Ex-Ante Evaluation (for Japanese ODA Loan)
South Asia Division 1, South Asia Department
Japan International Cooperation Agency
1. Name of the ProjectCountry: India
Project: Assam Health System Strengthening Project
Loan Agreement: March 31, 2022
2. Background and Necessity of the Project(1)

Current State and Issues of the Health Sector/Assam and the Priority of
the Project in India

The Government of India is pursuing policies to improve social services andachieve economic development and a balanced social development, but there
are various issues in the health sector preventing the achievement of universal
health coverage (hereinafter referred to as "UHC") where everyone has accessto health care services. The neonatal mortality rate (24 per 1,000 live births; World
Health Organization (WHO), 2017) and maternal mortality rate (113 per 100,000;
World Bank, 2017) are both significantly behind Japan (0.8 per 1,000 and 3.3 per
100,000, respectively; Ministry of Health, Labour and Welfare, 2021) and the
SDG indicator targets for 2030 (12 per 1,000 and 70 per 100,000, respectively).
India has the second largest number of cumulative COVID-19 infections in theworld, with over 35 million people infected, and the third largest number of
COVID-19 deaths in the world with over 480,000 deaths (as of January 6, 2022).
During the second wave in April and May 2021, the healthcare system collapsedin many cities due to a shortage of medical oxygen and hospital beds, exposing
the vulnerability of the healthcare system.
This vulnerability is mainly due to a lack of healthcare infrastructure, healthcare
human resources, and the management of healthcare services. The number ofhospital beds (0.9 beds per 1,000 people; Fitch, 2019) is significantly lower than
the global average (2.9 beds per 1,000 people; World Bank, 2017). The numberof doctors (0.86 doctors per 1,000 people) is also below the WHO’s standard of
ensuring at least one doctor per 1,000 people (WHO, 2018). In addition, in orderto provide appropriate medical services, it is essential to develop a management
system to effectively utilize medical resources, but India has a wide range ofchallenges, such as appropriate maintenance and management of medical
equipment, strengthening of referral systems, and efficient management ofpatient information at each hospital. In addition, India’s weak healthcare financing
1

is laid behind these challenges. Since the mid-2000s, the Government of India
has strengthened its healthcare policies several times, and increased the shareof healthcare spending to 3.4% of all government spending (World Bank, 2019),
but it remains below the average for lower middle-income countries (about 5.5%).
Assam, the target of this project, is the largest state in northeastern India interms of area (78,438 km²) and population (about 31.2 million in 2011), and yet it
falls below the national average for the country’s primary social indicators. The
state’s healthcare system is one of the most vulnerable in India and ranked thelowest among all Indian states in terms of the achievement of SDG 3 (health andwell-being for all; NITI Aayog, 2020). Basic health indicators, such as maternaland child health indicators (neonatal mortality rate (33 per 1,000 live births;
Government of India, 2015) and maternal mortality rate (215 per 100,000; World
Bank, 2017)), are also worse than India’s average.
In order to improve this situation, it is important that Assam people have access
to, at least, a minimum level of health care services. However, few can use costly
private healthcare services in this state where the poverty rate (32%) is higher
than the Indian average (22%; Government of India, 2019). Meanwhile, publichealthcare institutions handle 70.9% of all inpatient cases in the state (Ministry of
Statistics and Programme Implementation, India (MOSPI), 2018) and provide
free healthcare services to the local population. The Government of Assam set
the improvement of public healthcare services as one of the priority areas forbudget allocation and has been promoting the development of primary carefacilities and the training of medical personnel, focusing on countermeasuresagainst infectious diseases and the improvement of maternal and child health,based on the National Health Mission led by the central government. Adding to
its existing eight medical college hospitals, the government has also started
building eight new medical college hospitals with its own funds to increase thecapacity for Bachelor of Medicine and Bachelor of Surgery (MBBS) students to
1,200 and is working to expand its human resource development system. In
addition, the construction is underway for Guwahati campus of the national All
India Institute of Medical Sciences (AIIMS), a top referral hospital. Nevertheless,the system of public healthcare institutions in Assam still has the following serious
vulnerabilities.
Firstly, the medical infrastructure is inadequate. Among the eight tertiary carefacilities (medical college hospitals) in Assam, there are only two Super Specialty
Hospitals that provide highly specialized medical care and train medical2

