Asia
1. Outline of the ProjectCountry:

Project title:

Indonesia

Technical Cooperation Project for Improvement of District HealthServices in South Sulawesi

Issue/Sector:

Cooperation scheme:

Health/Medical Care

Project-type Technical Cooperation

Division in charge:

Total cost:

Medical Cooperation Department, First Medical
Cooperation Division

704 million yen

Period of Cooperation

Partner Country's Implementing Organization:

1 April 1997 - 31 March2002

The Department of HealthSupporting Organization in Japan:
International Medical Center

Related Cooperation:
Grant Aid "The Project of Strengthening District Health Services in Sulawesi"
Loan Aid "The Project of Strengthening District Health Service System in Sulawesi"
Project-type Technical Cooperation Project for Improvement of District Health Services in South Sulawesi

1-1 Background of the Project
The infant and maternal mortality rate of Indonesia had been higher than those of its ASEAN neighbors, accounting for 55
deaths per 1,000 births and 390 deaths per 100,000 births, respectively. There also existed rural-urban disparities in healthindicators. Under these circumstances, the Government of Indonesia requested technical cooperation from Japan to foster
those engaged in medical fields such as district doctors, midwives and clinical technologists and to improve the skills ofsanitation managers in the planning and execution of the health project on the island of Sulawesi where the health situation wasparticularly distressful.

1-2 Project Overview
For the purpose of improving the skills of senior-level officials in the field of sanitation in the planning and execution of the healthproject and further developing the skills of medical practitioners such as doctors, midwives and clinical technologists, thefollowing activities in four different fields were conducted: (1) introduction of the problem solving oriented action research(PROAR) method to the health center (2) introduction of the examination system to district examination centers, examination
rooms in district hospitals, and the health center, and securing the accuracy of the system (3) fostering district health managers(4) fostering those whose jobs relate to the health of mother and child such as midwives and nurses.
(*) The PROAR method: This? method of problem-solving involves searching out? the cause of the problem and planning asolution based on data. The solution is evaluated by practitioners in order to refine or adjust the plan for the next action or stage.
The method was developed and practiced in this project.
(2) Project Purpose
1) Regional and Pukesmas (Public Health Center) staff is able to solve health problems using PROAR method.
2) Appropriate Quality Assurance System is established and practiced on regular basis at the central lab, district hospitallaboratories and Pukesmas labs.
3) District health managers are able to solve local problems.
4) Improve the service quality of midwives/nurses in the districts.

(3) Outputs
1) PROAR method is developed, and the implementation team is established.
2) Staff of the Pukesmas, districts and provinces are trained on PROAR method.
3) Equipment is provided to the selected Pukesmas, district hospital labs and Central labs, personnel are trained on Internal
Quality Control (IQC) and External Quality Assessment (EQA) and IQC and EQA are introduced to selected district hospital labs
and Central labs.
4) Knowledge, awareness, and attitude of doctors, medical technologists, hospital chiefs and regional health officers areimproved.
5) Standardized and quality training program is developed and formally accredited.
6) Capacity of trainees is improved and training programs remain sustainable and marketable.
7) Verbal autopsy form, maternal death case conference and survey of high risk pregnancies are improved and trainers and staff
are trained to for the use of social safety net scheme.
8) Basic Delivery Module (ASUHAN Persalinan Dasar: APD) is established, and the district midwives are trained.
(4) Inputs
Japanese side:
Long-term Experts

11

Equipment

169 million yen

Short-term Experts

29

Local Cost

87 million yen

Trainees received

14

Tanzanian side:Counterparts

27

Local Cost

1,159 million Rupiah (16 Million Yen)

2. Evaluation Team
Members of Evaluation
TeamLeader: Makoto DOI, Director of the Bureau of International Cooperation, International MedicalCenter of Japan
Sanitation: Seiki TATENO, Director, the 1st Expert Service Division, International Medical Centerof Japan
Clinical technologist: Tadao KINOSHITA, Chief of Medical Technologist, Clinical Laboratory
Division, International Medical Center of Japan
Evaluation and Plan: Hisakazu HIRAOKA, First Medical Cooperation Division, MedicalCooperation Department
Project Evaluation: Hiroshi NAITOU, CRC Overseas Cooperation Co., Ltd.

