Summary of Final Evaluation
1. Outline of the ProjectCountry㧦 The Kingdom of Cambodia

Project title㧦 National Tuberculosis Control Project
Phase 2

Issue/Sector㧦Health - Tuberculosis Control

Cooperation scheme㧦 Technical Cooperation Project

Division in charge㧦 Infectious Disease
Control Division, Health Human Resource andInfectious Disease Control Group, Human
Development Department

Total cost (estimated at completion of the Project)㧦
790 million yen

Period of
Cooperation

Partner Country’s Implementing Organization㧦National Center for Tuberculosis and Leprosy Contrl(CENAT), Minstry of Health

R/D: From August 1, 2004 toJuly 31, 2009

Supporting Organization in Japan㧦Japan
Anti-Tuberculosis Association (JATA)
1-1 Background of the Project
In Cambodia, infectious diseases still a major cause of mortality, and among those, tuberculosis (TB)
is one of leading causes. As most TB patients are aged between 20 and 50 years old, which is amongproductive generation, TB infection directly affects socioeconomic situation. In 1994, National
Tuberculosis Control Program (NTP) introduced DOTS (Directly Observed Treatment with
Short-course chemotherapy) in Cambodia, and JICA commenced “National Tuberculosis Control
Project” in 1999 with five years cooperation period, to support NTP for nationwide expansion of DOTS
service. Having achieved a significant progress in DOTS expansion and improvement in cure rateduring the five-year cooperation period, the major focus for TB control had shifted to better quality
management and increased attention to difficult-to-reach areas and groups. Rapid expansion of DOTS
services caused lack of trained health staffs engaged in TB control and supervision activities, as well aslack in its quality. In addition, spread of HIV/AIDS increased the number of TB patients, and there also
was difficulty to develop an evidence-based plan of TB control because of insufficient surveillancesystem.
Responding to the above situation, Tuberculosis Control Project Phase 2 was requested by theGovernment of Cambodia for a period of five years, and commenced in August 2004. The project has
been providing technical assistance to the NTP for improving the TB control program withsustainability and quality, and for expanding the improved program nationwide. The Project consistedof three components: The first was to prevent the spread of new infections through increased casedetection and expansion of DOTS services, the second provided quality TB control services forvulnerable groups of patients, and third strengthened the capacity for research and surveillance tocontinuously monitor, appraise, evaluate and improve the NTP interventions and their outcomes.
1-2 Project Overview(1) Overall Goal
TB morbidity and mortality are reduced.
(2) Project Purpose
Sustainable quality TB Programme is implemented nationwide.

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(3) Outputs
1) Management capacity of the NTP is improved.
2) Sustainable quality DOTS is expanded nationwide.
3) Suitable services and guidelines beyond routine DOTS are developed.
4) Quality of laboratory services to support DOTS, TB/HIV activities and surveys is improved.
5) Effective IEC/advocacy activities to support TB control program are implemented.
(4) Inputs
Japanese side㧦 Long-term Expert total: 3 persons, Short-term Experts: total 27 persons, Training inJapan: 12 persons, Provision of equipment: 518 thousand US dollars, Local cost expenditure:
1,511 thousand US dollars
Cambodian side: Counterpart personnel: total 35 persons, Provision of land and facilities: officespaces, Local cost expenditure
2. Evaluation Team
Members of
Evaluation
Team1) Team Leader: Dr. Mitsuo ISONO, Senior Advisor (health sector), Japan
International Cooperation Agency (JICA)
2) TB Control: Dr. Hitoshi OSHITANI, Professor, Department of Virology, Tohoku
University Graduate School of Medicine
3) Evaluation Planning: Ms. Ayako MATSUOKA, Infectious Disease Control Division,
Health Human Resources and Infectious Disease Control Group, Human
Development Department, JICA
4) Program Management: Ms. Shoko SATO, Project Formulation Advisor (Health
Sector), JICA Cambodia Office5) Evaluation Analysis: Mr. Masahiro OSEKO, Consultant, Nevka Co., Ltd.