specialists. The existing facilities have inadequate or outdated medical
equipment and do not have the capacity to cope with the increasing number ofpatients. In addition, most of the secondary care facilities have insufficient or
outdated basic facilities and equipment for diagnosis and treatment, and primarycare facilities lack the materials and equipment for basic first aid and diagnosis,
so patients are concentrated in higher medical institutions.
Secondly, there are serious issues in the doctor training system and distributionof doctors. The number of physicians in the state (0.56 per 1,000 people) is far
below the WHO standard and national average, and there are issues regarding
the expertise and quality of the physicians being trained. In Assam’s medical
education system, there are only 29 seats in specialized courses for training
highly specialized doctors in two medical colleges with highly specialized
hospitals. Most of the doctors trained in the state are generally at the basic
medical level. With the prevalence of non-infectious diseases and the demand
for advanced medical care expected to increase, the construction of a system forproviding specialized healthcare services is urgently needed. In addition, many
doctors prefer to work at large urban hospitals and private medical institutions
where there are many opportunities to acquire new skills and the facilities andequipment are relatively well equipped. As a result, a shortage of doctors at
primary and secondary care facilities in rural areas in Assam where the system
is inadequate has become the norm, with vacancy rates of 35.4% at primary carefacilities, 34.6% at secondary care facilities, and 22.7% at tertiary care facilities
in 2020 (JICA Survey Team).
Thirdly, even if a certain amount of resources, such as healthcare infrastructureand human resources, are available, there is no sufficient management system
in place to utilize them effectively. For example, medical information such as
patient medical records are not properly recorded and consolidated, hindering
their utilization. The design of patient flow lines and hygiene management
systems is also inadequate, with much room for improvement in terms ofappropriate and efficient hospital management. In addition, there are still issues
to be addressed in the patient transport and referral system, as well as in thesystematic coordination among regional hospitals regarding medical resources
such as human resources, equipment, and expertise.
In these circumstances, the residents of Assam seek at least somewhat higher
quality medical services and concentrate in tertiary care facilities in urban areas,
regardless of the severity of their symptoms, and only 21% of patients visiting3

tertiary care facilities are referred from secondary care facilities (JICA SurveyTeam). This excessive concentration of patients at tertiary care facilities hascaused problems such as delays in the provision of medical services to patientsrequiring advanced medical care.
This project tackles the above challenges by improving the quality of medical
services for the residents of the target areas in the state of Assam. It willcomprehensively promote the development of public medical institutions (mainly
secondary and tertiary care facilities that will serve as core medical centers),
boost the capacity of medical personnel, and improve the management of
medical services. It is therefore positioned as an important project in the healthsector of Assam.
(2)
Japan’s and JICA’s Policy Cooperation Policy and Operations in the
Health Sector/Assam
North East India is the area where Japan’s Free and Open Indo-Pacific foreign
policy and India’s Act East policy converge. Support for this region is therefore
critical in a diplomatic view. The Country Assistance Policy for India (March 2016)
formulated by the Government of Japan establishes the support of sustainable
and inclusive growth as a priority area and states its support for the health andsanitation sector as a part of it. Additionally, the JICA Country Analysis Paper for
India (March 2018) mentions inclusive rural growth as a major development issue
and analyzes the need for further expansion of health services to improve theliving conditions of the poor. This project is consistent with these policies andanalysis. It is also in line with some of the effort to “establish and strengthen
systems for infectious disease diagnosis and treatment” as a part of the “JICA’s
Initiative for Global Health and Medicine” supporting former Prime Minister Suga’s
speech at the United Nations General Assembly on September 25, 2020.
Furthermore, the project will contribute to the achievement of SDG 3 (ensure
healthy lives and promote well-being for all at all ages). Therefore, JICA’s support
for the implementation of the project is highly necessary.
(3)
Other Donors’ Activities
The World Bank presented a policy that emphasizes boosting healthcare
services and promoting UHC, and it approved a total of 1.42 billion USD for thehealthcare sector in India in January 2022. It is conducting a Mizoram Health
System Strengthening Project (2021 to 2026) in Mizoram and a Nagaland Health
Project (2017 to 2023) in Nagaland to strengthen regional healthcare systems,
but has not yet launched any such assistance projects in Assam.
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The WHO has set the acceleration of UHC development in India as a priority
area. It has an office in Guwahati, the largest city in Assam, and has been
providing surveillance assistance to monitor the spread of COVID-19 there.
With the continued spread of COVID-19, the Government of India announced
a COVID-19 Emergency Response and Health Systems Preparedness Package
as a roughly 2 billion USD healthcare sector policy, and the World Bank and the
Asian Development Bank (ADB) have pledged 1 billion USD and 500 million USD,
respectively, towards the package.
3. Project Description
Project Objective(1)

The objective of the Project is to improve the quality of medical services for the
residents of the target areas in the state of Assam by comprehensively promoting
the development of public medical institutions, mainly secondary and tertiary
medical facilities that will serve as core medical centers, the capacity
development of medical personnel, and improvement of the management of
medical services, thereby contributing to achieve UHC in the state.
(2)
Project Site/Target Area
State of Assam (Population: approximately 31.20 million (2011))(3)
Project Components
i.

ii.

