Japan’s contribution through ODA to the Health MDGs in Asia and the Pacific Lessons Learned from the Good Practices Submitted at the High Level Forum on Health MDGs in Asia and the Pacific 21-22 June 2005 in Tokyo 1. Development of a sound policy and guidelines under the strong ownership of each government is critical to make health system function effectively, with the support of donor agencies when necessary. Indonesia: Project for Strengthening District Health System in Sulawesi (L/A＊ FY1996) In Indonesia, the policy and guidelines pertaining to safe blood supply (including inspection criteria and operation/maintenance standards for machinery and equipment) are weakly implemented. In particular, among several organizations engaged in blood supply such as the central government, regional governments and NGOs, there is no clear division of roles or strong ownership, resulting in fragmented blood supply operation. The project adopts an approach to improve and strengthen the blood supply system by constructing a blood center/blood bank, installing machinery and materials, and providing training programs for blood laboratory technicians and doctors in the Sulawesi region. In addition, a Japan provided support for formulating policy and legislation to upscale this effort to the national level. Sri Lanka: Master Plan Study for Strengthening Health System (2002-2003) The aim of the study was to prepare a Master Plan for improving comprehensive health service delivery and management system, through intensive collaboration between Japanese consultants and Sri Lankan partners of the Ministry of Health, Nutrition and Welfare. Throughout the process, due attention was paid to cJICA ＊ L/A= Loan Agreement 1 promote the sense of ownership and build capacity of the Sri Lankan partners. The effort to promote the local ownership is embodied in the fact that the Master Plan was largely written by the Sri Lankan partners, who are now engaged in adopting the plan as a national health sector plan for implementation. The strategy and the priority interventions proposed in the Master Plan over the next five years was widely accepted by various stakeholders including other donors, as a result of regular and close consultation during the formulation process. For example, the Master Plan served to give clear directions to project design by the World Bank and JBIC (Japan Bank for International Cooperation). 2. An integrated approach combining interventions addressing different aspects of the health system such as health facilities, medical supplies and institutional and human resource development is essential to produce maximum and sustainable results. Cambodia: Improvement of Maternal and Child Health Through Capacity Development of National Maternal and Child Health Center (1995-2000, 2000-2005） In order to improve maternal and child health (MCH) status in Cambodia, Japan has been working closely with Ministry of Health (MoH), particularly with National Maternal and Child Health Center (NMCHC), for more than ten years. An integrated approach was adopted to promote safe motherhood through a variety of measures including (i) construction of the new building for the NMCHC, (ii) provision of medical equipment, (iii) improvement of management capacity of NMCHC, (iv) strengthening of training and clinical care activities at NMCHC, (v) improvement of human resource development at the community level through training at NMCHC and (vi) revitalization of existing community health resources such as traditional birth attendants. The grass-root level activities including community awareness raising were also implemented in cooperation with local NGOs. As a result, the coverage of antenatal care and the availability of skilled birth attendants at delivery points were improved at the community level. At the top referral level, an increased number of pregnant women suffering complications have been able to benefit from Cesarean Sections according to the statistics. It was proved that such a comprehensive and balanced approach linking multiple levels is effective in producing the maximum results and long-term sustainability. Vietnam: Integrated Interventions To Strengthen Health System (since 1995- ) Widening regional disparity in quality of and access to health care services has emerged as a major issue in Vietnam, mainly due to insufficient regional health administration capacities and dysfunctional referral system. Japan has extended integrated support to two national center hospitals in Vietnam, namely, Cho Ray Hospital in the Southern Region and Bach Mai Hospital in the Northern Region to help address these challenges. The assistance combined human resource development with construction of hospitals and procurement of medical equipment. The medical staff of the provincial hospitals has received training conducted at the national center hospitals using DOHA (Direction Office of Healthcare cJICA MCH Project 2 Activities) system, through which a unit has been established in each higher-level health facility to manage training for staff of lower-level health facilities. Japan’s assistance to these two national hospitals contributed to not only the improved skills and knowledge of the health personnel but also strengthened DOHA system. Furthermore, Japan has recently conducted a study to formulate a loan that supports the development of a regional hospital and human resource development, to further strengthen the referral system and promote the sustainability of the project impacts. 