Japanese ODA Loan
Ex-Ante Evaluation (for Japanese ODA Loan)
South Asia Division 4, South Asia Department
Japan International Cooperation Agency
１．Name of the Program
Country: The People’s Republic of Bangladesh
Program: COVID-19 Crisis Response Emergency Support Loan Phase 2
Loan Agreement: November 22, 2021
２．Background and Necessity of the Program(1) Current State and Issues of the Health Sector and the Priority of the Program in
Bangladesh
In Bangladesh, the first cases of infection with the novel coronavirus (COVID-19)
were confirmed in March 2020, after which the number of cases increased. As of
mid-September 2021, the cumulative number of cases was roughly 1.5 million, andthe number of deaths was roughly 27,000. Bangladesh recorded the second
largest number of infection cases in South Asia after India (World HealthOrganization (WHO), 2021). Since the government of Bangladesh instituted anationwide lockdown lasting from July 1 to August 10 of 2021, the number of newcases per day has fallen to around 2,000 as of mid-September. However, factors
such as the lack of progress in administering vaccinations throughout the country1
make it impossible to deny the possibility that the number of cases will surge again
as social activities resume after the lockdown. Accordingly, the country has anurgent need to undertake measures such as the strengthening of its virus testing
capacity to enhance infection prevention, improvement of the treatment system,and the rapid administration of vaccines. Additionally, after vaccinations areadministered, the country must monitor safety and engage in other forms of followup to implement the vaccine rollout swiftly and safely.
In addition to its national development plan titled “the Eighth Five Year Plan”(FY2020/2021 - FY2024/2025), the government of Bangladesh formulated the “4thHealth, Population and Nutrition Sector Programme” (January 2017 - June 2023)
in an effort to achieve universal health coverage (UHC) by 2030; however, there isa concern over the country’s vulnerability to COVID-19 due to the persistent issues
with securing enough medical facilities and personnel, and the quality of healthservices, as explained later in this document (World Bank, 2020). Therefore, thecountry has an urgent need to improve the health sector.
Regarding community clinics, it is important to improve access to and the qualityof these primary medical facilities for local residents; however, given that each
1 Through mid-September 2021, only 12.6% (roughly 21 million people) of the country’s population had received

their first dose of a vaccine, and only 8.4% (roughly 14 million) had been fully vaccinated (Bangladesh Ministry of
Health and Family Welfare, 2021).

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facility serves an average of roughly 6,000 to 12,000 people (Ministry of Health andFamily Welfare, 2019) and that facilities in neighboring India serve roughly 3,000
to 5,000 (Ministry of Health and Family Welfare of the government of India, 2019),
Bangladesh has not secured a sufficient number of facilities, and must constructmore clinics in order to improve access to health services. Existing community
clinics and urban clinics known as Government Outdoor Dispensaries (GODs),
which are primary medical facilities in major city centers, are also facing the issuesof facility deterioration and insufficient medical equipment (Japan International
Cooperation Agency (JICA), 2018). Additionally, there is a severe lack of medical
personnel; the number of physicians per 10,000 people in Bangladesh is 5.8, which
is lower than the average for South Asia (9.4), and the number of nurses andmidwives (4.1) is far lower than the average for South Asia (19.7) (WHO, 2018). In
urban areas, despite the urgent need for countermeasures against
noncommunicable diseases (NCDs), a risk factor of a severe case of COVID-19,
prevention and treatment have not been sufficiently implemented as a result of theinability to guarantee the quality of services due to factors such as theaforementioned lack of facilities, equipment, and medical personnel. Furthermore,
the country’s budget allocation of healthcare spending of GDP is less than 1%
every year, which is below the average for low-income countries (2.3%). This low
rate of budget allocation leads to a high percentage (roughly 74%) of out-of-pocket
healthcare expenditures (World Bank, 2018).
Under these circumstances, the government of Bangladesh expects to run deficits
of roughly 2 trillion BDT (roughly 23.5 billion USD) in both FY2020/2021 andFY2021/2022, in light of reduced incomes due to the pandemic as well as
increased expenditures on COVID-19 countermeasures and responding todevelopment issues in the health sector. The government estimates that theimplementation of COVID-19 countermeasures will require overall expenditures ofroughly 8.2 billion USD, and expects to receive funds totaling roughly 5.7 billion
USD from the World Bank, Asian Development Bank (ADB), and other donors as
explained later in this document, and will cover roughly 900 million USD with its
own funds, resulting in an envisioned gap of roughly 1.7 billion USD. Thus, thecountry faces the urgent task of securing the necessary funds.
COVID-19 Crisis Response Emergency Support Loan Phase 2 (“the Program”)
aims to realize a resilient health system through concessional financing by
supporting the smooth implementation of policies to strengthen the COVID-19
response capacity in the health sector, to enhance economic and physical accessto health services working towards the achievement of UHC, and to improve healthfinance.
(2) Japan’s and JICA’s Cooperation Policy and Operations in the Health Sector
As a cooperation policy for COVID-19, at the General Debate of the 75th session2