(4)

Development of medical care facilities (construction of new buildings(advanced specialized hospitals) and upgrading of medical equipment
at existing tertiary care facilities; construction of new buildings andupgrading of medical equipment at existing secondary care facilities;
and upgrading of medical equipment at primary medical facilities thatcan serve as a model)
Consulting services ((1) Bidding assistance, equipment procurement
and work supervision, assistance with environmental and social
considerations and other related activities, (2) Formulation of plansconcerning capacity building of medical personnel and running oftraining programs, and (3) Formulation of plans to improve themanagement of healthcare services and running of training programs)
Estimated Project Cost

58,106 million yen (Japanese ODA loan: 45,605 million yen)
(5)
Schedule
03/2022-04/2029 (86 months)
Project Completion is defined as that all package of buildings and equipment are5installed and become in use.
(6)
Project Implementation Structure1) Borrower: President of India
2) Guarantor: None
3) Executing Agencies: Health and Family Welfare Department (HFWD),
Government of Assam4) Operation and Maintenance Agency: Same as above(7) Collaboration and Sharing of Roles with Other Donors
1) Japan’s Activity: N/A
2) Other Donors’ Activity: N/A(8) Environmental and Social Consideration/Cross-Sectoral Issues/Gender
Categories1) Environmental and Social Consideration① Category: B② Reason for Categorization: The project is not located in a sensitive area,
nor has sensitive characteristics, nor falls into sensitive sectors under the
JICA guidelines for environmental and social considerations (April 2010),
and its potential adverse impacts on the environment are not likely to besignificant.
③ Environmental Permit: An Environmental Impact Assessment (EIA) reportfor this project may be required for one of the new facilities in accordancewith procedures in India. The state’s Environment Impact Assessment
Authority will decide if one is needed during the specific design stage.
④ Anti-Pollution Measures: Dust control measures with water sprinkling,
limitations on construction vehicle speed, and other mitigation measures
will be taken to ensure that the air quality, water quality, noise, vibrations,and waste levels meet India’s emission standards during the work. Afterthe commencement of services, medical wastewater will be treated at
wastewater treatment facilities and waste liquid treatment facilities
implemented as units by each facility, and the wastewater and waste liquid
will be released into the regular sewer system after detoxification. Waste
from medical facilities will be separated and stored according to laws andregulations, collected by a designated contractor, and treated at a medical
waste disposal site designated by the Government of Assam.
⑤ Natural Environment: Target sites for the project do not correspond tonational parks or other areas that are easily affected or nearby areas, andnegative effects on the natural environment are expected to be minimal.
6⑥ Social Environment: In this project, only existing hospital grounds andstate-owned land (HFWD) will be used, so no land acquisition or
involuntary resettlements will be required. A survey has been conducted
on residents living near the project site to confirm that no one has any
special oppositions to the project.
⑦ Other: Contractors will monitor air quality, water quality, noise, vibrations,waste, and other factors during construction, and the executing agencies
will monitor those factors after the commencement of services.
2) Cross-Sectoral Issues① Climate Change: N/A② Poverty Measures/Poverty Considerations: The project will contribute topoverty reduction by improving access to public medical services for thepoor.
③ Measures to Prevent Infectious Diseases Including AIDS/HIV: As aprogram to prevent the spread of COVID-19, the executing agencies
agreed to implement a list of measures (36 items) when developing andimplementing the project. This list clarifies the activities to be taken, suchas preparing communicable disease control equipment, developing thework environment including informing workers of the code of conduct,
supervising the work, and raising awareness. JICA will receive quarterly
reports of the status of execution from the executing agencies to monitor
whether attention is being given to the effects of COVID-19 and whether
the executing agencies are handling situations flexibly and appropriately
throughout the project stages. During the construction work stage, theconstruction contractor will implement HIV/AIDS prevention measures forthe construction workers.
3) Gender Category■Gender Informed (Significant) (Gender activity integration project)<Details of Activities/Reason for Categorization> In this project, the executing
agencies have agreed to install toilets, changing rooms, and separate waiting
rooms for men and women when developing the facilities to ensure women’ssafety and reflect gender needs. The executing agencies have also agreed toensure equal learning and employment opportunities and use equipment that iswell suited to women healthcare professionals in terms of needs and ease of use.
In addition, the primary care facilities that are being developed in this project will
be equipped with equipment for maternal and child health and provide related
7

services.
(9) Other Important Issues: None8

4. Targeted Outcomes(1) Quantitative Effects
Outcomes (Operation and Effect Indicators)
Indicator

Baseline(Actual value

Target (2029)[2 years after projectin 2021)completion]

