Asia
I. Project Summary
Country: The People's Republic of China
Project name: Anhui Province Primary Health Care Technical Training Center Project
Sector: Health and medical care Aid form: Technical cooperation projectOversight: Medical Care Cooperation Department, Medical Care Cooperation Section
Cooperation funds (at time of evaluation): 494,886 yen
Cooperation period(R/D):
August 1, 1999-July 31, 2004
(Extension):
August 1, 2004 - April 30, 2005
(F/U):(E/N)(No charge)
Recipient-related organizations: Anhui Province Department of Public Health/Science and Technology Agency
Cooperating organizations:Japan side:
National Institute of Public Health, Japan Association for Development of Community Medicine, Kochi Prefecture Health andSocial Affairs Division and Culture and Environment Division
Other related cooperation:

1-1 Cooperation Background and Summary
In its Eighth Five-Year Plan (1991-1995), the government of The People's Republic of China (referred to below as "China") set
the objective of every citizen enjoying primary health care (PHC) by 2000, and worked to expand and improve PHC. The
condition of PHC-related facilities and service systems in rural areas remained inadequate, however, and China's government
again established the objective of improving PHC in its Ninth Five-Year Plan (1996-2000), and has sought particularly toenhance PHC in rural areas. Under these circumstances, China's government requested the Japanese Government toimplement a project for the education of PHC employee human resources at the PHC Technical Training Center in Anhui
Province, a typical rural area in China. This request was accepted, and the project was initiated on August 1, 1999 incooperation with the Anhui Province Science and Technology Agency as the project management organization and theDepartment of Public Health as the organization implementing the project.

1-2 Cooperation Details(1) Primary objectives
1) Improve the level of PHC in rural villages in Anhui Province.
2) Establish Anhui Province as a model province for PHC human resources education in China.

(2) Project objective
Improve the training techniques for human resources education at the Anhui Province PHC Technical Training Center andestablish a training organization.

(3) Results
1) A PHC project office was established.
2) A training organization was created.

3) A series of PHC management and technology teaching materials was compiled.
4) Teaching materials for education and training and equipment for clinical training were improved.
5) Instructor training techniques were improved.
6) The activity level of the training recipients (PHC managers and technicians) was improved.

(4) Staffing, equipment and funding (at the time of evaluation)
Japan side:
Long-term specialists dispatched

6

Equipment grant

146,140,000 yen

Short-term specialists dispatched

17

Local cost burden

70,883,000 yen

Trainees hosted

16

Other

China side:
Counterpart placement

Placed according to need (Resident: 2)

Local cost burden

5,050,000 yuan

Provision of land and facilities
Other

II. Summary of Evaluation Committee
Investigators:
Leader:Shinozaki Hideo, National Institute of Public Health, DirectorCommunity healthcare:
Ieyasu Hidetaka, Kochi Prefecture Health and Social Affairs Division, Medical Care Policy Section, Section Chief
Public health:Ishikawa Shizukiyo, Jichi Medical School, Division of Community and Family Medicine, Physician
Evaluation plan:
Takahashi Yohei, Japan International Cooperation Agency, Medical Care Cooperation Department, Medical Care Cooperation
First Section
Interpreter
Kato Yoko, Japan International Cooperation Center
Evaluation analysis:
Ose Yasuko, Global Link Management Co., Ltd.

Evaluation period:
February 6, 2004-February 20, 2004

Evaluation category:
Final evaluation

III. Summary of Evaluation Results
3-1 Confirmation of Results
All six results expected for this project were achieved as planned and the project objective to "Improve the training techniques
for human resources education at the Anhui Province PHC Technical Training Center and establish a training organization" also
has already been achieved. With regard to the primary objectives, the committee evaluates the results to be moving positively
toward achievement of the primary objective"1) Improve the level of PHC in rural villages in Anhui Province", because theproject objective was achieved and the knowledge and techniques the training participants acquired through training at No. 1Training Center and No. 2 Training Center are being put to use in an effort to expand PHC in rural villages. Moreover, withregard to the second primary objective to "2) Establish Anhui Province as a model province for PHC human resources educationin China," the government plans to hold an international seminar in Anhui Province in fiscal 2004 as a venue to announce theproject results. By holding this seminar, the sense of "ownership" towards the project by the individuals related to the Anhui
Province project is expected to increase, which is likely to provide strong motivation to make Anhui Province a model province
for human resources education in China in the near future.

