評価調査結果要約表（英文）１．Outline of the ProjectCountry：Cambodia

Project title：The Project for Improving Maternal and Child
Health（MCH）Service in Rural Areas in Cambodia

Issue/Sector：MCH/Health Sector

Cooperation Scheme: Technical Cooperation Project

Division in Charge ： Human Development

Total Cost: 1.8 billion yen

Department, JICA
（R/D）
：2007.January 16~ 2010

Partner Organization： Ministry of HealthJanuary 15
Period of
Coorpera-（Extension）：

Supporting organization in Japan： International Medical
Centre of Japantion（F/U）:

Related Cooperation：（Grant） Construction of NMCHC（E/N）（Grant Aid）

（Technical Cooperation）MCH project phase 1 & 2（Development Study） Study for MCH Improvement

1-1 Background of the Project
Overall health status in Cambodia has improved over the last decade. However, many challenges
still exist to improve maternal health in childbirth in particular, as shown by the high maternalmortality ratio: 472 per 100 thousand live births according to the Cambodian Demographic and Health
Survey 2005. The main factors of the maternal deaths are the shortage of Skilled Birth Attendants（hereinafter referred to as “SBA”） and their limited capabilities, especially in rural areas.
JICA （hereinafter referred to as “JICA”）, together with the Ministry of Health of Cambodia（hereinafter referred to as “MOH”）, implemented Maternal and Child Health （hereinafter referred toas “MCH”） projects from 1995 to 2005. During the phase II period （2000-2005）, the MCH projectfocused on technical training for SBAs, including those in rural areas. While such SBA training itself
led to improvements in the technical capabilities of individuals, it was recognized that a morecomprehensive approach should be adopted to improve MCH services at health center level. For
example, in order for SBAs to fully exercise their skills and capabilities gained by the technicaltraining, the health administration system and community collaboration should be further strengthened
to support them so that the improvement in MCH services in broader regions can be expected.
To improve such a situation, JICA and MOH started to implement the Project for Improving
Maternal and Child Health Service in Rural Areas （hereinafter referred to as “the Project”） with theduration of three year cooperation period starting from January 2007, toward the goal of achieving
improvements in maternal and newborn care services in Kampong Cham Province as the model sites of
the Project, the results of which are then integrated into models and reflected in national programs.
Since the Project is about to be completed in the mid January 2010, JICA sent the Final Evaluation
Study team to principally review the progress of the Project and discuss any action that should be taken
by both Cambodian and Japanese sides until the completion of the Project.

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1-2 Project Overview(1) Overall Goral
The utilization of maternal and newborn care service with quality provided by Skilled Birth Attendants（SBAs） is increased.
(2) Project Purpose
Maternal and newborn care service in the model sites is improved, whose results are integrated intomodels and reflected in the national programs*.
（* National programs under NMCHC, particularly National Reproductive Health Program.）(3) Outputs
Output 1: The teamwork for supporting SBAs in Health Centers （HC-SBAs） is improved.
Output 2:The model of health administration system （PHD/OD） and clinical facilities （RHs） to
support the activities of HC-SBAs is formulated.
Output 3: The model of collaboration for the improvement of MCH in the communities is formulated.
Output 4: NMCHC identifies the issues in the rural areas and reflects this in the national programs.
(4) Inputs
Japanese Side：
Experts

102M/M

Provision of Equipment

Local Cost
Third country trainings :Indonesia （5）, Viet Nam （23）

Cambodian Side：Counterparts

ToT unit, NMCHCLand and Facilities: Providing the office space and venues for the training course
Local Cost:

Water and electricity for the office

Others: Cost sharing for meeting, symposium, others

53,902 US$

2．Evaluation Team
Members of
Evaluation
Team（Japanese side）
1.Mr. Keiichi Takemoto

Director, Human Development Dept., JICA

2.Mr. Ken Kubokura

Officer, Human Development Dept., JICA

3.Ms. Yumiko Sasaki

Assistant Resident Representative, JICA Cambodia Office

4.Dr. Hidechika Akashi

Senior Technical Officer, International Medical Center ofJapan

6.Ms. Akiko Okitsu

Chief Researcher, TAC International Inc.