3. Strengthening referral system through human resource development with high quality at multiple levels is critical for development of the overall health system. Philippines: Quality Tuberculosis Control Project (2002-2007) Japan has been supporting the Philippines’ effort to control TB under its National Tuberculosis Program since 1992. The first phase of the project assisted in testing the feasibility of the newly developed policies and guidelines on DOTS (Directly Observed Treatment, Short-Course) in a model province, together with the provision of training for laboratory technologists, TB coordinators and nurses to start quality DOTS service. The regional reference laboratory was also established to assure quality of smear microscopy in the targeted province. The success made in the model province was followed by the effort to expand the DOTS system nation-wide under the phase two of the project. Also the quality of DOTS practices have been promoted through capacity building of the health human resources, conduct of operational research on maintaining the quality of services, and establishment of laboratory network. As a result, the project has achieved the targets of DOTS (detect 70% TB patients while cure 85% of them) in the targeted provinces and successfully developed nation-wide quality assurance system. By the end of the current project period of 2007, the quality of DOTS is expected to be further improved to contribute to 2010 national target of decreasing the number of TB patient by 50%. Sri Lanka: Project for the Improvement of National Blood Transfusion Services (L/A FY2001) Sri Lanka’s current blood supply and its related services face a challenge to meet the demand in terms of timing, location and volume. In order to address this challenge, Japan has been supporting to develop a system that ensures effective supply of safe blood, by strengthening the health administration and referral systems, thus improving the quality of health services. The emphasis has been placed on the provision of quality training and education of health personnel according to the international standards, which has been conducted in cooperation with WHO. The project is also expected to help advance infectious disease control through the enhancement of blood testing capacity. Furthermore, the project is expected to help control hemorrhage at childbirth, one of the risk factors of maternity death, by supplying safe transfusion blood and upgrading clinical transfusion technology, thereby serving to reduce maternal mortality in Sri Lanka. cJapan International Cooperation Bank (JBIC) 3 . 1. A cross-sectoral or a multi-sectoral approach combining health, nutrition, education, agriculture and infrastructure is proven to be highly effective in achieving health MDGs. Bangladesh: Greater Faridpur Rural Infrastructure Development Project (L/A FY2000) The project supports comprehensive rural development by rehabilitating roads, sanitation facilities, and strengthening capacity of administration personnel, thereby contributing to the improvement of health conditions among the targeted population. The Philippines: Mindanao Sustainable Settlement Area Development Project (L/A FY2001) The project aims at reducing poverty among the farm households living in settlements in Mindanao, through a comprehensive support combining various interventions including developing basic infrastructure for agricultural production, social infrastructure development, support services for farm management, and education and health services. Health services include construction or improvement of community health posts as well as the provision of medical supplies. These comprehensive efforts are expected to not only eradicate hunger and reduce poverty in Mindanao but also contribute to the improved health status of the residents in a sustainable manner. The Philippines: Autonomous Region in Muslim Mindanao Social Fund for Peace and Development Project (L/A FY2002) The project, co-financed with the World Bank and the Canadian International Development Agency, aims to reduce poverty, which could become a spawning ground for conflict, thereby consolidating peace and stability in the Autonomous Region of Muslim Mindanao where poverty is increasing and deepening. The project supports community-led efforts to develop small-scale infrastructure development including road repair works and community centre construction, to help community residents to have better access to healthcare facilities, safe drinking water and sanitary toilets. Community development programs include education, health care, water and sanitation projects. Women, widows in particular, are strongly encouraged to participate in the planning and implementation process. cJapan International Cooperation Bank (JBIC) cJapan International Cooperation Bank (JBIC) 4 Thailand: Asian Center of International Parasite Control Project (2000-2005) In order to combat soil-transmitted helminthiasis and malaria, school-based projects have been implemented in two model provinces in Thailand with support from ACIPAC (Asian Center of International Parasite Control), which was established and supported by Japan to promote school-based de-worming programs modeled after Japan’s postwar parasite control experience. The project has been successful in not only improving children’s knowledge and awareness about the disease and hygiene but also in improving the overall standard of hygiene of the communities as the effects of the children’s health education indirectly extend to their parents and eventually to the whole community. The concerted efforts and improved coordination of Ministry of Health and Ministry of Education at multiple levels was an important factor for its success. 