Period of
Evaluation

From January 5, 2009 to January 20,
2009Type of Evaluation㧦Final Evaluation

3. Results of Evaluation
3-1 Achievement(1) Achievement of the Overall Goal
Targets (Objectively Verifiable Indicators) of Overall Goal were based on the global targets ofWHO, which were expected to be achieved by attaining 70% of smear (+) case detection rate and 85%
cure rate of smear (+) TB patients registered. These two targets of case detection rate and cure rate
were also the targets of Project Purpose of this project, and these targets were accomplished or nearlyaccomplished. Therefore, it was considered that the necessary conditions to achieve the Overall Goal
were fulfilled.
(2) Achievement of the Project Purpose
1) The indicator concerning cure rate was fully achieved since the cure rate among newly registeredsmear (+) TB patients has been maintained over 85% throughout the project period.
2) The indicator targeting the detection rate of smear (+) TB maintained 70% was achieved in the year
2005. Although, thereafter there was a slight decrease of detection rate with fluctuation,
considering that the absolute value of detected cases has been steadily increased during the period ofphase 1 of the Project, and reached a plateau and maintained during the period of phase 2., thisxii

indicator can be judged to have been achieved.
3) Though the target level to increase the registered cases of smear (-) “twice as many from the levelin 2003” has not been achieved, taking following 3 observations into consideration, it was clear that
detection of smear (-) cases seemed significantly improved: (1)the number of the registered cases ofsmear (-) has been steadily increased during the period of the phase 1 of the Project, and reached aplateau in 2005 and maintained during the period of the phase 2 of the Project. (2)The registeredcases of TB/HIV and childhood TB, which were main components of this indicator, were also
increased. (3)Along with these, the target level of “twice as many from the level in 2003” did nothave concrete basis to support its adequacy.
4) The indicator concerning childhood TB cases was achieved, since the number of registered TB
cases in children was increased twice as many from the level in 2003.
(3) Achievement of Outputs
1) Output 1 “Management capacity of the NTP is improved.”
Output 1 was expected to be achieved by improving the capacity of planning, supervision,monitoring & evaluation, survey/research, data analysis and TB drug management. Management
capacity of NTP/CENAT has been improved in general. Successful mobilization of resources fromother donors, particularly, Global Fund indicated better management capacity of NTP/CENAT. While
the planning ability was also strengthened and annual plans of NTP/CENAT were formulated
accordingly, from the standpoint of program monitoring and evaluation, the quality of the plans,survey/research design and analysis should be further improved.
2) Output 2 “Sustainable quality DOTS is expanded nationwide.”
Output 2 was expected to be achieved through the activities on DOTS, C-DOTS (Community
DOTS), 6MSCC (6 Month Short Course regimen) and PPM-DOTS (Public-Private Mix DOTS).
The Project has started some initiatives and played significant roles in C-DOTS, 6MSCC and
PPM-DOTS. The technical know-how obtained in the pilot trials was applied for the expansion of
actual operations of these programs. CENAT has promoted C-DOTS nationwide with the guideline
developed through assistance by several stakeholders including the Project. However, at the practicallevels, the guideline for C-DOTS is not strictly followed by some partners and there are variations in
actual implementation in the community.
3) Output 3 “Suitable services and guidelines beyond routine DOTS are developed.”
Output 3 was expected to be achieved by introducing services of TB/HIV, pediatric TB and smear(-) detection. The Project implemented Mobile VCT (Voluntary Counseling and Testing) in four (4)ODs (Operational Districts) in Phnom Penh municipality, targeting patients who had difficulties invisiting VCT. Concerning pediatric TB, the Project has contributed to providing pediatric TB
guidance to all TB supervisors nationwide, and pediatric TB specific training courses were held.
Through these activities, the number of registered TB cases in children was increased. In order toincrease the detection of smear negative cases, the Project has been conducting the trainings on
X-ray reading and diagnosis technique for clinical doctors and radiology technicians respectively.
Although further improvement is needed, these activities resulted in enhanced capacity for X-ray
diagnosis, which contributed to increase the number of smear negative case detection.
4) Output 4 “Quality of laboratory services to support DOTS, TB/HIV activities and surveys is
improved.”
Output 4 was expected to be achieved mainly through the trainings on TQM (Total Qualityxiii