（Cambodian side）
1. Prof. Koum Kanal

Director. NMCHC

2. Dr. Keth Ly Sotha

Deputy Director, NMCHC

3. Dr. Tung Rathavy

Deputy Director of NMCHC/ Manager of National
Reproductive Health Program/Secretary of High Level
Midwifery Task Forcexv

4. Ms. Ou Saroeum

Deputy Director of Nursing Department of
NMCHC/Executive Director of Midwifery
Association/Deputy Director of Midwifery Council

5. Dr. Lon Chan Rasmey

Deputy Director, Kg. Cham Provincial Health Department,
MOH

Periodofevaluation

27th Sept., 2009〜12th Oct., 2009

Type of Evaluation
Evaluation： Terminal

３．Results of Evaluation
3-1 Achievement of the Project3-1-1 Achievement of Activities
It was confirmed that the Project has implemented its activities as per the plan stipulated in the R/D
M/M/ PDM and PO without notable delays. Only few activities such as making guidelines anddissemination of those guidelines are not yet implemented, but there are good perspectives to complete
the remaining activities by the end of the project period.
3-1-2 Achievement of Outputs
Output1：The teamwork for supporting SBAs in Health Centers （HC-SBAs） is improved.
The Project team and the counterparts conducted trainings （MCT, MAT courses） for strengthening
SBA’s teamwork in the model sides. PHD/OD-MCH and RH-SBAs formulated action plans during
the MAT courses to support HC-MWs.
In output 1, all output indicators are met and showing satisfactory results. The NMCHC
counterparts and Japanese experts jointly prepared MCT and MAT courses and one MCT course andtwo MAT courses were implemented attended by 12 participants from PHC/OD level in the model sites.
4 ODs and PHD formulated the 46 action plans.
According to the group discussion, PHD/OD level MCH can recognize their roles as supporting
HC-MWs to strengthen the MCH services provision. Also according to the telephone survey done by
the Project, every HC-MW interviewed recognized the attitudinal changes of PHD/OD-MCH officials as
more supportive and cooperative. Therefore, we conclude that the output 1 has been achieved.
Output 2：The model of health administration system （PHD/OD） and clinical facilities （RHs）
to support the activities of HC-SBAs is formulated.
OD-MCHs implemented some of the HC-MWs supporting activities which they planned in theaction plan in order to improve the performance of the HC-MWs. The new supervisions wereconducted with revised checklist.
In output 2, all output indicators are met and showing satisfactory results. OD-MCHs in the modelsites implemented 12 action plans and PHD initiated 5 new activities to improve existing plan and has
implemented them. OD-MCHs made action plans which include conducting regular meetings either
monthly or quarterly, giving small lectures during the HC-MW meetings by involving RH-SBAs,
establishment of maternity waiting home, standardization of VHSG report form, integrated supervision,and some others. These activities have been carried out by the government budget and also by
mobilizing donor funds.
According to the group discussion and also telephone interviews, HC-MWs expressed the usefulnessof supports from RH-SBAs, though the available time of RH-SBAs is limited. HC-MWs expressedthat RH-SBAs have shown their behavioral changes and treat HC-MWs in a nice manner.
Involvements of RH-SBAs in regular HC-MW meetings to give small lectures are very useful and havexvieffects on strengthening the technical capacity of HC-MWs. OD-MCHs recognize the usefulness of
involving RH-SBAs in supervision activities. As another positive effect of the Project, OD-MCHs
improved managerial and planning capacity and developed presentation skills in meetings.
PHD-MCHs also recognize the usefulness of involving RH-SBAs in MDA activities. New
supervisions were conducted with using checklist modified by the Project; one OD continues to use it.
All of above evidences indicate that output 2 has been achieved. However, regarding the checklists
used for supervision and monitoring, there are several checklists existing which were introduced bydevelopment partners and the several programs/departments of MoH, so that the use of this checklist
modified by the Project is up to ODs due to variety of instructions from the national level.
Output 3: The model of collaboration for the improvement of MCH in the communities isformulated.
Good practices of community activities nationwide were reviewed. Stakeholder analysis andextracting the enhancing and inhibiting factors affecting Community Collaboration in the model sitewere carried out. An action list for ODs to support the community collaboration was developed andsome activities were implemented to improve the community collaboration.
In output 3, all output indicators were successfully achieved except indicator 4 which is also
expected to be completed by the end of the project period, however, it does not exactly mean that the
Project formulated “the model” for community collaboration between VHSG and HC. In fact, theProject did not intend to formulate “the model” for collaboration, but shifted the aim towards
strengthening the function of VHSG as is stipulated in the government policy. According to the policy“Community Participation Policy for Health”, the role of VHSG is to serve their community as amultipurpose health volunteer at community level, but the reality is that each VHSG often assists
specific service only （by programs or development partners’ projects）. Therefore, the Project decided
to create activities which would strengthen OD’s role as a leader in community health, particularly inthe relation to VHSG and to widen the VHSG‘s role as multipurpose health volunteers in the HC’scommunity health activities. The conclusion of output 3 is that, though the Project did not formulate
the replicable model on community collaboration for nationwide due to the various backgrounds of each
OD, they created the action list for ODs to support the Community Collaboration which would
strengthen the role of OD in the relation to VHSG’s stipulated role as multipurpose health volunteer andthe MCH services in their communities in the long run.
Output 4：NMCHC identifies the issues in the rural areas and reflects this in the national
programs.
NMCHC developed a new training curriculum based on MCT/MAT curricula and implemented it
nationwide and also monitor the effects. Report the study and analysis of the results of maternalmortality and morbidities to the NRHP and the National Maternal Death Audit Committee.
In output 4, all output indicators are successfully achieved except indicator 6, which is also expected
to be achieved by the end of the Project period. In order to expand the trainings to cover the nation,
MCAT curriculum was formulated based on MCT and MAT curricula. MCAT course was conducted
and was attended by 86 participants from 17 provinces which CAP3 RH （17 PHD/OD/RH） locate andthe Orientation Workshop for Health Managers were conducted which was attended by 51 healthmanagers. After the MCAT courses conducted to cover all 17 provinces with CPA3 RH, NMCHC has
carried out supervisions to see the effects of the courses. The Team confirmed that OD/PHD directors
and MCH officials understood their roles in improvement of MCH services and started to organize andfacilitate meetings and supervisions after the MCAT course. The communications between RH-SBAsand HC-MWs have been improved and RH-SBAs are more collaborative and supportive. Supporting
activities to SBAs have started in most provinces such as advising HC-MWs during referral, giving
small trainings by RH-SBAs in regular HC-MWs meetings, and conducting new supervisions.

