We analyzed the configuration of PDMs for JICA health-related projects using an analytical matrix with a link between the project PDM and the WHO’s conceptual health system framework. This study revealed the common characteristics of the JICA projects for technical assistance in health. The majority of JICA projects had prioritized assistance such as enhancement of the workforce and governance, as well as improvement of service delivery. Conversely, support for medical products and financing was modest. These findings reflect the JICA consensus statement, which emphasizes bilateral cooperation via capacity development. In particular, the JICA stresses the role of the health field in strengthening the health system, preventing and controlling infectious diseases including ATM and others, and MCH, which together accounted for 87.6% of JICA assistance. When examined in detail from the perspective of the health system, JICA projects appeared to be targeted at achieving governance, workforce and service delivery outputs through investment in activities involving the governance, workforce and information blocks. In particular, nearly 90% of the JICA technical assistance in health had directly focused on improving governance as the most crucial tactic for accomplishing its objectives.
Adam et al  reported that most health policy and system research publications have focused on human resources, service delivery and governance in low- and middle-income countries. Likewise, our results showed that the majority of JICA projects included in our analysis had contributed toward improving workforce capability and leadership, as well as governance. This implies that strengthening human resources and management functions were absolutely essential for achieving the goals of the projects . Since sustainability and autonomy are important for healthcare development, the enhancement of perpetual and autonomous management capability among the workforce is a crucial component of project activities . This underpins the rationale for JICA support for projects that strengthen management and governance through professional training and the creation of health networks [22, 23]. Additionally, the JICA has provided many opportunities for capacity development by conducting training courses offering support extending beyond project-type assistance .
Finance function is important to strengthening the health system in every nation [25–27]. Nonetheless, the majority of the JICA projects did not include activities for improving financial systems. This may simply be a consequence of lack of financial expertise among the JICA experts. While recruiting Japanese experts to participate in health-related projects, it is a common practice of the JICA to seek specialists in health and medical sciences from universities and educational and research institutes and organizations, rather than financial organizations. This restrictive recruitment process might have resulted in a paucity of finance specialists. In general, irrespective of the donor, interventions to finance organizations of recipient countries can be sensitive political matters [28, 29]. Assistance to strengthen financing systems may require not only specialists in the field, but also that they are afforded the power to make discreet and effective interventions.
We found that nearly half the projects analyzed were classified as health system strengthening; however, these projects did not comprehensively contribute to multiple health system blocks . Of 46 projects in the HS column in Table 3, workforce enhancement was the primary target for 22 and eight had focused on service delivery; only six were categorized as mixed type. These findings indicate that some projects that aimed to strengthen health systems had not always contributed to all of the building blocks. Instead, these projects focused on workforce development, service delivery and providing support to the governance block without any attention to financial aid. For example, a JICA project classified as a ‘governance only’ project that aimed to strengthen district health services in the Morogoro region of Tanzania had focused only on capacity development in the governance block within public health sector hierarchies, and on communication among vertical and horizontal health institutions. Also, a JICA project to strengthen the regional health network in Santa Cruz, Bolivia, had outputs and activities in the workforce and governance blocks to expand holistic assistance for improving the health network; however, this had been categorized as a ‘workforce’ project. Thus, many JICA projects classified as health system strengthening did not always provide input to all blocks, but instead had implemented assistance in alternative blocks such as workforce and governance.
The correspondence analyses revealed that the EPI project was associated with the medical products block. The vertical projects implemented for fields such as ATM, MCH and RH shared a close relationship with the service delivery block, while the projects for health system strengthening were also strongly related to workforce. These results match the EPI project’s primary aim to enhance procurement, storage and distribution of vaccines, consistent with categorization in the medical products block. Furthermore, vertical programs for ATM, MCH and RH mainly strove to provide universal high quality services relating to their fields. The close association between HS and workforce indicated that most of the projects under the title of health system strengthening aimed to improve workforce capability.
Our study had several limitations. Although collecting data from all available PDMs might have minimized selection bias, the process of categorization may have resulted in informational bias due to the difficulty in interpreting ambiguous and obscure descriptions contained in some of the PDMs. A second important limitation was related to confidentiality of the data source. One possible method for examining and systematically comparing the JICA projects would have been to use the PDM alone; however, there is a fundamental analytical limitation to employing the PDM in order to examine the project type, health field, characteristics and the association between outputs and activities of the project. The PDM does not necessarily include an exhaustive list of elements that the project entails, and it is quite usual for the PDM to be amended or modified during its implementation. The limited information from the PDM should be taken into account when interpreting the study findings.