3-2 Summary of the Evaluation Results(1) Validity
When the evaluation committee looked at project validity from the perspective of (a) consistency with the development policies
of China's government, (b) consistency with the aid policies of Japan's government, (c) appropriateness of selection of the target
group and (d) appropriateness of selection of the project target region (Anhui Province), we evaluated the project's validity to behigh for the following reasons.
First, with regard to (a), in its Eighth Five-Year Plan (1991-1995) and Ninth Five-Year Plan (1996-2000) China's government set
the objective that every citizen living in rural villages should enjoy PHC, and has been making an effort to improve PHC. Today,
enhancement of rural village PHC is cited as a top priority in the Tenth Five-Year Plan (2001-2005), and the orientation soughtby this project is consistent with the policy of China's government. With regard to (b), the objectives of this project are also very
consistent with the aid policies of Japan's government because the Japanese government has enumerated the elimination ofdifferences between urban and rural areas and support for the healthcare sector covering the poorest segment of the population
as a top priority issue for Japan's aid policy toward China. With regard to (c), we judged the project is moving steadily towards
accomplishing the primary objective to "improve the level of PHC in rural villages in Anhui Province" by focusing on both thePHC managers and technicians, the individuals to whom the project appeals directly, and on rural village residents, who will be
the ultimate beneficiaries, as the target groups. Moreover, a province designated as poor by the central government wasselected by priority when the selection of 15 branch offices was made, and the approach of putting top priority on the poorest
segment of the population was judged to be appropriate. Finally, when evaluating (d), the committee believes implementing thePHC human resources education project for Anhui Province was appropriate, based on considerations such as the fact Anhui
Province is a typical agricultural province, where approximately 80% of the population is engaged in agriculture, and the fact
several well-known PHC-related human resource education institutions exist in the province, including Anhui Medical University
and Anhui Medical College.

(2) EffectivenessAs indicated in "3-1 Confirmation of Results," the project objectives were achieved according to the initial plan. When reviewing
the achievements, the committee judged that the accomplishment of each result contributed substantially to the achievement ofthe project objective and the primary objectives through the use of various devices for the human resources education process,including (a) selecting as trainees individuals suitable to become instructors after the participants had attended the lectures, (b)advising the instructors to enable them to respond to differences in the level of the trainees and (c) using a participatory
approach and visual teaching materials to improve the effectiveness of the training. Moreover, in this project the trainees who
attended the training did not take a leave from their work, but continued in their current positions, and were able to put theknowledge and techniques learned to use in their present activities. The trainees also held presentations to convey theirknowledge to the medical care staff in country hamlets and villages, and the committee judged the results of the humanresources education have been firmly linked to the achievement of the project objective and the primary objectives, and soevaluates the effectiveness of this project very positively.

(3) Efficiency
With regard to staffing, equipment and funding, aspects of the program such as the number of long-term and short-term
specialists dispatched, their specializations and the timing and length of their dispatch were evaluated by both the specialists
and their counterparts as appropriate. In particular, the combination of short-term dispatches of specialists and training in Japanearned high marks. Because the specialists whose counterparts received training in Japan were afterwards dispatched to local
areas as short-term specialists, this enabled the counterparts to select appropriate trainees beforehand when these same
specialists provided training locally. Moreover, for the short-term specialists as well, this made it possible to prepare technicalinstructions that would be effective in the local areas in advance, before being dispatched to the local areas, because the shortterm specialists already understood their counterparts' knowledge, technical level and needs. Moreover, with regard tocounterpart placement, two counterparts were assigned to the project office overseeing the entire project, and project offices
were also set up at the 15 branches of the Anhui Province Department of Public Health and an individual responsible for theproject was assigned to each office. This type of organization proved effective in ensuring instructions from the central project
office to each prefecture concerning project activities were thoroughly provided. Furthermore, the equipment provided to the No.
1 Training Center and No. 2 Training Center and the vehicles used to disseminate the healthcare training that were supplied by
the province were managed and maintained appropriately, and these equipment and vehicles helped to extend PHC to theresidents in rural villages. For the reasons mentioned above, the efficiency of this project is evaluated very positively.

(4) ImpactA number of results can be cited as the positive impact from implementation of this project, including (1) improvement of theknowledge and technical level of the PHC staff in hamlet public health clinics and village public health offices, (2) change in ruralvillage residents' attitudes concerning health as a result of the dissemination of health and hygiene education and (3) indicationsof medical care and prevention being integrated into healthcare measures. With regard to (1), as a result of implementing thisproject the PHC-related individuals at the province level who attended the PHC-related training at the No. 1 Training Center andNo. 2 Training Center became instructors themselves after attending the training and are providing training for individuals
engaged in PHC in hamlets and villages. As a result, the knowledge and technical skills of the PHC staff in hamlet public healthclinics and village public health offices have improved, and rural village residents can enjoy a higher level of PHC services thanbefore. With regard to (2), concerns about the health of rural village residents have increased because of negative events suchas SARS and flooding that are impossible to anticipate, and this was linked to an emphasis on health education in the second
half of the project. The service to provide visiting medical examinations to rural villages using the vehicles for disseminating
healthcare education is popular among rural village residents, and residents' health awareness continues to grow. With regard
to (3), the concept of prevention continues to spread among residents along with the dissemination of health education, and theintegration of medical care treatment and prevention approaches continues to spread for PHC measures as well.

