Independent Evaluation

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Evaluation of the Health and Population Project in the Republic of Marshall Islands
Completed: 2005

The Health and Population Project in the Republic of the Marshall Islands (RMI) was the first ADB intervention for the health sector in RMI, which at that time, was confronted with financially unsustainable dependence on overseas medical referrals and rising prevalence of infectious, parasitic, and chronic diseases; teenage pregnancy; and infant and child malnutrition.

This Project aimed to support the Government to shift the emphasis of health service provision from expensive curative services to preventive services based on a primary health care (PHC) approach. It provided for the organizational management support for PHC, training of health personnel in PHC services, and for construction of 26 outer island health centers.

The Project also contained special features for community participation, women's participation, and environmental dimensions. However, evaluation results showed that the participatory, community-based model of PHC, which the project sought to promote, may have been unrealistic in view of the realities of Marshallese culture, social problems, and atoll environment.

Summary of Findings

• The Project was rated partly successful. The objectives were consistent with national social and economic needs, the Government's population policy, and ADB's health policy and country strategy for the RMI.



• Although ADB made a sincere effort to address health and population issues in the RMI, given the magnitude of the challenges, the design was based on an overoptimistic assessment of what might realistically be achieved.



• The Project lacked adequate leadership, and there were weaknesses in implementation. The performance of the consultants was variable, and the contracted consulting companies performed below expectation.



• Improved access to PHC services was partly achieved by the provision of the outer islands health centers and specialized centers on Majuro. However, most of the outer islands health centers are still delivering curative rather than PHC and preventive services. The loss of trained female health assistants reduced the effectiveness of the Project in prioritizing the health needs of women. The provision of maternal and child health care (and other key PHC services) to the outer islands still depends on the overstrained capacity of mobile public health teams sent from Majuro.



• The technical support components and provisions for health promotion and population awareness activities achieved few of the expected outcomes and impacts.



• The educational and social mobilization measures to promote PHC in the Project were not successful as they relied heavily on assumptions that the behavioral changes required to improve public health could be achieved by public education. (See detailed analysis [PDF] on why the Project did not successfully achieve its objective for promoting behaviour change for healthy lifestyle).

  Lessons Identified

• Greater efforts should have been made during project preparation to ensure the participation of key PHC personnel in the formulation of the project design to ensure ownership and sustained support by MOH for the project strategies.



• To be effective, PHC must be based on an integrated strategy to provide safe water, sanitation, waste disposal, food security and improved housing, as well as on improving the delivery of the basic elements of PHC services, especially maternal and child health care.



• Project experience demonstrates the need for different parts of ADB's country program to be coherent. ADB's lack of coordination in its country program resulted in the policy recommendations made by the Policy Advisory Team for Economic Management to MOH and to Government on reforms in the health sector conflicting with some of the project outputs on institutional strengthening.



• Maintaining physical infrastructure is expensive and difficult in the RMI due to the atoll environment, the remoteness of the country, and the distances between atolls and islands. In future projects with infrastructure components, ADB should explore the possibility of including a sinking fund for repair and maintenance, with the Government matching in the assistance package.