No. of newly installed bed(in the new SSHs at the targeted 6
MCHs and in the targeted 4 CDHs of
Type 1) (beds)

N/A

600 （CDHs）
780 （MCHs）

Bed occupancy rate
(average of the new SSHs’ beds at
the targeted 6 MCHs and at thetargeted 4 CDHs of Type 1) (%)

N/A

70~80 （CDHs）
80~90 （MCHs）

No. of OPD patients(total of the targeted 8 MCHs and the
6 CDHs) (persons/year)

2,536,000

2,721,000

013,50015,07016,171

N/A

3,180

N/A

1,960

No. of angiography (tests and/or
catheter interventions)(total of the new SSHs at the targeted
6 MCHs) (times/year)
No. of delivery (including normaldelivery and LSCS)(total of the targeted 6 CDHs)(times/year)
Cumulative total No. of medical staff
who have participated in the
training(s) related to patient-centeredcare, improved internship program
and refresher training(s) (persons)
Cumulative total No. of staff who haveparticipated in the training(s) andactivities of 5S-KAIZEN and Total
Quality Management (TQM),
training(s) on eHospital andManagement Information System
9(MIS) management (persons)
Cumulative total No. of trainers to be
trained regarding strengtheningreferral system and promotion ofhealth awareness of local residents to

N/A

246

change their medical behavior(persons)(2) Qualitative Effects
Reduction in the number of outpatients seeking primary health care1 at tertiarycare facilities, enhancement of the inter-hospital referral system, training of highquality healthcare personnel, increase in patient satisfaction with healthcare
services, improvement in the health of local residents, and reduction in poverty
through the increased participation in economic activities achieved with improved
health(3) Internal Rate of Return
Based on the assumptions listed below, the economic internal rate of return(EIRR) for the project is 23.1%. Financial Internal Rate of Return (FIRR) is not
calculated since many medical services are provided free of charge at the public
medical institutions covered by this project.
[EIRR]
Costs: Project, and operation and maintenance costs (excluding tax and duties)
Benefit: Saving the medical expense by patients that would be required at private
hospitals if not for the project; economic benefits of participating in economic
activities by improving the health of residents; reducing the travel andaccommodation costs for hospital visits through the improvement of nearby
medical facilities.
Project Life: 36 years
5. External Factors and Risk Controls(1)(2)

Preconditions: None
External Factors: Public order in the target areas does not worsen
significantly.

6. Lessons Learned from Past Projects

10From the ex-post evaluation of the “Rural Health Infrastructure Strengthening
Project” for Thailand (evaluated in fiscal 2005), the lessons were learned thatthe capacity of the medical institutions receiving assistance varies in projects
that assist in upgrading equipment at numerous medical institutions. It istherefore effective to boost the capacity of hospital management so that theequipment being upgraded can be utilized effectively. Also, the medical
equipment should be selected after thoroughly examining the capacity of
hospital staff for maintenance and management and the maintenance andmanagement budget.
Part of the current project will also involve training to enhance hospital
operation and management capacity. Also, to ensure the upgraded hospital
equipment is used effectively, the capacity of users of the medical institutions
where equipment is being upgraded will be thoroughly assessed, and thecapacity required for the appropriate operation, maintenance, management
methods will be strengthened as a project component. When selecting equipment,
the maintenance and management budget allocation will be examined to ensure
the right equipment is selected.
7. Evaluation Results
This project is suitable for the development issues and development policies ofIndia, as well as the assistance policies and analyses of Japan and JICA. The
objective of the project is to improve the quality of medical services for the
residents of the target areas in the state of Assam by comprehensively promoting
the development of public medical institutions (mainly secondary and tertiary carefacilities that will serve as core medical centers), the capacity development of
medical personnel, and the improvement of the management of medical services.
Moreover, it will contribute to the achievement of SDG 3 (ensure healthy lives andpromote well-being for all at all ages). Therefore, JICA’s support for the
implementation of the project is highly necessary.
8. Plan for Future Evaluation(1) Indicators to be used
As indicated in Section 4.
(2) Future Evaluation Schedule
Ex-post evaluation: 2 years after project completion11