Management), CD4 㧔Cluster Differentiation 4 Counting㧕, smear examination, bacteriologicalexamination, and EQA (External Quality Assessment) for DST (Drug Susceptibility Test). The
Project introduced the quarterly EQA instead of semiannual EQA in seven (7) pilot provinces. By
increasing the frequency of EQA, the feedback became to be provided timely and the quality of test
was improved. Given the fact that quarterly EQA was more effective than semiannual one to improve
the quality of testing, CENAT has extended this quarterly EQA further to sixteen (16) provinces withfinancial support from other partners. For developing capacity of culture examinations, TB culture
centers were set up at CENAT and two (2) provincial hospitals under the guidance by the Project,and DST has become able to be carried out at CENAT. As a result, the quality of test was ensured bysuccess of panel test in 2005 and 2006. For diagnosis of smear negative cases and MDR (Multi Drug
Resistant)-TB, CENAT was expected to continue and promote the best utilization of culture
examination regularly.
5) Output 5 “Effective IEC/advocacy activities to support TB control program are implemented.”
Output 5 was expected to be achieved by developing and implementing strategies for
IEC/advocacy. The concept of IEC/advocacy was shifted to ACSM (Advocacy, Communication andSocial Mobilization), as a global trend adopted by the Stop TB Partnership.. Due to this change, IEC
strategy was accordingly changed as ACSM strategy in the middle of the Project period, the draft of
ACSM strategy was prepared. The Project has been assisting CENAT to conduct activities for
ACSM, including advocacy meetings for factory owners for the PPM activities in Phnom Penh andthe ACSM training for VHVs (Village Health Volunteers) at C-DOTS pilot areas, which enabled tostrengthen activities for Output 1 to 4 from advocacy side.
3-2 Summary of Evaluation Results(1) Relevance: Very HighTB control was one of the global priority issues targeted in the MDGs (Millennium Development
Goals) with strategies to control TB including emphasis on new issues beyond routine DOTS activities
such as TB/HIV, MDR-TB, TB in childhood and C-DOTS. The Project, thus, was inline with theglobal directions and the strategies of TB control. Regarding to the national health plans of
Cambodia, TB was identified as one of the priority issues in “National Strategic Development Plan
(NSDP) 2006-2010,” “Cambodia Millennium Development Goals (CMDG)” and “Health Strategic
Plan (HSP) 2008-2015.” And these strategies and plans shares the same indicators for prevalence,mortality rate, case detection rate and cure rate of TB. Indicators of Overall Goals and Project Purposeof the Project were consistent with these plans of Cambodian government.
Since Cambodia was and is one of those 22 TB High Burden Countries defined by WHO, thus
necessity of TB control for Cambodian people is very high. Japan’s ODA policies such as “Stop TB
Japan Action Plan 2008,” “Country-Specific Plan for Cambodia 2006 (JICA)” and “Issue-based
Guidelines Tuberculosis Control 2007 (JICA)” considered TB as one of high priority targets in healthsector, and suggested promoting quality improvement of DOTS and introduction of Beyond DOTS
strategies. The Project, therefore, were highly relevant in terms of Japanese international cooperation
policies. Besides the Project, Japan extended grant aid assistance for infrastructure construction of
CENAT (2001) and procurement of TB drug (2003-2005). These assistances furnished the basis for the
Project, and working on this basis the Project has been extending technical and managerial assistances
to CENAT/NTP. This kind of long-term cooperation by mobilizing resources through various
cooperation schemes can be highly evaluated as a relevant and effective approach.