of the UN General Assembly in September 2020, then-Prime Minister Yoshihide
Suga indicated in his statement that Japan would make proactive efforts to help
developing countries achieve UHC in order to prepare for health crises caused by
the pandemic. In addition, JICA’s Initiative for Global Health and Medicine sets out
targets aiming to strengthen treatment systems and the prevention of infectious
diseases; targets include strengthening health service systems through thecultivation of medical personnel, disseminating COVID-19 vaccines in recipient
countries, and enhancing health protection systems. The Program will provide
concessional financing to the government of Bangladesh in support of theimplementation of pandemic policies in the health sector, and thus is aligned withthe aforementioned policy and initiative.
As a cooperation policy for the health sector, Japan’s Country Assistance Policy for
Bangladesh (February 2018) aims to contribute to the achievement of UHC by
improving the quality of health services and providing assistance to strengthen thehealth system under the focus area of “overcoming social vulnerability.” The JICA
Country Analysis Paper for Bangladesh (March 2019) also sets out policies forstrengthening the health system; the Program is also consistent with this policy
and analysis.
The Program sets policy actions (e.g. implementing health protection programs,
making considerations for gender in the construction/reconstruction of clinics) that
address poverty, disabilities, gender, and other issues. Thus, the Program
contributes to the realization of SDGs 1 (no poverty), 3 (ensuring healthy lives forall), 5 (achieving gender equality), and 10 (reducing inequality).
(3) Other Donors’ Activities
The World Bank is providing assistance for strengthening the Bangladeshi
government’s capacity to manage the finances and other aspects of the healthsystem, enhancing the health system, improving access to health services, andmore under the Health Sector Support Project (500 million USD, approved inAugust 2017), which is grounded in the sector-wide approaches of the aid
coordination framework. A vaccination assistance program (500 million USD) for
Bangladesh has also been approved.
To assist with the socioeconomic impacts of the pandemic, ABD provided financial
assistance to the government of Bangladesh to expand economic measures andsocial security through the COVID-19 Active Response and Expenditure Support
Program (500 million USD, approved in May 2020), which was co-financed with
Phase 1 of the Program (COVID-19 Crisis Response Emergency Support Loan
(approved in FY2020) (“Phase 1 Program”)). Additionally, the Strengthening Social
Resilience Program (Subprogram 1) (250 million USD), a financial assistanceprogram for improving the social security system for the socially vulnerable, wasapproved in June 2021 and will be co-financed with the Program.
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Furthermore, the French Development Agency (Agence Française deDéveloppement, AFD) formulates program-type assistance for the health sector,
which includes COVID-19 responses (expected 200 million EUR), and will be cofinanced with the Program in addition to the aforementioned ADB loan.
３．Program Description(1) Program Objective(s)The objectives of the Program are to realize resilient health system throughconcessional financing by supporting smooth implementation of policies tostrengthen COVID-19 response capacity in health sector, to enhance economic
and physical access to health services towards the achievement of the UHC, andto improve health finance, thereby contributing to the promotion of the economic
stabilization and development efforts of the country.
(2) Program Site / Target Area
Throughout the country(3) Beneficiaries of the Program (Target Group)
Citizens of Bangladesh (Population: Roughly 165 million (World Bank, 2020))(4) Program Components
The Program will provide concessional financing to the government of Bangladesh
in three policy areas (emergency responses to COVID-19, health service provision,
financial protection) agreed upon with the government. Additionally, the Program issplit into two tranches based on the respective objectives of the policy actions.
(5) Estimated Program Cost (Loan Amount)
40,000 million Yen(6) Schedule
The Program will begin when the L/A is signed, and will be complete when theloan disbursement is concluded (scheduled for February 2022).
(7) Program Implementation Structure1) Borrower: The Government of the People’s Republic of Bangladesh
2) Guarantor: N/A
3) Executing Agency: Finance Division, Ministry of Finance(8) Collaboration and Sharing of Roles with Other Donors
1) Japan’s Activity
The technical cooperation titled “Project for Strengthening Health Systems
through Organizing Communities” (FY2017–FY2022) is presently providing
assistance for endeavors such as formulating operating guidelines for GODs
as measures against NCDs among urban populations. Additionally, thetechnical cooperation titled “Project for Capacity Building of Nursing Services”(FY2015–FY2020) involves initiatives to cultivate nurses and improve thequality of nursing education through such efforts as introducing a nursing
college certification system. Preparation for Phase 2 of this project is underway4

