Ex-Ante Evaluation (for Japanese ODA Loan)
Southeast Asia Division 2,
Southeast Asia and Pacific Department
Japan International Cooperation Agency
1. Name of the Project(1) Country: Kingdom of Cambodia (Cambodia)(2) Project: Regional Hospital Development Project(3) Project Site/Target Area: Siem Reap Province and Kampong Cham Province(population: approx. 1.91 million in total)
Loan Agreement: March 14, 2024

2. Background and Necessity of the Project(1) Current State and Issues of the Health Sector and the Priority of the Projectin Cambodia
In Cambodia, the basic public healthcare service system has been developed
to improve basic health indicators for the health of mothers and children, leading
to a reduction of the under 5 mortality rate (2000: 106, 2021: 25, per 1,000 livebirths) (2021, World Bank (WB)) and maternal mortality ratio (2000: 488, 2017:
160, per 100,000 live births) (2017, WB), etc. On the other hand, the number ofbeds, medical care functions, and medical practitioners in healthcare facilities
remains insufficient, and there is particularly striking disparity between the capital,Phnom Penh, and provincial areas. Furthermore, in Cambodia, noncommunicable diseases (NCDs) such as stroke, ischemic heart disease andcirrhosis of the liver account for 64% of the causes of death, and the increase in
NCDs is becoming more serious (2019, World Health Organization (WHO)).
Hospitals that can provide advanced diagnosis and treatment are limited tocertain national hospitals in Phnom Penh, and provincial residents need to travelto the capital or neighboring countries for medical examinations, so there is anurgent need to correct regional disparities in relation to the quality of and accessto medical services toward achievement of Universal Health Coverage (UHC).
In its National Strategic Development Plan 2019-2023, the Cambodian
government positions improvement of the quality of healthcare services as a keypolicy. Likewise, in the Pentagonal Strategy - Phase I formulated by the newadministration in 2023, improvement of the health and well-being of the people islisted under development of human resources which is one of five pillars. Also,
the Fourth Health Strategic Plan 2023-2032 currently being formulated by

Cambodia’s Ministry of Health (MOH) with support from WHO, is expected to set
forth correction of regional disparities in healthcare as a priority policy, including
the development of health infrastructure and medical equipment as well asensuring the necessary quality and quantity of health personnel. Additionally, theNational Strategic Plan for the Prevention and Control of NCDs (2022-2030) aims
to reduce the morbidity and mortality rate of NCDs and outlines the training ofhealth workers and new application of digital and ICT, etc. Furthermore, basedon the Investment Plan for Regional Hospital Development (2022), among the 25
provincial hospitals throughout Cambodia, there are plans to upgrade 7 provincialhospitals (Phnom Penh, Kampong Cham Province, Svay Rieng Province,
Kampot Province, Battambang Province, Siem Reap Province, Stung TrengProvince) as “regional hospitals” from the perspectives of geographicaldistribution, population scale, and the clinical skill level of hospitals, etc., with theaim of establishing a system for delivery of high-quality advanced healthcare in
the provinces. This is also expected to alleviate congestion at national hospitals,
strengthen comprehensive regional health systems, and enhance healthcare
personnel training and practice facilities.
Under these circumstances, the Regional Hospital Development Project for
Siem Reap Province and Kampong Cham Province (this Project) was requestedby the Cambodian government. Of the 7 hospitals to be upgraded as regional
hospitals, this Project focuses on the two above-mentioned provincial hospitals,
which have large population of beneficiaries and high priority to be upgraded, andis also positioned as a high-priority project in the Cambodian government’s
national development plan.
(2) Japan’s and JICA’s Cooperation Policy and Operations in the Health Sector
Japan’s Country Assistance Policy for Cambodia (July 2017) positions
healthcare as a priority area that will contribute to the improvement of quality oflife. Also, the Global Health Strategy of Japan (May 2022) sets forth ensuring
access to quality services as an important strategy connected to theenhancement of health systems toward UHC. Strengthening Diagnosis andTreatment Capacity of Core Hospitals is stated under Health in the JICA GlobalAgenda, as is the enhancement of systems to provide medical services throughnew establishment/expansion of core hospitals and medical personnel training,and this Project is consistent with these policies and analyses. Furthermore, thisProject is expected to contribute to Goal 3 of the Sustainable Development Goals(SDGs), “Ensure healthy lives and promote well-being for all at all ages”, since itwill support the achievement of UHC through correction of regional disparities inrelation to quality healthcare services.

