Summary of Terminal Evaluation
1.

Outline of the ProjectCountry：Lao Peopleʼs Democratic Republic

Project title ： Project for Human Resources Develop

ment forNursing/Midwifery
Issue/Sector：Health

Cooperation Scheme：Technical Cooperation Project

Division in Charge：JICA Laos OfficeTotal cost（As of December 2009）
Total：about 360,408,000 JPY (4,158,872USD)

Period of Cooperation：May 2005 ‒ May 2010

Partner Countryʼs Implementing Organization：
Ministry of Health (MOH), D epartment of Organization and Personnel,
Department of Health Care (former Department of Curative Medicine)
Supporting Organization in Japan： The Japanese Red Cross Kyushu
International College of Nursing
Related Cooperation：- (Grant Aid) “The Project f or Strengthening Regional Education andTraining Institutions for Nurses and Primary Health Care Workers”- JOCVs, SVs

1-1

Background of the ProjectIn the Lao People’s Democratic Republic (the Lao PDR), nurses/midwives play an important role in providing health careservices. The level of these services is low, and there was an urgent need to develop nurses/midwives with appropriate
knowledge and techniques in order to improve the services. Under these circumstances, the Lao PDR requested the Governmentof Japan to provide a Technical Cooperation Project targeting improvement of the nursing/midwifery education system anddevelopment of nurses/midwives with adequate knowledge and techniques. In response to the request, the Project for Human
Resources Development of Nursing/Midwifery was started in May 2005 for the period of five years.

In November 2009, sixmonths before the termination of the Project, JICA dispatched the Terminal Evaluation Study Team.
1-2

Project Overview(1) Overall Goal：The holistic system for development of nursing/midwifery personnel is established.
(2) Project Purpose：The basis for development of nursing/midwifery personnel is improved, and nursing/midwifery education
system is strengthened.
(3) Output ：Output 1
Functions of governmental administration of nursing/midwifery for clinical service and human resources
development are intensified.
Output 2
Nursing and Midwifery Regulations are established and implemented.
Output 3
Guidelines

for the Scope of the Nursing Practice are established and implemented.

Output 4
SchoolManagement and Implementation Guidelines are established and implemented.

Output 5
Guidelines for the Scope of the Midwifery Practice are established and implemented.
Output 6
Projectmonitoring and evaluation are implemented for effective management.

Output 7i

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The capability of nursing teachers of Public Health School (PHS) and clinical practice instructors of Provincial
Hospital (PH) and nurses of the model provincial hospital regarding fundamental nursing is strengthened.
Output 8The

clinical practice collaboration between the model PHS and the model provincial hospital is strengthened forstudent clinical practice.

Output 9
Data
1-3

management of personnel and equipment is improved at the model PHS.

Inputs（As of December 2009）＜Japanese side＞
Long-term expert

5Short-term expert

1 1

Third-country short-term expert 12

Acceptance of trainees (in Japan)
Equipment supplied
Local Cost

16

Of fice equipment (photocopier, computers, etc.)

US$324,546 (as of March 2009),＜Lao side＞
Counterparts (CP)Local cost

13

P ersonnel cost f or CP, p rovision of office space for Project team , cost for materials andconsumables, land for Project Office (to be used training center)2.

Evaluation Team

Members of 1. Mr . Koichi Takei (Leader) Senior Representative, JICA Laos OfficeEvaluation

2.

Team

International Cooperation, International Medical Center of Japan, Ministry of Health, Labor & Welfare
3.

Ms. Chiyoko Hashimoto (Nursing Education I)
Ms. Wilawan Senaratana (Nursing Education II)

Assistant Director, Expert Service Division, Bureau of
Staff, Health Systems Division, Human Development

Department, JICA
4.

Ms. Kaori Osone (Evaluation Planning I) Representative, JICA Laos Office

5.

Ms. Maki Agawa (evaluation Planning II) Associate Expert, Health Human Resources Division, Health

Human Resources and Infectious Disease Control Group, Human Development Department, JICA
6.