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(2) Effectiveness: HighCENAT has successfully achieved the global target in TB, i.e. 85% of cure rate and 70% of smear
positive TB case detection rate, which are Indicators of Project Purpose of the Project. The Project hascontributed to it from the aspects as follows. Sustainable quality DOTS was expanded nationwide by
the DOTS expansion activities including C-DOTS, 6MSCC and PPM. Most of these new strategies
were piloted under the leadership of the Project and expanded nationwide by CENAT/NTP (Output 2).
Guidelines beyond routine DOTS for TB/HIV and pediatric TB, and the algorithm chart for the
diagnosis of smear negative TB were prepared by the NTP and the Project together with other partners.
Services relating to them also have been extended in conformity to these guidelines (Output 3).
Quality of laboratory services was improved through the activities implemented under the leadershipof the Project introducing quarterly EQA and culture examination (Output 4).
(3) Efficiency: High
Most of the inputs from Japanese side such as dispatch of experts, trainings of counterparts in Japanand in the third countries, provision of equipment and local cost support were executed as planned.
Cambodian counterparts highly evaluated the assignment timing, expertise and teaching capacity ofJapanese experts, and mostly satisfied with contents, timing and duration of counterparts’ trainings.
Equipment granted has been put to practical use as so intended. Cambodian side assigned counterpartsfor implementing the project activities and ensuring the sustainability. Only a few counterparts weretransferred to other departments or sent to long-term trainings overseas. Therefore, no serious negative
effects were encountered for the Project. Smooth communication among NTP stakeholders has been
maintained by systematic information sharing and discussion opportunities through TB Annual
Conference (annual), Joint Coordination Committee (annual), Interagency Coordination Committee(quarterly) and CENAT/JICA Project Meeting (monthly).
(4) Impact: High (Big)
1) Achievement of Overall Goal
Indicators of Overall Goal and Project Purpose were based on the global targets of WHO, andIndicators of Project Purpose have been achieved or nearly achieved. Therefore, necessary
conditions to achieve Overall Goal were fulfilled by accomplishing Project Purpose.
2) Other Impacts
࡮Piloting the innovative approaches such as C-DOTS, 6MSCC, EQA, PPM was supported by the
Project in conjunction with other partners. Based on the experiences and know-how acquired fromthese pilot activities, CENAT/NTP has now extended them to other areas or nationwide.
࡮By strengthening the management and technical capacity of the NTP, the Project furnished asatisfactory basis for further development of TB control services. The foundation built by the
Project has been attracting further support from other partners. US-CDC and MSF, for example,
are now planning to introduce liquid culture, a newly developed technique for TB control, in the
TB culture centers set up by the initiative of the Project.
3) No negative impacts are observed.
(5) Sustainability: Political, organizational and technical sustainability: High
Financial sustainability: Fair
1) Political aspect: The commitment of the Cambodian government for TB control is high andxv

displayed in the form of well-established consistent health policies described by the NSDP followedby the HSP and others as stated above in 3-2 (1).
2) Organizational aspect: CENAT is and will be the central and only organization responsible for
implementing NTP nationwide. And strong leadership by the present director of CENAT has
contributed to facilitating the smooth implementation of NTP.
3) Financial aspect: Along with the termination of financial support from several development
partners including World Bank, CENAT failed to gain Global Fund round 8. In this circumstances,
further efforts to mobilize funds for financial sustainability are required.
4) Technical aspect: Technical transfer to the Cambodian counterparts has been under favorable
progress and the technical sustainability is considered to be high. Most of the training courses
organized by the Project are now facilitated by Cambodian personnel. But there are some morerooms to be further strengthened in areas such as supervision and monitoring, designing ofresearch/survey, data analysis, X-ray diagnosis, EQA and culture examination.
3-3 Factors promoted realization of effects(1) Factors concerning to Planning
Having the project office inside of the CENAT building, forming the very close relationships with
CENAT/NTP, the Project has been assisting in almost all the areas of TB control, targeting the wholecountry of Cambodia for long-term of ten (10) years by implementing phase 1 and 2 of the Project.
Such long-term and wide range assistance enabled for Japanese side to provide their technicalassistance step-by-step according to the progress in all necessary areas. The long-term assistancealso enhanced human relationship between Japanese experts and Cambodian counterparts, which
resulted in the development of mutual and firm trust between them. These approaches have brought
about a successful achievement of global target in TB control program.
As stated above in 3-2 (1), Japan extended grant aid assistance for infrastructure construction andprocurement of TB drug, and these assistances furnished the basis for the technical cooperation
project. This kind of long-term cooperation by mobilizing resources through various cooperation
schemes can be highly evaluated as a relevant and effective approach.
(2) Factors concerning to Implementation Process
When stock-out of reagents occurred at central level in 2007, the Project responded quickly byconducting training of laboratory staff on in-house production of reagents, and the negative effect of
this incident was mitigated to the minimum level. In-house production of reagents is still being
performed when necessary. This was a noteworthy case as a conversion of a risk into an opportunity.
In the process of extending PPM (Public-Private Mix), the Project enlarged the circle ofstakeholders involving the Cambodian Ministry of Labor by extending PPM to PPPM
(Public-Public-Private Mix) and Cambodia Anti-Tuberculosis Association (CATA). This approach canbe highly evaluated for improving the sustainability of the project’s effects.
3-4 Factors that impeded realization of effects(1) Factors concerning to Planning
Since qualitative components were not incorporated in Indicators in PDM, this aspects of expected
results of the Project have tended to be unconsidered. Besides, there were some indicators whosetarget levels were set on the ambiguous scientific basis.