2. Incorporating components addressing health issues in projects that are not directly related to the health sector such as infrastructure is an effective way to improve health indicators and avoid any adverse effects on health. India: Incorporating anti-malaria interventions in Rengali Irrigation Project (L/A FY2003) The primary objective of the project is to increase agricultural yields and improve farmers through a construction of irrigation facilities feeding an area of approximately 30,000 hectares in the Brahmani River. Located in a malaria high-risk area, the project collaborated with the State Health Department to prevent malaria infection through measures such as provision of insecticide-treated nets, malaria testing, and capacity building for community involvement, so as to prevent an increase in malaria infection rate as a result of the newly constructed irrigation facilities. The Philippines: Incorporating anti-schistosomiasis intervention in Catubig Agricultural Advancement Project (L/A FY2001) The project supports the development of agricultural infrastructure, irrigation facilities in particular, to improve farmers’ livelihoods. In order to combat schistosomiasis expected to increase as a result of poor drainage, the project incorporated various preventive interventions such as improvement of drainage and public toilets, as well as awareness-raising activities. Thailand and Laos: Incorporation of HIV peer education activities in Second Mekong International Bridge Construction Project (L/A FY2001) A concern was raised that the project to construct Second Mekong International Bridge connecting Laos and Thailand would increase the various social risks including the spread of HIV and other sexually transmitted infections (STIs), as a result of sudden and massive influx of migration workers who would stay away from their families. There was also concern that entertainment and sex industry would rush to the construction site to enjoy brisk business targeting these migrated construction workers. To deal with such a risk, HIV/STI cJapan International Cooperation Bank (JBIC) 5 prevention programs were conducted with the fund from the IPPF Japan Trust Fund for HIV/AIDS, prior to and during the bridge construction project financed by Japan (JBIC). The AIDS prevention program included the provision of peer education and “Edutainment” (combining education and entertainment), delivery of condoms, counseling and testing for HIV for mobile construction workers and the surrounding communities. Also, gender perspectives were well incorporated throughout the planning and implementation of these activities. (Note) Other projects that incorporated the HIV/AIDS prevention components in port construction project include “the Sihanoukville Port Urgent Rehabilitation Project in Cambodia” (L/A FY1999). 3. Transport infrastructure is essential for ensuring access to health services in terms of both supply (provision of quality health services / supplies) and demand (user’s accessibility to such services). Impact Study of Road Development on Maternal Health in Indonesia (Thematic Evaluation conducted by JBIC, 2004) When planning road construction project, Japan carefully considers the expected project impact on the access to health facilities, since it recognizes that broader-based infrastructure development projects have an important role to play in achieving the health-related MDGs. A post-evaluation study on rural roads projects in Indonesia evaluated the impact of road development on the health status of pregnant women and safe birth. Sample interviews covering approximately 200 women suggested that improved access by paved roads greatly contributed to increasing the number of pregnant women who use antenatal care facilities. The study suggested that the paved roads lead to less travel time and cost for pregnant women who seek antenatal care. cJapan International Cooperation Bank (JBIC) 6 1. Placing economic growth at the heart of the overall development policy is essential to ensure sufficient and sustainable finance needed to realize health MDGs. Vietnam: Poverty Reduction Support Credit (PRSC) (L/A FY2004) PRSC for Vietnam, co-financed with the World Bank, supports (i)private sector reforms and infrastructure development to help complete the transition to the market economy; (ii)social sector development including health, education, water and environment; and (iii)financial management of the public sector to strengthen governance. Placing economic growth as an overall objective PRSC in Vietnam is expected to produce long-term finance, which is imperative to realize poverty reduction and health MDGs in a sustainable and self-help manner. Under the healthcare component of the PRSC, a fund has been made available for the “Health Care Fund for the Poor”, targeting selected populations in all 64 provinces. Thus, PRSC is also expected to improve an access to quality health care and medical services by the poor. 2. Promoting and strengthening support for South-South