (DOH)

Dr. Joyce Ducusin

OIC, Director III, Family Health Office, DOH

Ms. Jocelyn T. Sosito

Senior Health Program Officer, Bureau of International
Health Cooperation, DOH

Period ofFrom 8 to 23 November 2016

Type of Evaluation:
Terminal Evaluation

Evaluation
3. Results of Evaluation
3-1. Achievements/ Performance of the Project(1) Output 1

Geographical differences between four sentinel sites (RITM, Eastern Visayas Regional
Medical Center (EVRMC), Ospital ng Palawan (ONP) and Biliran Provincial Hospital (BPH)) forthe pneumonia incidence and the patterns of the causative pathogens were found out to beinsignificant. Positive rate of the bacteria detection (2.5%) was low. Hence the impact as bacterial
etiological agents was unclear. Etiological pathogens associated with the mortality were identified
as HAdV-7, EV-D68, Bordetella pertussis. Respiratory Syncytial Virus (RSV) was commonly
associated with the severe pneumonia. RSV specific risk factors were identified to be analyzed
further. Testing not only the severe cases, also mild cases under the cohort system enabled todescribe the comprehensive viral factors contributing to the acute respiratory infections.
(2) Output 2
The Project assigned two municiparities in the Biliran provinceas cohort sites. The Cohort
study was conducted during the period of February 2014 to June 2016 with a total of 4,071 cohort
children enrolled, 5,677 person-year observed. The incidence rate of all pneumonia detected at ahealth facility and household (i.e., child was not brought to any health facilities) were 331/1,000
person-year and 52/1,000 person-year respectively, thus 14% of caregivers did not take a proper
action even they recognized difficulty of breathing. 70% of all pneumonia case was diagnosed at
Rural Health Unit (RHU), whereas 73% of very severe pneumonia case was diagnosed at BPH.

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There were eight deaths during the Project period, where three cases were due to pneumonia, inother five cases, three were from other infectious diseases and two were from non-infectious
diseases. Comparison between the cohort incidence rate and Field Health Statistics Information
System (FHSIS) revealed the lower sensitivity to detect pneumonia by FHSIS (37%), which maylead to underestimation for the health policies.
(3) Output 3The Output 3 is based on the results of Output 1 and 2. Clinical manifestations such as
grunting and fever, Integrated Management of Childhood Illness (IMCI) category of very severpneumonia and bacterial pathogen are risk factors for deaths in all age groups. Cost distance (timeto the facility) to RHU and lower Socio-Economic Status (SES) are identified as common risks forbeing contracted with pneumonia. No health seeking when child being dyspnea are potential risk
identified. Duration of illness of those who did not seek healthcare has doubled compared to those
who seek healthcare. Therefore, the health seeking behavior of the caregiver was selected as one of
the Project’s intervention targets. Age (younger than 2) and sex (female) are the specific risk
factors to get RSV.
(4) Output 4
The interventions were implemented from July 2015 until June 2016 with the following threeobjectives: 1) IMCI+ (digital device based IMCI with pulse oximeter) by midwives to manage thepatients at BHS/RHU, 2) Evaluation on the WHO new guideline for the pneumonia severity
category, 3) Education on the health seeking behavuior (such as when to consult, etc.) provided by
Barangay Health Workers to the community. With regard to intervention 1), it was found that theintroduction of IMCI+ contributed to the improvement of child pneumonia management such asimproved referral capacities of health personel. As for intervention 2), safety of the new WHO
guideline was confirmed in this setting. The findings of intervention 3) will be revealed by theProject ends.
(5) Output 5
Achievements of the progress and research outcomes are shared regularly with relevant local
and national health authorities including Local Government Unit (LGU) and DOH. The study
results are published in several peer-reviewed internationally recognized scientific journals andpresented in various international conferences.
(6) Project Purpose
New scientific findings related to prevention and control of childhood pneumonia arepublished in more than 10 peer-reviewed internationally recognized scientific journals. Discussions
regarding the utilization of intervention package and/or recommended strategy for reducing childmortality due to pneumonia are started with the health personnel who participated in theintervention with IMCI+. In the feedback forum and the qualitative survey, positive comments onxi