Period of Evaluation

10 October 2001 - 2November 2001

Type of Evaluation:
Terminal Evaluation

3. Results of Evaluation
3-1 Summary of Evaluation Results(1) RelevanceThe concepts of quality assurance in clinical inspection, the PROAR method, the improvement of the district health manager's
skill were all in line with "The Five Year National Development Project Part 6" in Indonesia. As mentioned in the plan above,
improvement of quality has been important in the health-care services of Indonesia and, thus, the purpose of the project,disseminating health-care services, is relevant to the health policy developed by the Government of Indonesia. The traininggiven to district health managers is consistent with the policy of improving the delivery of rural health-care services, as describedin the National Development Program, "PROPENAS".

(2) EffectivenessAfter compiling the PROAR method manual and implementing training and seminars, PROAR small-scale projects wereimplemented in the 64 pilot health centers within the project area. The system to guarantee the accuracy of clinical inspection
was almost established in the central examination facility, district hospitals and examination facilities in the health center. This
was achieved through accuracy assessment in the central examination laboratory and by training in clinical inspection. About
100 people participated in the training which was held once a year. Furthermore, 18 out of 52 trainees were promoted in thethree year period at their workplaces, such as the Department of Sanitation. Out of those 52, the project hosted 32 participants,
paying their expenses to attend the seminar, and 11 are so out of promoted 18. The test achievement result before training on
the knowledge of mother and child health rose to 79.2/100 from 54.5 after the training program. These activities enabled thedistrict health managers to solve health problems with their knowledge of sanitation. As a result of the training given to themidwives/nurses of the health centers, the level of services was improved as midwives/nurses are able to examine and study
the maternal death casesin Pilot districts, and they have started to conduct research on expectant mothers with higher risk. As awhole, the improvement of the districts' health-care services was almost accomplished through the cooperation in these fields.
(3) Efficiency
Through the proper inputs such as long- and short-term experts, equipment for training and proper cooperation by Indonesiancounterparts, the project enabled health personnel to identify community health problems and solve them by themselves using
the PROAR method. In introducing Internal Quality Control and External Quality Assurance technologies, the appropriate
equipment was selected and installed to 16 laboratories. Also, the equipment for educational purposes has been well utilized in
conducting training for local health personnel and mother and child health-care personnel, contributing to the efficiency of theproject.
(4) Impact
The improvement of district health services was attained through the achievement of four subprojects. Through maintaining thequality of services at least at the current level, it will eventually lead to improvement of health indicators. So far, the number ofpeople who use a medical or health care institution has increased due to the improved services such as the emergency
examination provided by the central clinical inspection laboratory. In addition, it became possible to diagnose health problemson the scene in a move toward decentralization, and not only district health services were improved but also the influence ofhealth services and some of the activities are now known in east Indonesia as well as in South Sulawesi, the first target district.
(5) Sustainability
Through its application during the project, PROAR was found to be effective and important at the health center level, and thewillingness on the Indonesian side suggests that the new activities introduced by the Project will be continued. The percentageof the people who participate in the training program at their own expenses is on the rise. The share of self-financing
participants has risen from none to 36 percent for the training course for senior level managers. Similarly, the share increased
from 27 percent (1997/98) to 100 percent for the postgraduate level course. The training programs for the district midwives andmidwives/nurses of the health center are now budgeted, and many of the training programs meet the requirement for thesustainability development both in terms of institution and policy, and demonstrate the prospect of attaining the effects as well.

3-2 Factors that promoted realization of effects(1) Factors concerning Planning
N/A(2) Factors concerning the Implementation Process
Against the backdrop of decentralization started in 2001, the local governments, especially middle management, was highly
motivated and channeled hard work into this project, which made accomplishment of its purpose possible.

3-3 Factors that impeded realization of effects(1) Factors concerning Planning
N/A(2) Factors concerning the Implementation Process
N/A3-4 Conclusion
The project has successfully achieved its intended objectives. It considerably contributed to the improvement of the humanresources development program for district health services. Furthermore, the project's provision of the required health personnel
was timely in view of the health services decentralization that started in January 2001.

3-5 Recommendations
To achieve delivery of higher quality services and further organizational and institutional strength, the parties concerned should
consider continuing monitoring and ways to retain a good relationship with the Japanese side.

3-6 Lessons Learned
In a project aiming at human resources development through the improvement of the health-services system, it is effective toinvolve Japan Overseas Cooperation Volunteers to coordinate with what is going on at the grassroots level. In the field of
medical health, these efforts should be planned as comprehensively as possible.

3-7 Follow-up Situation
A district medical policy adviser was dispatched in 2003.