Ms. Erika Tanaka (Evaluation and Analysis) Researcher, Social Development Department, Global Link

Management
Periodof 15 November 2009 –5 December 2009

Type of Evaluation：Terminal evaluation

Evaluation
3.Results of Evaluation
3−1

Summary of Evaluation Results(1) Relevance
Relevance is g enerally high in terms of health sector policy and needs in Lao PDR, Japanese policy of Of ficial
Development Assistance (ODA) toward Lao PDR, and project approach.
Human resources development is one of the key issues in “Sixth Five-year Health Sector Plan”. “Health Strategy up to
the Year 2020” also points out strengthening

the ability of h ealth service staf f in one of six development areas. Thoseinterviewed in Terminal Evaluation at MOH, including DOP, Department of Hygiene Prevention, and Department of Planningand Finance comment that nurses play an important role in health sector improvement.
Nursing education is relev ant in terms of Japanese ODA policy as well.

Both Japanese ODA Country Data book and

JICA’s assistant policy toward Lao PDR name improvement of health services as one of six priority areas.

Human resources

development and institutional development of health sector are pointed out as one important strategy to improve health services.
The design of the Project, with two components, is relevant.

iLThe Project tries to lay foundations of nursing education by

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developing regulations and guidelines.

Although regulations and guideli nes are essential to prescribe roles and functions of

nursing/midwifery and serves as foundations of nursing education, they did not exist before the Project. Befor e the Project,
there were many nursing teachers who had no t received organized training on n ursing education.

The Project put focus on

fundamental nursing, which is also relevant, as fundamental nursing is basis of nursing edu cation and can be utilized for
nursing in other areas and midwifery.
Establishment of Regulations and Guide lines is relevant in project design. Nursing and Midwifery Regulations is anational legal framework stipulating nursing and midwifery work at MOH for a long-term. It is expected that all the healthfacilities implement nursing/midwifery meet the standard of Regulations and implement duties based on th e Regulations andGuidelines developed by the Project. Even though it may be difficult for some health facilities to follow all the articles in theRegulations at this moment, it is important to establish Regulations and Guid elines as norm and standard to reach.

MOH

officials and Project stakeholders interviewed stressed the importance to have legal framework of nursing/midwifery.
The technical transfer approach of the Project is appropriate.

The Project put importan ce on respecting initiatives CPs

and having meetings among related stakeholders to discuss and agree on issues in the Project, which is desirable to develop
capacity of CPs and enhance sustainability. It is considered that the process of development of regulations, guidelines, andtraining materials served as opportunities and process of capacity development of involved stakeholders.
(2) Effectiveness
Effectiveness is high.

Outputs are achieved and Project Purpose is being gradually achieved.

Nursing and Midwifery Regulations and three Guidelines related to it were developed under Curative Law. The Project
aims to h ave Regulations and Guidelines well utilized b y the stakeholders during the Project p eriod.

The booklets ofRegulations and Guidelines and promotion posters were distributed to Provincial Health Office (PHO), PHs, District Hospitals,and Health Centers nation-wide.

To inform the contents of Nursing and Midwifery Regulations and two Guidelines authorizedin January 2008, the Project or ganized dissemination meeting at the three locations to explain the contents of Regulations andGuidelines to participants of all the provinces.

In addition, taking opportunities of visit to health facilities, the Project checkthe distribution and utilization status of Regulations and Guidelines and explain the contents of them to those at health facilities.
The Project is planning to have dissemination meeting for Guidelines for Scope of Midwifery Practice from December 2009 to
February 2010. According to interview, Regulations and Guidelines are utilized by nurses as reference at PHS and PH andincorporated in curriculum at P HS at Champas ak and Vientiane Province. Th rough enacting Regulations and Guidelines,
nurses feel that roles and functions of nurses were made clear, nursing was organized, and nursing work is recognized better
than before.

Some interviewed mentioned that a part of other health workers including medical doctors understand the roles

and functions of nurses better th an before, while others commented doctors do not understand the Regulations and Guideline,
which made it difficult for nurses to observe Regulations and Guidelines.
Capacity of nu rsing education is greatly enhanced though further strengthening is necessar y. Technical Team (TT)members improved their knowledge and skills as nursing teachers, they are now capable of teaching fundamental nursing andauthorized by MOH as fundamental nursing trainer. TT trained 109 nurses in s even provinces, and Regional trainers trainedby TT trained 100 nurses in Ch ampasak.
provinces.