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3-1-2 Achievement of the Project Purpose
All indicators to measure the achievement of the Project purpose “Maternal and Newborn Care
service in the model sites is improved, whose results are integrated into models and reflected in the
National Programs” show that the MCH services are on the track of improvement in the project modelsites and the program elements are adopted by national programs. Meanwhile, the Team recognizes
that the various interventions and incentives besides the Project also contributed to the increase of
MCH service provisions and utilizations in the model sites. It is difficult to evaluate how much eachelement were contributing to the achievement of the project purpose, but all elements are notcompeting but complementing each other to improve the service provision and utilizations.
3-1-3 Prospects of Achievement of the Overall Goal
The indicators to measure the achievement of the overall goal show the positive perspective toachieve the project overall goal in the next 5 years or so after the project is completed. Other positive
aspects to indicate the achievement of the overall goal are 1）. There would be continuous policy
support expected to expand the utilization of maternal and newborn care services in the country at least
until the country will achieve the CMDG5, 2）. There would be still many donors who would support
MCH services provisions and utilizations in the country and 3）. The Project developed the “MCAT
course” and “Orientation workshop for health managers” curriculum and materials jointly with the ToTunit of NMCHC, so that at least at national level it is possible to continue the trainings nationwide,
however the curriculum needs to be endorsed by the Secretary of State in order to support HC-SBAs in
improving their MCH services with quality.
On the other hand, there are some challenges foreseen to achieve the overall goal in the next 5 years
or so. Those challenges are 1. Building health center facilities for existing non-MPA HCs, allocate
midwives to MPA HCs which do not have any MWs assigned yet, provide necessary equipment,
adequate payments, operational costs, medicines, and materials supports for MCH activities, provide
more space inside/outside of HCs to accommodate increasing number of deliveries, transportation
support for referral. 2. Improvement of road conditions to secure better access to health facilities and torefer the patients from the rural remote communities to a RH. And 3. Quantity and quality of SBAs arelimited, so that there should skill trainings for SBAs to provide quality services. 4. The financial
capacity to support the expansion of MCH services at the HC level is rather complex issue. At thetime of evaluation, there are 2 or 3 different incentive schemes running parallel inside and outside of
the Project site. Therefore, HCs are more cooperative towards MCH services especially delivery
services, however, the continuation of such collaboration within HCs is a question after finishing thoseexternal inputs for MCH services. This financial aspect needs to be watched.
3-2 Summary of Evaluation Results(1) RelevanceThe relevance of the Project is graded as high from the following reasons. 1）. The degree ofpriority of the Project in the development agenda and policy is high. The national strategic plan
（NSDP） and health strategic plan （HSP 2） identifies the importance of tackling the issue ofmaternal and newborn care in the country. Clearly the project followed the direction of the national
policy and served as a part of those efforts to meet the national objectives to improve the quality andquantity of MCH service provisions and utilization. 2）. The Project is in line with the Japanese ODA
policy on the supporting socially vulnerable people such as mothers and children. Also the directionof the Project is consistent with the JICA’s Country Assistant Plan for Cambodia, which addresses theimportance of strengthening the MCH service to improve CMDGs with emphasis on improving thequality and quantity of MCH service providers. 3）. In the current situation of the health sector in the
country, HC-MWs have not been having proper supports technically and morally from various levels ofxviii