Cooperation is an effective way of sharing good practices and know-how among developing countries faced with similar challenges and should be supported by donor countries. (Note) The effectiveness of South-South Cooperation is also relevant for discussion in Session 3. Thailand: Asian Center of International Parasite Control Project (2000-2005) The Asian Center of International Parasite Control (ACIPAC) was established in Thailand in 2000, under the cooperation of the Governments of Thailand and Japan as a part of the Hashimoto Initiative to promote global efforts on parasite control. The center has supported other neighboring countries such as Cambodia, Laos, Myanmar, and Vietnam, in their efforts to promote school-based de-worming and health care. The center has been serving as an important hub for information/research and human resource development in the region through a wide range of activities including regional training, field visits, conduct of pilot projects and establishment of information network. The activities are already showing positive impacts, e.g. a significant reduction in parasitic infections among the children at Cambodia’s pilot project site. ACIPAC has also started establishing network with its African counterparts, namely the Eastern and Southern Africa Centre of International Parasite Control (ESACIPAC) and the West African Centre for International Parasite Control (WACIPAC). Thailand: HIV/AIDS Regional Coordination Center Project（2005-2008） Japan supports Thailand’s efforts to share its advanced experiences in controlling the spread of HIV/AIDS with its neighboring countries in the region, through assistance to the ASEAN Institute for Health Development (AIHD) that was established within the Mahidol 7 University in Thailand in 2004. The AIHD has been facilitating human resources development, sharing of information and experiences, and networking among the member countries, with an aim to reduce and minimize new HIV infection and to improve the quality life of people living with HIV/AIDS in the region. It is expected that the RCC will effectively make use of the Thailand’s abundant knowledge and experiences on HIV/AIDS control in such an area as youth education, voluntary, counseling and testing services (VCT), treatment of HIV/AIDS and other opportunistic diseases, while training modules for each country are developed carefully to reflect each country’s specific needs and situations. 3. Building partnerships among various stakeholders at the community, national and international levels is important for mobilizing resources and increasing effectiveness. Bangladesh: Debt relief for health care (FY2003) In Bangladesh, donors including Japan are joining efforts to support the country’s Health, Nutrition, and Population Sector Program (HNPSP). A budget pool for the sector has been set aside for an integrated, programmatic investment under HNPSP. Contribution to the pooled fund includes allocation from the Japan Debt Cancellation Fund. This financial resource was made available through the decision of the Japanese Government to cancel debts of Bangladesh owed to Japan. Cambodia: Tuberculosis Control Project (1999-2004, 2004-2009) Efforts to combat Tuberculosis, the most serious communicable diseases in Cambodia, are progressing thanks to efforts of different stakeholders under the coordination of the Cambodian Government with support from Japan. Japan has assisted Cambodia’s National Tuberculosis Control program since 1999 and strived to expand DOTS (Direct Observed Treatment Short-course, known as the global standard of TB control) to various levels, in order to improve the accessibility by people to TB-cure-services. Japan’s assistance includes (i) construction of the National Tuberculosis Control Center; (ii) provision of equipment and materials such as Micro-scopes and Anti-TB drugs; and (iii) improvement of management capacity of National Tuberculosis Program. Furthermore, Japan has been facilitating donor coordination, which resulted in an increased support to NTP by different donors. Such support includes technical assistance by WHO, IEC development and community based TB control by USAID, food provision to TB patients by WFP and provision of anti-TB drugs for urgent needs by the Global Drug Facility. Thanks to the coordinated efforts under NTP, TB burden is gradually decreasing. In fact, the number of cured TB patients increased to 30,000 in 2004, as opposed to 15,000 in 1999. cJICA/Kosuke Okada 8 Indonesia: Promotion of MCH handbooks to improve maternal and child health (1998-2003) Japan assisted the Government of Indonesia with the development and utilization of Maternal and Child Health (MCH) handbooks to improve the MCH status in the country, based on its own experience of using MCH handbooks that contributed to a rapid improvement of MCH status in post-war Japan. Through the project, the communication between health personnel and mothers was greatly improved, which lead to the improvement in the quality of MCH services as well as in mother’s knowledge and behavior towards child care and health. The success attracted much attention from not only Indonesian Government but also other donor institutions such as World Bank, Asian Development Bank, UNICEF, and UNFPA, which started adopting MCH handbook in their activities. Utilization of MCH handbooks expanded gradually to the other provinces, with several local governments