A total of 209 nurses are trained and fundamental nursing is implemented in seven

According to the results of pre- and post- test of training conducted at the Project, reg ional trainers and nurses

improved their capacity. In knowledge test, the average scores of nurses are 51.3 in pre-test and 79.4 in post-test, and in skill
test of vital sign, only 20 % of them achieved expected level. The Project requests those who failed in the test to study
themselves and conducts additional test later.

Interview at Champasak also made it clear that Regiona l Trainers improved

their knowledge and skills on fundamental nursing education and they are now confident than before but many of them feel
their capacity is not sufficient yet.
institutes.

F undamental Nursing Training Guide Book was developed by TT and distributed to health

The Guide Book is the first teaching manual developed by Laos in Lao PDR. The Evaluation Team confirmed that

nurses are referring to Guide Book during their work at Champasak PH.
All nine Outputs are importan t aspects in nursing education and contributed to Project Purpose. In PDM2, distinction
between some Objectively Verifiable Indicators of Project Purpose level and Output level is not clear, which makes it a littleiii

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difficult to understand expected achievement level and the logic from Activity, Output, and Project Purpose.
(3) Efficiency
Efficiency is high. Both Lao and Japanese sides implemented planned inputs and inputs are efficiently implemented andcontributed to produce Outputs.
Japanese experts, long-term and short-term, were dispatched almost as planned, although dispatch of some exper ts wasdelayed than schedule.

Along with Japanese experts, short-term Thai experts were dispatched. Thai experts provided very

important support b ecause their experience and environment of nursing are similar to those in Lao PDR. In addition, Lao
stakeholders and Thai experts can underst and each other without much language difficulties.

One difficulty in rega rd to

dispatch of Thai experts is that Japanese experts do not have enough information of resource persons in Thailand.

Most ofThai experts were selected and invited among those that Lao stakeholders have individual contacts. Both Japanese and Thai
experts were highly committed and provide d necessary support to Lao CPs and stakeholders adequately.

JOCV assigned at

PHS and PH in Champasak facilitated the communication between Japanese experts and Champasak PHS and PH.
Lao side assigned CPs and other stakeholders to be involved in the Project based on PDM and PO.
full-time CPs of both DOP and DHC contributed a lot to implement the Project smoothly .

Assignment of two

Lao CPs and stakeholders arehighly motivated and improved their capacity during the Project.
Project Office constructed by Japanese financial support pro vided favorable working environment for the Project,
especially for regular meetings. It also served as a training venue for fundamental nursing training. M OH issued an official
letter to the current Project Office to be utilized as nursing training center.

As the building was constructed before the Project

launched activities in Component 2, the building may be a little small to accommodate many participants for certain contents ofnursing training. The Project tries to prepare the building as training center, installing beds for practice, for example, however,the building is not sufficiently equipped with models and materials for practice yet.
Provision of equipment was limited, basi cally to equipment of Project Office. The Japanese side provided Champasak
PH a small scale of practice kit comprised of simple instruments such as scissors, which was very useful for clinical practice.
School building and education equipment for practice at Champasak PHS provided by Japanese Grant Aid are well utilized andenhanced the effectiveness of training conducted at PHS.

All the equipment and instruments provided are well utilized andmaintained.
A total of sixteen personnel at MOH and Champasak PHS and PH were dispatched to CP training in Jap an.

Accordingto interview of three persons dispatched, CP training was useful as it provided opportunity to learn s ystematic nursing
education.

One of CPs dispatched to Japan left the position after training.

All the activities were implemented to produce Outputs and activities and Outputs are logically related.
(4) Impact
There is a prospect of achievement of Overall Goal in three to five years after the Project period, but not very certain at
this moment.
Dissemination of Regulations and Guidelines are in steady progress.

The Project is also planning to have a meeting forsix provinces (Oudomxai, Lu angohabang, Xiangkhoang, Khammouan, Savannakhet and Champasak) to expand the Guidance
for Clinical Practice Collaboration in April 2010.
It is necessary to expand nursing training to P HS and PH in other provinces to achieve Overall Goal.

TT has beenformulated and trained, and Regional trainers have also been trained. Six provinces other than Champasak formulated training
plan to the Project.

In the plan, 422 nurses are planned to be trained, and in Vientiane Capital, 722 nurses at four central level

hospitals are planned to be trained.

The Project is planning to dispatch TT for the training.

Each health institute is planningto bear the training cost and MOH has already secured budget for monitoring these training courses.