supervisors. It was, therefore, relevant of the Project to show how we can support HC-MWs.
Together with provision of adequate medical equipment and materials to the HS-MWs, the Project
could demonstrate how we can improve the performance of HS-MWs in the provision of MCH services.
4） The Project was also timely in a sense because every effort to increase the quantity of MCH service
provisions has been happening in the country, however, there were no other such interventions that
improve the quality of services by improving the working environment of HC-MWs. Therefore, these
efforts could complement each other to increase their own effects. 5） This project could show the way
to improve the existing capacity and quality of services within the available and existing system without
putting much input. In this sense as well, the project is relevant in the current Cambodian health sector
context. 6） Every government officials who are target groups/counterparts of the Project mentioned
about the appropriateness and relevance of the Project approach/attitude that is not pushing thenumerical targets for them to achieve but instead showing how to achieve what PHD/OD officials madeas objectives.
These elements show the relevance of the Project is very High.
(2) Effectiveness
The Effectiveness is graded as high, as it is shown by the indicators of Project Purpose, described in
3.1.2. It is concluded by the Team that the MCH services are on the track of improvement in the projectsites and the program elements are adopted by national programs. Also, it is confirmed that there aresome external factors which have given impacts on achievement of the Project Purpose. Those factors
are, for example, each OD is having various interventions and inputs from other national and donor
funded projects and programs. Overall Government policy change towards filling the gaps in terms ofhuman resources and facilities is giving a big impact on MCH services everywhere in the country. Those
factors and the Project efforts have been complementing each other to achieve the Project Purpose.
However, it is not adequate to analyze how much each factor contributes to the achievement of Project
Purpose.
(3) Efficiency
The overall efficiency is graded as high. The Team concluded that the overall efficiency of the
Project is high since the Project expanded the MCAT course to the nationwide within 3 years of Project
period. The factors for promoting efficiency are several. First of all, the accumulated experiences at
the NMCHC made the implementation smooth and efficient, and the Project utilized existing humanresources internally, and all Project staff made maximum efforts to make the Project effective andefficient. There are some other factors to make the Project effective. First, the Cambodian
government shared high percentage of costs to conduct various meetings and trainings with the Project,secondly, the Project did not conduct training in Japan which is more costly, but instead conducted
several study tours in the province and third county trainings. As a consequence, the Project reduced
the constraints of counterparts in terms of time to spend on trainings.
All inputs are executed according to the plan.
(4) Impact
Impact is graded as high as following reasons. It was examined and perceived by the evaluation
tem that prospects of the achievement of overall goal is high by the reason explained in 3.1.3: Prospectsof Achievement of the Overall Goal. In this sense, the impact of the project is considered as high.
However, if the achievement of overall goal is attributed to the achievement of the project purpose is notthat simple question to answer. The provision and utilization of MCH services are influenced byvarious conditions such as policy interventions, regulations, skill and human resource development,material supports, and many others. Therefore, the achievement of the Project is a part of the factors toxixincrease the MCH service provision and utilization, but is not a mere factor for it. The project works
on rather linking the PHD/OD’s managerial capacity and RH’s technical capacity at the OD level inorder to maximize the existing capacities within the MCH services and enhance the sustainability of theservice provision in the country.
Other positive impact of the project are; 1. The Project influenced on the Government policy
direction on MWs, 2. PHD-MCH Kampong Cham tried to expand the concept of supporting model for
HC-NWs to 6 other non-model site ODs in the province, 3. The Project contributed to build the trust
between PHD/OD level government officials and HC-MWs, 4. NGO’s activities were also becomingsmooth due to the cooperation from RH-SBAs and 5. The study of existing overlapped incentives doneby the Project induced the attentions from other organizations on the incentives and the practice of
mapping such incentives was done by a NGO.
No negative effects were expressed by the stakeholders interviewed.
(5) Sustainability
The sustainability of the Project is graded as “moderately high” by the following reasons. The
sustainability was examined from three aspects; policy and regulation, financial capacity, and technicalcapacity.
1) Sustainability in the aspect of policy and regulations: Within the framework of the HSP 2
2008-2015, the improvement of MCH services will continue to be the priority area in the country.
Together with Fast-track intervention for RMNCH, the gaps in quality improvement of continuum
care, better access to safe delivery, and quality improvement in referral hospitals would be thepolitical agenda in the country until the country will achieve the CMDG5.