(project commencement scheduled for FY2021). Furthermore, the ODA loans
titled “Health Services Strengthening Project” (approved in FY2018) and“Maternal, Neonatal and Child Health (MNCH) and Health System
Improvement Project” (approved in FY2015) are providing support for the
conducting of training and installing facilities and equipment at medical facilities
to serve as measures against NCDs and improve maternal and child healthservices. The Program sets policy actions linked to these technical cooperation
projects and ODA loans in an effort to expedite the projects and ensure that
their outcomes take hold.
Additionally, in the Phase 1 Program, JICA provided financial assistance to thegovernment of Bangladesh to expand economic measures and social security
for the socially vulnerable affected by COVID-19 pandemic, whereas theProgram will provide concessional financing with emphasis on implementing
pandemic policies in the health sector.
2) Other Donors’ Activity
The Program will be co-financed with the ADB Strengthening Social Resilience
Program (Subprogram 1) (250 million USD) which shares some policy actions
regarding health service provision, and will collaborate with monitoring andother efforts.
The Program will also be co-financed with AFD’s program-type assistance inthe health sector, and will collaborate with monitoring and other efforts inaddition to sharing all aspects of the three policy areas in the policy matrix(emergency responses to COVID-19, health service provision, financial
protection).
(9) Environmental and Social Consideration/Cross-Sectoral Issues/Gender Category
1) Environmental and Social Consideration① Category: C② Reason for Categorization: The Program is likely to have minimal adverse
impact on the environment under the JICA Guidelines for Environmental andSocial Considerations (April 2010).
2) Cross-Cutting Issues: Under the Program, multiple policy actions are set forcontributing to anti-poverty measures, infectious disease control measures, andconsiderations for people with disabilities.
3) Category of Gender: GI (S) (Integrated gender activity program)
Activity Component(s)/Reason for Categorization: Among other reasons, theProgram set the policy action for the construction/reconstruction of community
clinics which hold a high percentage of female users, and are planned to be
designed with consideration for convenience and safety for women (e.g.
establishing nursing rooms and separate toilets for men and women, installing
sufficient lighting).
5

(10)

Other Important Issues: N/A

４. Targeted Outcomes(1) Quantitative Effects
Outcomes (Operation and Effect Indicators)
Baselines(Actual value in March
2021)

Targets (February
2024)[Expected value 2
years after program
completion]

The percentage of vaccination
coverage (percentage of the
population
that
is
fully
vaccinated*)

2%

40%

Total number of students
studying at accredited nursing
college(s) (per year)

N/A

300

The number of urban dwellers
who have visited GODs where
the GOD operational guideline
introduced (per month)

N/A

10,000The budget
allocation ofhealthcare spending of GDP

1.0% (FY2019/20)

1.3% (FY2022/23)

Indicator*Refers to two doses for vaccines that require two doses, and one dose for vaccines that require
one dose.

(2) Qualitative Effects
Preventing the spread of COVID-19 infections, improving access to and the qualityof health services, enhancing health finance, driving sustained growth bypromoting investment and business activities of foreign companies, and more.
(3) Internal Rate of Return
IRR is not calculated as this is a program loan.
５. External Factors and Risk Control(1) Preconditions: N/A(2) External Factors: N/A
６. Lessons Learned from Past Projects
The ex-post evaluation of the ODA loans for Pakistan titled “Energy Sector Reform
Program” and “Energy Sector Reform Program (II)” (evaluated in FY2017) pointed outthat JICA’s implementation of technical cooperation in specific sectors alongside its
provision of the development policy loan, which aims to help with the execution of thepolicy actions presented with the development policy loan, will make it possible toachieve more effective policy improvement and reform.
6In light of this lesson, in an effort to ensure the effectiveness of policy improvement
and reform, the Program will be implemented alongside existing technical cooperation
for cultivating nurses and implementing measures against NCDs to help with thesteady execution of policy actions.
７. Evaluation Results
The Program aims to realize a resilient health system in Bangladesh, where COVID19 is spreading, through concessional financing by supporting the smooth
implementation of policies to strengthen the COVID-19 response capacity in the healthsector, to enhance economic and physical access to health services working towards
the achievement of UHC, and to improve health finance. The Program is consistent
with development issues and development policy in the health sector as well asJapan’s cooperation policy and JICA’s analysis, and should contribute to therealization of SDGs 1 (no poverty), 3 (ensuring healthy lives for all), 5 (achieving
gender equality), and 10 (reducing inequality). Thus, there is a substantial need for
JICA to support the Program.
８. Plan for Future Evaluation(1) Indicators to be Used
As indicated in Sections 4.
(2) Future Evaluation Schedule
Ex-post evaluation: Two years after the program completion
END
Attachment:
COVID-19 Crisis Response Emergency Support Loan Phase 2 Policy Matrix