the interventions were common, although, there was a concern on the sustainability. More detailed
convincing cost-effectiveness data should be required in the recommendation.
3-2. Summary of Evaluation Results(1) Relevance: Excellent
The Project is still consistency with the national health sector policies and development
policies of the Phillippines, the Japan’s Country Assistance Policy for the Philippines, and with theneeds of the target groups.
Taegets and methods for the Project intervention were determined in December 2014, andmodified due to the change in the WHO guidelines.
The Project aims to achieve its Project purpose by using advanced technical expertise andextensive experience of the Japanese Experts, an example of which includes successful introductionof microplate method developed in Sendai, Japan. The method is designed to handle many samples
for virus isolation. Without this method, it was not possible to isolate many viruses.
(2) Effectiveness: GoodFive Outputs of the Project are designed to achieve the Project purpose. The Outputs of theProject have designed and structured to be proceed one after another as follows: “Etiology Studies(Output 1)” and “Disease Burden Studies (Output 2)” would be contributed interactively; “Riskfactor analysis (Output 3)” is done based on the results of Output 1 and 2; and “InterventionStudies (Output 4) is finally done based on the all the findings and observations to achieve theProject purpose. The Project purpose is likely to be achieved at the completion of the Project if allremaining activities for the Outputs completed before the completion of the Project.
Retaining and continuing the cohort under the different project (Japan Initiative for Global
Research Network on Infectious Disease: J-GRID) will be meaningful, specifically targeting on theRSV, and its transmission pattern in the community and the multiple ingfection.
(3) Efficiency: Good
The inputs are appropriately provided from both the Japanese side and the Philippines side asplanned and all inputs are fully utilized to generate the intended Outputs. The quality, quantity, andtiming of inputs are also appropriate.
In the general technical cooperation projects supported by JICA, human resources for theproject activities shall be allocated by counterpart organizations from the aspect of human resource
development. Meanwhile, day-to-day sample collection in large numbers and subsequentbacteriological testing, as well as pre-treatment and shipment of samples for further examination to
the RITM have been carried out at four sentinel sites. Furthermore, the Project had conducted
relatively large-scale field surveys at communities. For these reasons, it is rationale to hire staffs(medical doctors, nurses, medical technologists, Information technology personnel, etc.) by theProject for the implementation of Project activities.
Project activities are well received by the Counterpart personnel. Several kinds of trainingsxii

for the Counterpart personnel and several kinds of feedback forums are welcomed by theparticipants. Most participants are satisfied with the contents, theoretical and practicalmethodology, duration, and skills and expertise of trainers/presenters of the trainings. However,some of the Counterpart personnel sometimes faced difficulties in attending all Project activities
due to their engagement in their routine assignments in their respective organizations.
(4) Impact: Positive
Through the various Project activities, it can be said that the impact on the Overall Goal of
the Project is positive.
No negative/indirect/unintended/unexpected impact has been reported.
(5) Sustainability: Expected to Some Extent
From plicy aspects, it is expected that the strategies and policies for the reduction ofmortality rate due to the childhood pneumonia will remain favorable.
In terms of organizational aspects, it is expected that the Counterparts could pursue relevant
activities to keep Project effects after the completion of the Project.
The Counterparts must make serious efforts to secure proper funding from the concernedauthorities. Therefore, financial aspects are a matter of concerns for the sustainability of Project.
Eight laboratory staff initially hired by the Project were permanently employed by the RITM
after the termination of their contract with the Project. To ensure the technical sustainability of theProject, it would be necessary for the RITM to continue the technical assistance, particularlyorganization of different kinds of trainings and periodical updating of different kinds of manuals
for the prevention and control of the childhood pneumonia.
3-3. Contributing Factors for the Implementation of the Project(1) Concerning the project design
No specific contributing factor was observed.
(2) Concerning the implementation process of the Project
The main contributing factors are summarized as follow.
1) High motivation of Counterparts, particularly the decision-makers, for the participation in theProject activities.
2) Cooperation by the health facilities, such as hospitals, RHUs, and BHSs. The RHUs under
the target municipalities had supported the Project staff to conduct the rapid assessment aswell as the census by providing them household data and by accompanying them forinterviews at the remote areas.
3) Incentive for hospital in-patient enrollment, such as free testing service and medicines,
promoted enrollment.

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3-4. Hampering Factors for the Implementation of the Project(1) Concerning the project design
No specific hampering factor was observed.
(2) Concerning the implementation process of the Project
The main hampering factors are summarized as follow.
1) Delays in several Project activities, such as posting of the first Project Coordinator,
setting-up of the laboratories and operation for the power distribution work for the back-up
generators at BPH and ONP, obtaining the ethical approval by the Institutional Review Board(IRB) for the protocol and the singing of the Memorandum of Agreement (MOA) between
RITM and the Biliran Province to start the census survey and the enrollment of the children
for the cohort study.
2) A disastrous typhoon Yolanda in Philippines in November 2013 which severely damaged theProject sites, especially in Eastern Visayas region.
3) Limited human and financial resources of Counterparts.
3-5. Conclusions
The Porject purpose is likely to be achieved at the completion of the Project if all remainingactivities for the Outputs completed before the completion of the Project.
3-6. Recommendations(1) Reflecting the evidence to the national and international policies and guidelines
The effective outcomes with scientific evidence of intervention studies should be shared with
DOH for reviewing the existing strategy and guidelines. To this end, the Project should actively
work with the policy making body at DOH and other stakeholders such as WHO and UNICEF toreflect them in the national policy. Though the results of intervention study on evaluation of WHO
new guideline would support its safety and effectiveness, and facilitate to scale up the nation-wide
introduction of the guidelines, more detailed convincing cost effectiveness data on IMCI+ isrequired.
(2) Collaboration between RITM and Tohoku University for Introduction of Vaccines
Though the Project will end in March 2017, research collaboration between RITM andTohoku University will continue using the other research funding scheme. RITM and Tohoku
University are recommended to continue collecting data on childhood pneumonia after the end of
the Project and provide the collected data to DOH. This will be useful for introduction of newvaccines, including RSV vaccine, to the Philippines.
(3) Proper funding for continuing the Project activities
RITM and Tohoku University should make sincere efforts to secure proper funding to keep
continuing the necessary Project activities, and recommend employment of the Project-hired staff
to keep the Project impacts.

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