allocating their own budget to the printing of the handbooks to improve the MCH services. Today, with support from not only Japan but a number of other stake holders including local governments, other donors, international organizations and NGOs, Indonesia’s government implements its own MCH handbook project in more than 26 provinces. cJICA 9 1. An approach based on human security, which takes the perspective of individual security and emphasizes protection from threats and empowering the people, is important in addressing disparity. China: Strengthen public health services to fight against infectious diseases (L/A FY2003) The outbreak of Severe Acute Respiratory Syndrome (SARS) in China revealed the weakness of the public health system especially in inland provinces which are relatively vulnerable to epidemic of communicable diseases. The project strengthens health strategies and system against communicable diseases, provides medical equipments for laboratories and communicable diseases control center (CDC), and supports capacity building of public health personnel in 10 inland provinces (e.g. Henan Province, Hubei Province). It is expected that risk vulnerability will be reduced and they will be able to take appropriate measures to prevent the outbreak of infectious diseases like SARS. Sri Lanka: Small-Scale Infrastructure Rehabilitation in multi-sectors (L/A FY2004) This is an example of multi-sector approach to improve socio-economic situation in rural poor to ensure their human security. Nation-wide small-scale infrastructure rehabilitation in education, health and rural agriculture sector improves universal access to education and health services for the poor. It is expected that rehabilitation of medical facilities, laboratories, operating rooms, procurement of medical equipment together with water supply systems and wiring systems will raise the living standard of the poor and improve general socio-economic situation of the communities. That would augment household income for health services. Thailand: Comprehensive HIV/AIDS prevention and care through empowerment of communities including people living with HIV/AIDS (PHA)（1998-2003） The project, implemented in the northern region in which HIV/AIDS situation was particularly serious, adopts an approach to empower PHA, their families and communities to cope with HIV/AIDS through comprehensive care and services including counseling, treatment of opportunistic diseases, establishment of community volunteer care networks and income generation activities, in addition to capacity building of health sector personnel and improvement of quality of health services at the decentralized levels. In this project, PHA are regarded as not only beneficiaries but also as agents who can take an active role in preventing and combating against AIDS through the community care networks. As a result, the quality of life of PHA was improved and HIV transmission from PHA was prevented. The project contributed to the dramatic decline in HIV infection rate in the region from 10.6 % in 1994 to 2.3 % in 2001. cJapan International Cooperation Bank (JBIC) cJapan International Cooperation Bank (JBIC) 10 2. Identifying and addressing various types of disparities, not only social disparity including gender but also geographical, urban-rural and economic disparity, is an effective approach towards realizing equity. China: Tuberculosis control outreach program to challenge regional disparity (2000- ) Chinese Ministry of Health aims to reduce the number of the TB patients by half by 2010 in collaboration with WHO, WB, NGOs and bi-lateral donors including Japan. The challenge is to improve regional disparity in terms of access to health services. This program focuses on the rural areas where people have difficulties to access to TB treatment on a regular basis, such as 9 provinces in extreme poverty and 3 autonomous regions such as Tibet, Inner Mongolia. As a result of this program, 90% of the population should have access to TB treatment by 2005, in other words, 220,000 TB patients will benefit from DOTS. This will prevent further transmission of TB and mitigate the financial burden of the patients’ families. Indonesia: Providing higher-level medical education to the rural poor to increase medical personnel in rural areas (L/A FY2004) In Indonesia, shortage of medical personnel and skewed regional distribution of higher education has resulted in urban-rural disparity in terms of access to qualified medical personnel. This project aims to provide the rural poor with equal opportunities for higher-level medical education and training including scholarship program at the Faculty of Medicine and Health Sciences of Syarif Hidayatullah State Islamic University in order to train medical personnel who will be engaged in basic health services in rural areas of their home provinces. Pacific Region: Strengthening EPI in the Pacific Region to reach each island (2005-2010) EPI (Expanded Program on Immunization) in 13 countries/areas in the Pacific region aims to improve the quality of EPI services and to reach out to the people in the islands. The project supports 13 governments to develop the national "Reach Each Island" guidelines for outreach activities in line with the "Global Reach Every District" strategy set by WHO. This guidelines helps them to identify the additional outreach activities and develop action plans. In addition to those activities, the