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Attachment: COVID-19 Crisis Response Emergency Support Loan Phase 2 Policy Matrix
Policy Action
Policy Area

Policy Objective

Tranche 1

Tranche 2(Achieved by March 2021)(Achieved by December 2021)(1) Emergency Responses to COVID-19
PolicySmoothformulation andimplementation ofbudget allocation

vaccination based on

for COVID-19

the vaccine

vaccine provision

procurement andand vaccination

vaccination plan set byprogramthe government of
Bangladesh・ The vaccine procurement plan to be
formulated and approved

・ Procurement of vaccines to cover 20%
of total population2

・ Vaccine regulatory pathway (including
vaccine import requirements) to be
formulated and approved
・ Vaccination strategy (including
identification of priority groups) to be
formulated and approved

・ Vaccinating 10% of total population3
・ COVID-19 vaccine safety surveillance tobe executed

・ Development of an Application for COVID19 vaccination registration
Relevant policies

Realizing sustainable

for health sector

responses to COVID19 by ensuring
incentives to health・ Circular to be issued to provide special
honorarium to government doctors, nurses
and medical workers

facilities and medical

・ Budget allocation for FY2020/2021 toprovide special honorarium to government

workers dealing with

doctors, nurses and medical workers

2・ Budget allocation for FY2021/2022 toprovide special honorarium togovernment doctors, nurses andmedical workers

Refers to procurement of two doses for vaccines that require two doses, and procurement of one dose for vaccines that require one dose. The procurement of vaccines purchased by
the government of Bangladesh shall be deemed to be completed when purchase contract is signed, whereas the procurement of vaccines provided via COVAX facility shall be deemed
to be completed when country-by-country allocation plan indicating vaccine brand and supply schedule is set.
3
Refers to two doses for vaccines that require two doses, and one dose for vaccines that require one dose.

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COVID-19 patients
Infection

Preventing COVID-19

prevention

infections

measures

・ The government’s COVID-19 response
plan to be formulated and approved
・ Guideline for the expansion of COVID-19
testing capacity to be developed

against COVID19(2) Health Service Provision
Improvement of

Improving physicalaccess to healthaccess to clinics inservice・ Procurement Plan including construction
and reconstruction of community clinics for・ Procurement Plan including construction
and reconstruction of community clinics

order to raise

FY2020/2021 to be approved (target clinics

for FY2021/2022 to be approved (target

utilization rate of healthare limited to the ones constructed withoutclinics are limited to the ones

service

additional land acquisition)

constructed without additional landacquisition)
・ Infection prevention control guidelines
for community clinics to be approved

Improvement ofStrengthening training

health service

system for medical

qualityworkers and・ Training plan for medical education andhealth manpower development for
FY2020/2021 to be approved

expanding training

・ Training plan for medical education andhealth manpower development for
FY2021/2022 to be approved
・ Nursing college accreditation to be
executed

participants in order tosecure health service
quality9

Strengthening

・ Urban Health Strategy 2020, which aims toresilience and self-help
improve health and nutrition of urban
system of communities

population, to be prepared and approved

・ Operational Guideline of Government
Outdoor Dispensary (GOD), which isused mainly by the poor and vulnerable

to deliver healthin urban area, to be approved

services especially・ GOD Operational Guideline to start
implementation in at least 8 GODs

with a focus on NCDs
(3) Financial Protection
Health Finance

Ensuring that the use

・ Budget to be allocated by finance authorityof health services does
to prepare for the implementation of
not expose the user tonational health protection program in pilot

financial hardshiparea aimed at the future operation acrossthe country
・ Approval of national target to expand
budget allocation of healthcare spending to
2.0% of GDP by 2025

10・ Approval of FY2021/2022 budget planfor the implementation of national healthprotection program in pilot area
・ Drafting of health protection act as partof achieving UHC