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(2) Factors concerning to the Implementation Process
When the management of the Project was sifted from direct management of JICA to consignment
basis management to JATA, there were some confusion in business routines and it caused delays ofsome activities of the Project.
3-5 Conclusion
CENAT has successfully achieved the global target of TB control program, i.e. 85% of cure rate and
70% of smear positive TB detection rate, which were Indicators of Project Purpose of the Project, and
the Project has made significant contribution to this success. In this respect, the success of the Project
was highly evaluated.
Among five (5) evaluation criteria, four (4) criteria of relevance, effectiveness, efficiency and impact
were evaluated “very high” or “high.” Sustainability on political, organizational and technical aspects
was evaluated “high” while financial aspect was evaluated “fair” since it is expected for NTP/CENAT
to make further efforts to mobilize external funds such as Global Fund.
3-6 Recommendations(1) CENAT has successfully achieved the global target in TB control program and JICA has madesignificant contribution to this success through implementing technical cooperation projects for 10
years. Regarding to the current project, since most of the expected outcomes of the project have beenachieved, it is recommended that JICA terminate this project in July 2009 as planned.
(2) CENAT has successfully developed human resources for TB control at all levels. However, CENAT
still needs to improve its capacity, especially for management of human resource and developing new
staff to cope with new technical skills.
(3) CENAT has established quality DOTS through developing supervision and monitoring system.
However, it is needed to strengthen its capacity of program monitoring and evaluation. Thus, it isrecommended that this capacity to be developed at all levels, i.e. CENAT at the central level, PHD,
OD and HC at the local levels, upon clarifying their roles for program monitoring and evaluation ateach level, considering the expected changes due to decentralization policy of the Government.
(4) CENAT developed its capacity to conduct and analyze survey/research by technical assistance of the
Project. However, still CENAT does not have enough sustainable capacity for designing of survey
and adequate data analysis, particularly a large scale survey such as the national prevalence survey.
Thus, it is recommended that the Project assist to enhance its capacity through conducting practicalsurvey such as sero-prevalence survey for TB/HIV planned in the remaining project period.
(5) CENAT has promoted community DOTS nationwide through technical and financial assistance by
several stakeholders. However, at the practical levels, the guideline for community DOTS is notstrictly followed by some partners and there are variations in actual implementation in thecommunity. This may result in hampering to maintain quality of DOTS. Thus, it is recommended that
CENAT to improve coordination among stakeholders.
(6) The project has assisted CENAT to implement quality pediatric TB service in 2 provinces. Further
expansion of the service is crucial and it is recommended that the Project enhance quality of services
in these 2 provinces as practical model so that CENAT will be able to expand the service to otherprovinces.
(7) CENAT has made tremendous achievement to detect smear negative cases by improving the capacityfor X-ray diagnosis. However, as pointed out by the Project expert, the quality of X-ray diagnosis