Specific plan to establish

nursing education program beyond fundamental nursing is expected to be discussed in near future.
One concern is Objectively Verifiable Indicators 1 of Overall Goal, employment rates of graduates from PHS and CHT(College of Health Technology), which related to adequate allocation of trained nurses.

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Several MOH officials interviewed

during evaluation pointed out that only less than 50% o f graduates of PHS c an obtain positions at MOH hea lth institutes.
According to data calculated by the Project, only about 10 % of graduates of nursing school can obtain a position as official
employment within a year.

Although some of graduates get position in pr ivate sector, including NGO, allocation of nurses inhealth institutes is precarious . Im plementation of health manpower plan for nursing/midwifer y is on e of Important
Assumptions in PDM2, which means implementation of health manpower plan is the responsibility of MOH. Therefore, it isdesirable that MOH monitor the Indicator continuously after the Project period to enhance the expectation of achievement of
Overall Goal..
One unexpected positive impact is poin ted out. During development of R egulations and Gu idelines, technical terms
became standardized as well as legal terms.

Also in Fundamental Nursing Training Guidebook, titles of each 19 subject are

indicated in bo th Lao and English, whic h may help to disseminate common concept of nursing terminology. As some of
medical and clinical terms in Lao do not h ave widely accepted clear concept, this can be said as a positive contribution.

Nonegative impact can be observed so far.
(5) Sustainability
Sustainability can be expected to a certain extent.
Sustainability in the aspect of policy is high.

In the framework of Health Strategy up to the Year of 2020, priority will be

continuously placed on health human resources development, including nurses. Training of nurses is important as a part ofhuman resources development of midwives as nursing is the basis of midwifery.
Organizational sustainability is relatively high. MOH has intention tocontinuously support nursing tr aining.

Authorization of TT will pave the way to implement activities continuously and interviewed TT members have a strong will tocontinue activities. The building of Project Office has also been authorized as Training Center. One concern is that the planon how to continue activities of Nursing Technical Support Committee (NTSC) is not clear although NTSC has been playing animportant role in establishing nursing education as a kind of advisory body.
Financial sustainability is e xpected to a certain extent.

It is not ver y certain if MOH secu res sufficient budget tocontinuously conduct training by TT. However, the Project developed the training program on fundamental n ursing which
does not require expensive inputs, considering financial sustainability. If US$200 to US$300 of training cost for one training
course can be o btained, training course can be conducted.

Currently apart from training planned in the Project, MOH isplanning to organize regional training courses with TT in three provinces (Attapu, Xekong and Salavan) in southern part andnecessary budget is requested to MOH.
Technical sustainability is m edium.

TT members are well trained and they will be able to conduct training without

technical support. The capacity of Reg ional Trainers is improved but man y of them still n eed further training to conduct
training on their own with confidence.
3-2

Factors that promoted and impeded realization of effects(1) Planning
One of contributing factors is that elements necessary to human resources dev elopment for nursing/midwifery wereincorporated in the Project design.

The Project was laun ched with activities concerning to Co mponent 1 and proceeded to

implement activities of Co mponent 2, based on the results of Component 1.

This implementation is appropriate in one sensethat the project planning can be adjusted flexibly but the project implementation was not always smooth as all the activities ofComponent 2 had to be implemented in a limited time.
(2) Implementation
One contributing factor is high commitment of both Lao and Japanese sides. Careful dissemination of Regulations andGuidelines is another contributing factor. Vast difference in k nowledge, skills, and edu cation background among regional
trainers and nurses is on e of difficulties to effectively implement training courses.
workshops and conduct monitoring to enhance the effect of training.

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The Project repeated training and3-5

Conclusion
Outputs are expected to be achieved.

Nursing and Midwifery Regulations and three related Guidelines are developed,

authorized, and being disseminated on a nation-wide scale.

Regulations are utilized as a basic norm of nursing/midwifery andGuidelines are also being used at PHS and health facilities as a reference of education and nursing. For fundamental nursing
training program, activities of NTSC have been implemented effectively and TT has been trained and condu cting training.
Nursing education system is gradually being established through activities in model province.
As Project Purpose is likely to be achieved, the Project is going to be terminated as was ini tially planned.