(3) Other Donors’ Activities
Donors such as WB, Australia’s Department of Foreign Affairs and Trade, andthe Korea International Cooperation Agency are supporting the improvement ofhealthcare service quality and development of health insurance for low-income
citizens through co-financing. Also, WHO provides technical support for diseases
control, UHC, health security, and inter-sectoral cooperation and coordination,
while various partners such as United Nations Children’s Fund, the United
Nations Population Fund, Asian Development Bank, the United States Agency
for International Development, and the German Agency for International
Cooperation (GIZ) are providing technical support and equipment.

3. Project Description(1) Project Description① Project Objective
This Project aims to improve access to advanced healthcare in provincial
areas and thereby contribute to improvement of the health of the local
population by developing medical facilities and equipment that arenecessary for upgrading provincial hospitals in Siem Reap and Kampong
Cham provinces to regional hospitals.
② Project Componentsa) Construction of medical facilities: New establishment of outpatient/inpatient ward and advanced healthcare ward, etc. (2 buildings in Siem
Reap Province (total floor area approx. 27,000 m2) and 2 buildings inKampong Cham Province (total floor area approx. 29,000 m2))b) Procurement of medical equipment (MRI, CT scanners, angiographic
devices, endoscopes, etc.)c) Development of hospital information patient management systemsd) Consulting services (detailed design, bidding support, constructionsupervision, support for environmental and social considerations,enhancing the abilities of medical practitioners, etc.)③ Project Beneficiaries (Target Group)
Direct beneficiaries: Hospital staff receiving personnel training andorganizational ability enhancement (577 persons) (Siem Reap Provincial
Hospital: 97 doctors, 154 nurses, 56 midwives; Kampong Cham Provincial
Hospital: 71 doctors, 131 nurses, 68 midwives)
End beneficiaries: Residents of provinces and neighboring provinces using