xviishould be further improved. Thus, it is recommended that CENAT make maximum utilization oftechnical assistance by the Project to develop quality of X-ray diagnosis in the remaining period.
(8) The project has initiated to develop EQA system for smear examinations and CENAT stared to
expand this system nationwide and in 16 provinces the EQA system has been initiated. However, thesystem is not fully functioning, especially for adequate feedback mechanism of the results andpractical instruction to improve the quality of smear examination by on site evaluation. Thus, it isrecommended that the Project assist CENAT to enhance quality of EQA in the remaining period.
(9) Now CENAT is planning to introduce fluorescence microscopic technique for smear examinations.
Thus, it is recommended to develop quality assurance system for this technique, too.
(10) The project assisted CENAT to develop capacity for culture examination in 3 major laboratories.
However, culture examinations have not yet been fully utilized according to the criteria. Thus, it isrecommended that CENAT promote best utilization of culture examination for diagnosis of smear
negative cases and MDR-TB by enhancing practical instruction, including stipulation of the criteria
in the guideline for MDR-TB, which is under development.
(11) For culture examination in CENAT, it is recommended that adequate bio-safety and infection
control be implemented.
3-7 Lessons Learned(1) The Project has made significant results and impacts on the Cambodian TB control program. This
was attributed mainly to the provision of optimum assistance for wide range of technical aspects
together with other factors such as long-term assistance and an application of a variety of cooperation
schemes such as grant aid assistance.
In phase 2, the Project has extended its activities into the new field including culture examination,
TB/HIV, PPM and pediatric TB, which was made possible on the basis prepared by the phase 1
project, and this expansion was indispensable for the step-up of Cambodian TB control program. Thisapproach enabled the Project to make foundations in all necessary areas and caused their significant
improvements. In addition to this, a wide variety of activities expanded the Project’s relationships
with a variety of stakeholders, and thus enabled the Project to play key roles among all the
stakeholders involved in Cambodian TB control program.
This has become possible because JICA started its assistance relatively early timing after the
Cambodian postwar rehabilitation, i.e. the beginning of TB control in Cambodian. In thesecircumstances, having its base in the central office, targeting the whole country and piloting inselected areas for policy set-up, the Project has been made notable contributions to the TB control in
Cambodia. This kind of project design and implementation processes could be valuable lessons
learned for other and future projects.
(2) The project assisted CENAT to develop capacity for culture examination, and three (3) major
laboratories have started their operations. However, the catchment areas of culture examination ofthese three laboratories are limited to their surrounding areas mainly due to the lack of specimentransportation cost. Although the category 2 patients are targeted to be examined, only some cases ofthem are actually tested, and the established culture examination facilities have not yet been fully
utilized under the certain criteria. While other partners are planning to introduce liquid culture tothese laboratories, it is required to plan the implementation system of culture examination with theemphasis on cost effective operation.
This is partly because culture examination was originally introduced for the research of MDR-TB,

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but mainly because of the inadequate examination system including collection and transportation of
specimens. Particularly, the application of culture examination is not clearly specified nor thoroughly
adopted, and consequently the current culture examination is not fully functioning also for the
purpose of MDR-TB and TB/HIV. Therefore, it is recommended that CENAT stipulates the nationalguideline for MDR-TB.
For a TB control technical cooperation project extending assistance for culture examination, it isrecommended to include the development of operation system for culture examination including
MDR-TB.
(3) Since qualitative components were not incorporated in Indicators in PDM, qualitative aspects of
expected results of the Project have tended to be unconsidered. Besides, there were some indicators
whose target levels were set on the ambiguous basis, and some indicators illustrated only work
processes but not targets. Indicators are expected to be the ones which enable the project to monitor
its progress and performance, thus to bring issues and problems to the surface and suggest solutions
for proceeding to the next step. In this respect, Indicators of this project could have been further
improved. When a project for TB control is designed hereafter, with reference to the experiences ofother TB control projects, it is recommended to set indicators which will serve to the effective andefficient management of the project.

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