2) Sustainability in the aspect of organization and financial capacity: NMCHC/PHD/OD-MCH
expressed to continue the activities started in the Project period by using government AOP funds.
However, some of PHD/OD level activities could be limited by the availability of resources.
Some of MW supporting activities such as advice on referral would remain because of no budgetaryrequirements.
Challenge identified in the financial capacity is that the disbursement of planned budget isunpredictable and PHD/OD level managers might not itemize the activities due to their perceived
low priority on the activity.

3) Sustainability in the technical capacity
The NMCHC gained the ownership on the various trainings developed in the Project and improved
the planning and financial management skills and conducted MCAT covering 17 PHD/ODs whichhave CPA3.
ToT unit is planning to expand SBA supporting mechanism nationwide coordinatedwith NRHP.
Some positive attitudes were seen among PHD/OD-MCH and OD directors who received MCAT
course in terms of being more independent from the national level. OD-MCH expressed that theywould like to continue making action plans for supporting MWs to improve the MCH services intheir area. OD directors expressed that they will continue monthly MW meetings involving
RH-SBAs and new supervisions because these are very important for HC-MWs to improve theirtechnical capacity and to motivate them to improve their performances. Some OD-MCH
mentioned that they would like to expand the involvement of VHSG by teaching their roles in thecommunity health, and by improving the reporting form of VHSG.
However, some challenges are expressed by those stakeholders in the aspect of technical capacity.
These challenges are 1. Limited RH human resources and increasing workload in their own services,
2. Limited teaching skill among RH-SBAs, and 3. Further coordination between the NMCHC andprovince levels in terms of expanding of MWs supporting activities.