Some issues

still can be pointed out. For example, revision plan of Guidelines is not clear, activity plan of NTSC after the Project is not
fully discussed, and some of Regional trainers do not have enough capacity. To fully achieve Project Purpose an d to enhancesustainability of the Project, it is necessary to address these remaining issues toward the end of the Project.
3-6

Recommendations

Recommendations toward the end of the Project-

MOH should develop a clear activity plan and implementation system of NTSC after the Project.

-

MOH should also develop a clear activity plan of TT.

-

To facilitate activities of NTSC and TT, MOH should take m easures to have NT SC and TT recognized as organizations
under Human Resources Health Technical Working Group (HRH-TWG).

-

MOH and the Pr oject should dispatch TT to provide technical support to Regional trainers who received training courses
but do not have enough teaching capacity.

-

MOH should conduct monitoring for training in provinces other than Champasak-

MOH and the P roject should promote dissemination of R egulations and Guidelines developed by the Pr oject to related
institutes and health facilities under MOH.

The Regulations and Guidelines are; Nursing and Midwifery Regulations,

Guidelines for the Scope of the Nursing Practice, Nursing/Midwifery School Management and Implementation Guidelines,
and Guidelines for Scope of Midwifery Practice.
-

MOH should disseminate R egulations and Guidelines to health workers other than nurses, in cluding medical d octors.

-

To have nursing education s ystem and re sources developed by the Project to be continuously utilized after the Project,

Directors of hospital should provide explanation of Regulations and Guidelines to medical doctors.
MOH, with support of the Project, should continuously provide presentations in regard to the results of Project activities
and nursing edu cation system, including materials, developed by the Project to related departments of MOH and other
Development Partners through sector-wide coordination mechanism such as HRH-TWG meeting. The Project should
also present the achievements of the Project in other events to related departments and health institutes of MOH.
-

JICA should consider provision of equipment for nursing training such as simulators and mannequins for the Project.

Incase the pro curement of equipment is not eno ugh, MOH sho uld develop a p rocedure to allow the Project to borrow
equipment from teaching hospitals of MOH to facilitate nursing training.
-

Project should consider the possibility of conducting fundamental nursing training in northern provinces.

Recommendations after the Project period-

MOH should continuousl y support and utilize nursing education system developed by the Project for future humanresources development plan.

Nursing education system includes the organization and activities of NTSC and TT, training

methods, school data mana gement at PHS, co llaboration system between PHS and PH so that school andhospitalcollaboration can be adapted to areas other than fundamental nursing.
-

MOH should ut ilize materials developed by the Project for other human resources development plan at MOH, whenapplicable. The materials include Regulations and Guidelines, Guidance for Clinical Practice Collaboration, Fundamental
Nursing Training Guide Book, DVD for nursing training.

MOH should utilize know-how and experiences acquired in theprocess of developing those materials for future activities at MOH.
-

MOH should revise Regulations, Guidelines, and Guide Book when necessary.

-

MOH should implement th e National Polic y on Human R esources for Health and Strategic Plan (2009-2020 ), which

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includes allocation plan of trained nurses to health facilities.
-

Based on the Decree (No. 199/ MOH 02 Feb. 2 009), MOH sho uld utilize the current Project Office as nursing training
center after the Project.

3-7 Lessons Learned-

Dispatch of competent Thai experts was effective as the experiences and environment of nursing are similar to those in
Lao PDR. Besides Thai and Lao people can communicate without much language difficulties. It is effective to dispatch
third-country expert with similar experiences and language.

For smooth dispatch of third-c ountry expert, it is desirable

that JICA regional office and J ICA headquarter prepare a list of resource perso ns in c ountries neighboring CP country
based on the information from the Project.
-

TT members were app ointed by Decree to d evelop and conduct nursing education program during the Project.

In

September 2009, by another Decree (No. 1468/MOH, 8 Sep 09), TT members were authorized as fundamental nursing
trainer (Central). As in TT in this Project, it is important that CP organization takes measures to authorize organizationand members trained by project to enhance sustainability of activities after the Project period.
-

In dissemination of m aterials such as regul ations, guidelines, and t eaching guidebooks, it is important to grasp the
distribution and installation status at actual facilities and to inform the contents of materials, instead of just distributing
them. Organizing meetings to confirm distribution and to inform the contents of the materials may be one solution for
effective dissemination.

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