project also provides relevant health personnel in outer island with technical training on cold chain and vaccine management to carry the vaccines to the islands in good condition. It is expected that the immunization rate will be increased by strengthening those outreach activities. cJapan International Cooperation Bank (JBIC) cJICA 11 Philippines: Autonomous Region of Muslim Mindanao Social Fund for Peace and Development Project in（L/A FY2003） This Project supports local community-led small infrastructure development in the Autonomous Region in Muslim Mindanao (ARMM) where legacies of the conflict increased and exacerbated poverty. The southern Mindanao experienced a localized armed conflict for more than 30 years until the peace agreement was signed in 1996. It is one of the poorest regions in the Philippines today. Being in post-conflict society, women often found themselves in a difficult position psychologically, economically and socially. Therefore, reconstruction process needs to incorporate gender perspective. Even in planning process and at implementation of small infrastructure development, special attention was paid to the involvement of widows who lost their spouses in the conflict. Women are involved in making specific plans in the ARMM, which include local community-led small infrastructure development (repairing / building health posts (clinics) and improving / increasing medical equipment) and community development (public health training). It is expected to improve access to health facilities, drinking water and hygienic toilets. Vietnam: Working with Primary Care Providers and Women’ Volunteers for the Reproductive Health in the Rural and Mountainous Area (FY1997-2000, 2000-2005) Reproductive Health Project started in 1997 with an objective to improve the Reproductive Health (RH) services in Nghe An Province, one of the poorest and rural provinces in Vietnam. The phase I was conducted in the 8 target districts of the 19 districts of the Province and made considerable achievements in Safe Motherhood. Aiming for further progress, target areas were expanded to all 19 districts of the Province, including the mountainous area, where ethnic minorities are concentrated and MCH indicators are relatively poor. As a strategy for strengthening RH in the mountainous area, the project introduced refresher training for hamlet health workers, who can provide primary health care in the area. Another remarkable characteristic of the project is the partnership with Women’s Unions, which are the community-based voluntary organizations lead by women and mothers. Under this partnership, many community-based MCH promotion activities such as “Aiiku-han” were organized. “Aiiku-han (meaning raising a family with love and care in Japanese)”, which was originated in Japan, is one of the women’s unions which is composed of trained volunteers. They visited all the households in the community in order to improve maternal and child health. As a result of this partnership, the ownership of the project by those mothers who participated in Women’s Union was generated and safe motherhood in the community was improved. cJICA/Mayumi Katsube 12 3. Establishing social safety net through health financing schemes (community based insurance, social funds) is an effective way to enhance the access to health service for the vulnerable and the poor. Cambodia: Innovative health care financing for the poor through the “Equity Fund” (2004) ADB Japan Fund for Poverty Reduction financed by the Government of Japan supports an equity fund in Cambodia to provide financial support for the health expenses of the poor and vulnerable populations, through the provision of targeted, demand-side subsidies. It will cover medical expenses for major health emergencies, such as road accidents, obstetric interventions, and debilitating illnesses, for the poor in 10 health operational districts where the ADB-backed Health Sector Support project is providing assistance. A non governmental organization will be contracted to pre-identify the poor and ethnic minorities to receive coverage based on local definitions of what constitutes poverty and vulnerability. In areas with a high population of ethnic minorities, entire communities will be covered. Those identified will be given a health card that will allow them to receive support from the equity fund when they seek the health care. The project, Cambodia's first multi-district equity fund, builds on the experience of a number of ongoing small-scale pilots, which address the problem of government subsidies not reaching the poor. The project is expected to ensure that subsidies reach the poor directly and reduce the risk of further impoverishment due to health care emergencies. Vietnam: Poverty Reduction Support Credit (PRSC) (L/A FY2004) PRSC is a program loan for structural adjustment to support the implementation of the Poverty Reduction Strategy Paper (PRSP) prepared by the recipient country government. The Vietnamese version of PRSP is Comprehensive Poverty Reduction and Growth Strategy (CPRGS). In the area of healthcare, CPRGS includes the establishment and implementation of the Health Care Fund for the Poor (HCFP) in all the 64 provinces. The HCFPs, directly targeting the poor, is expected to make funding available for health services to the poor. Nearly 37 percent of the target beneficiaries are located in the Northern Mountains region. 13