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3-4

Conclusion, Recommendations and lesson learned
3-4-1 Conclusion
Overall, the Project has been successfully implemented and achieved the Project purpose according
to the indicators listed in the PDM. It should be noted that the Project not only developed the model andreflected it in the national programs, but also implemented it through MCAT to the nationwide in spiteof the limited three year cooperation period. Then the Project could confirm MW supporting activities
happening at the MCAT covered areas.
However, it is difficult for the Team to conclude how much the Project contributed to the increase of
key indicators such as the number and percentage of ANCs and deliveries attended by SBAs due to theintroduction of new policy on Fast-track interventions for RMNCH, the various otherprograms/projects, which provide performance based incentives and various funds in the model sites of
the Project.
3-4-2

Recommendations(1) Endorsement of curricula and guideline on MW supporting activities
It is essential for NMCHC to have curricula and guideline of MCAT course and Orientation WS
which are the tools for MWs supporting mechanism/model. Therefore, it is essential for NMCHC andthe Project experts to complete the curricula and guideline. The Team recommends that the MoH shallendorse them subsequently by the end of the Project period.
The evaluation team recommends the Project to complete the “Community Collaboration Handbook
for OD” and submit to NMCHC for authorization. The Team also recommends the Project todistribute the handbook by the end of Project period, in order ODs to utilize VHSG efficiently as healthvolunteers for community health.
(2) Budgeting MW supporting activities in the respective AOPs
The Team recommends MoH/PHD/OD to budget MW supporting activities in the respective AOPs
under Program 1 for RMNCH, Sub-Program 3 for MCH. For the year 2010, the Team recommends
PHD/ODs to negotiate with development partners in respective ODs to fill the gap.
(3) Expansion of MW supporting mechanism
The Project demonstrated how to improve the quality of MCH services provision by supporting theexisting and newly deployed MWs in HCs technically and also morally. The Project also
demonstrated the importance of the mechanism to form a supporting team which is called “MW
Alliance Team” consisted of PHD/OD-MCH and RH-SBAs. This is a mechanism/model which can beapplied to uncovered areas where have different surroundings and conditions. Therefore, the Team
recommends NMCHC and PHD/OD to coordinate as “a team” in order to further expand MW
supporting mechanism to uncovered areas. A plan with adequate strategy needs to be planned out at
the national level by the end of Project period. The Team also recommends the MoH to strengthen theclinical and teaching skills of RH-SBAs and teachers in RTCs in order to improve the quality of MW
supporting activities.
(4) Expansion of Orientation to the Health Managers
In order to achieve the above recommendation 5.2.3, the Team recommends NMCHC to conduct“Orientation WS for Health Managers “at the national level prior to conducting MCAT course to gain
the understanding of health managers on MCH services including supporting MWs and MW alliance
team.

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(5) Harmonization of monitoring/supervision systems
The Team recognized some existing confusions in the monitoring/supervision systems due tocomplicated tasks with multiple checklists for supervisors to carry on in some areas.
Therefore, theTeam recommends the MoH and the development partners to discuss the issue ofmonitoring/supervision systems with multiple checklist（s） to be harmonized.





3-4-3
Lesson Learned
Strengthening health systems is one of the priority development agendas for global health in recent
years. Many international organizations and bilateral donors have been exploring any effective
approaches to strengthen health systems. The Project showed a possible approach to improve district
health systems without large financial inputs. That is to make each counterpart recognize their own roleand to improve the capacity of counterparts not by the technical trainings but by setting up
opportunities for knowing each other and working together to solve the problems at the sites, which led
to change of the mind-set to work as a team and consequently strengthen the function of district healthsystems.
The counterparts gained high ownership as the implementers of the Project and they explain theprocess and issues with their own thoughts and words to the stakeholders outside the Project. First,
this high ownership of counterparts was created by being positively involved in the Project processes
such as planning, implementation and monitoring/supervision as an equal partner of the Project
implementers. Secondly, the approach of letting counterparts decide the activities from the options
extracted from the existing good examples could generate the ownership on the activities they chose.
Thirdly, the long history of Japanese assistant to the Cambodian health sector with respect to the
Cambodian ownership contributed to the gradual increment of the ownership in the Cambodian
counterparts who have been there throughout during the cooperation.

xxii