(5) Development of self-reliance
The committee judged the development of self-reliance through this project to generally be high when evaluated after the projectcompletion from perspectives such as (1) policy aspects, (2) organizational capabilities of the implementing institutions, (3)technique retention rate and (4) management and maintenance of equipment and the vehicles used to disseminate healthcare
education. With regard to (1), as mentioned previously China's government has declared the enhancement of PHC in ruralvillages as a top priority in its Tenth Five-Year Plan (2001-2005), and government support concerning PHC measures isexpected to be continued in the future. With regard to (3), the trainees who received training through the project are giving
courses to share the knowledge and techniques learned with the PHC staff at hamlet public health clinics and village publichealth offices, without resigning their positions. Because the PHC human resources education provided by the project is
contributing in this manner to the spread of new PHC-related knowledge and techniques to rural villages, the development ofself-reliance from a technical aspect also is judged to be excellent. With regard to (4) as well, the equipment donated so far isbeing managed and maintained properly, and the institutions are expected to provide management and maintenance in thesame manner in the future. For the vehicles to disseminate healthcare education, training in Japan concerning procedures forusing the medical examination vehicles is scheduled to be held in May 2004 for staff at the provincial level. The individuals whoattend this training will be responsible for the operation and management of the health education vehicles in the future, and aredeemed capable of performing management and maintenance appropriately in the future. For the reasons indicated above, thedevelopment of self-reliance through this project is generally evaluated to be excellent. With regard to (2), however, although asystem to continue similar PHC human resources education in the future has been established, the outlook for ensuring
sufficient funding to maintain this organization faces some difficulties, and securing ongoing funding is a future issue.

3-3 Factors that contributed to the results shown
A number of unanticipated negative events occurred during the project period, including an outbreak of SARS in April 2003,
floods in June of the same year and avian influenza in January 2004. There was a silver lining, however, because local
residents’ interest in public health and preventive care was spurred by SARS and the epidemics resulting from the flood
damage, and the heightened need for health education in Anhui Province was a positive result. Therefore such unanticipated"negative" events became a factor promoting the spread of health education, causing the counterparts to emphasize healtheducation in the latter half of the project, and simultaneously served to create greater interest in public health and preventive
care among rural village residents as well.

3-4 Problems and causative factors
Because several unanticipated negative events such as SARS, flooding and avian influenza occurred, the project team wascompelled to make changes in the initially planned training schedule. Through steps such as adding a course on nosocomial
infections to the training during the period of the SARS outbreak, however, the counterparts were able to respond flexibly to theunanticipated negative factors as well. As also described in "3-3 Factors that contributed to the results shown," residents’interest in health was heightened by the occurrence of negative factors such as SARS and flooding, and the counterparts linked
this to the dissemination of health education.

3-5 Conclusions
All six results expected for this project have been achieved nearly as planned, and a PHC human resources education system
has already been established at the provincial and state levels. Therefore the project objective to "Improve the PHC humanresources education at the Anhui Province PHC Technical Training Center" is judged to have been achieved. In addition, thehealth education activities that began to be emphasized from the latter half of the project are proceeding well, and the creationof a system to expand this activity is a future issue.

3-6 Proposals (specific measures, proposals and advice concerning said project)(1) New medium to long-term objectives to be met 5-10 years after the project ends should be established because the infantmortality rate, vaccine immunization rate and facilities birth rate indicators set as the primary objectives have already beenachieved.
(2) Additional support will be necessary after the project ends in order to expand rural village PHC, including health education.
(3) For the international seminar scheduled in 2004, plans should be made to announce the project results domestically andinternationally, so they will be beneficial for future rural village PHC activities in Anhui Province.

3-7 Training (Matters that will serve as a reference for the identification/formation, implementation andoperation and management of other similar projects derived from a said project)(1) For training implemented as a human resources education project activity, effective training can be achieved by flexibly
combining lecture formats and types of participation according to content and the individuals being trained.
(2) An outlook that can convert unanticipated negative factors that are encountered into positive factors is required (example:
the outbreak of SARS and occurrence of floods became an opportunity to place emphasis on health training).