Regional Hospitals (approx. 3.95 million people) (Siem Reap Province andneighboring provinces of Oddar Meanchey, Preah Vihear, Kampong Thom:
approx. 1.93 million people; Kampong Cham Province and neighboring
provinces of Tboung Khmum, Kratie, Mondulkiri: approx. 2.02 millionpeople)(2) Estimated Project Cost
25,457 million yen (Japanese ODA loan: 21,104 million yen)
(3) Schedule
March 2024 - July 2031 (89 months)
The opening of the facilities for use (in July 2030) is considered as thecompletion of the Project.
(4) Project Implementation Structure① Borrower: The Royal Government of Cambodia② Guarantor: None③ Executing Agency: Ministry of Health, Cambodia④ Operation and Development System: Siem Reap Provincial Hospital andKampong Cham Provincial Hospital(5) Collaboration and Sharing of Roles with Other Donors① Japan’s Activity
For the two hospitals targeted by this Project, equipment and facilities weredeveloped through grant aid in the Project for Improvement of Referral
Hospitals in Siem Reap Province (E/N signed in 2020) and the Project for
Improvement of Kampong Cham Hospital in Kampong Cham Province (E/Nsigned in 2008), contributing to the enhancement of a basic health services
delivery system. This Project will build on this asset to add advanced medicalcare systems. This Project will also contribute to capacity building of nursing
personnel as well as tangible enhancement in the diagnosis and treatment ofNCDs, linking with the Project for Strengthening In-service Training System inCambodia (2021-2026) and the Noncommunicable Disease Control Project(2024-2027) targeting Kampong Cham province.
② Other Donors’ Activity: N/A(6) Environmental and Social Consideration① Category: C② Reason for Categorization: This Project has been deemed to have minimal
negative impact on the environment under the JICA Guidelines forEnvironmental and Social Considerations (announced January 2022).
(7) Cross-Sectoral Issues① Poverty considerations: The poverty rate in Siem Reap Province is 27.9%,
the ninth highest among 24 provinces (2013, Ministry of Planning), andthis Project is expected to improve access to medical services for the poor.
② Disability considerations: Outline of design has been developed to makethe facilities accessible to disabled persons (e.g., installation of ramps,
securing pathways and sufficiently wide passages for wheelchairs, etc.),
and it was agreed with the Cambodian government that the sameconsideration would be paid in the detailed design. It was also agreed on
the provision of reasonable accommodation for persons with disabilities in
the capacity building of implementing agencies and on the provision ofadvice on reasonable accommodation and non-discrimination against
persons with disabilities to medical professionals in the consulting services.
③ Measures against HIV/AIDS, etc.: This is a large-scale infrastructuredevelopment project in a region where there is concern regarding thespread of HIV infection, so clauses on HIV/AIDS measures (provision ofinformation, education on prevention, etc.) will be included in the bidding
documents which will be implemented for the construction workers.
(8) Gender Category<Details of Activities/Reason for Categorization>① Gender Categorization: [N/A] ■GI (Gender Informed)② Reason for Categorization: Although the risk of NCDs was analyzed bygender in a survey, this did not go as far as gender equality and women's
empowerment initiatives and the indicator setting/planning. However, it
was agreed with the executing agency to design facilities from a gender
perspective and to identify medical equipment with regard to gender needs.
It was also agreed to promote the employment of female staff andappointment of female personnel to management positions within theproject management unit of this Project and in the operation andmaintenance of the hospital, and to collect gender-disaggregated data formonitoring and evaluation.
(9) Other Important Issues
This Project is expected to introduce advanced Japanese technology formedical equipment. Furthermore, the hospital information patient management
system should be developed with a view to introducing the same system to theprovincial hospitals other than the two target hospitals of this Project.

4. Targeted Outcomes(1) Quantitative Effects
1) Outcomes (Operation and Effect Indicators)
Baseline(Actual value in 2022)
Indicator

Kampong
Siem Reap
Cham
Provincial
Provincial
Hospital
Hospital

Target (2032)[2 years after projectcompletion]
Kampong
Siem Reap
Cham
Provincial
Provincial
Hospital
Hospital

No. of outpatients(persons/year)

90,88329,857

112,533

38,684

No. of in-patients(persons/year)

24,455

19,50831,333

23,469No. of CT scans(cases/year)

4,320

1,042

5,389

1,312

No. of MRI scans(cases/year)

00

2,567

625

No. of catheter operations(cases/year)

00360

360

No. of malignant tumor
operations (cases/year)

108

0392

371

No. of neurosurgicaloperations (cases/year)

91

0

114

107

No. of heart operations(cases/year)

00

86

81

7,156

3,355

8,861

4,347

No. of patients referredfrom lower-level medical
facilities (persons/year)(2) Qualitative Effects

Improvement of medical services provided by regional hospitals, nurturing ofquality health workers, health promotion of local residents, improvement ofpatient satisfaction, alleviation of congestion in national hospitals in the capital,
and reduction of referring patients from provincial areas to the capital(3) Internal Rate of Return
Based on the assumptions listed below, the economic internal rate of return

(EIRR) for the Project is 10.5%. On the other hand, the financial internal rate ofreturn (FIRR) is -6.1%, because the initial investment and the cost of major
repairs and medical equipment replacement assumed every 10 years far exceed
the projected revenue. Since this Project is not expected to be profitable due toits nature, it has been agreed with the Cambodian government that government
budget will be set aside for the period until 7 years after opening the hospitals,
which is when the current account balance is predicted to return to annual
profitability.
[EIRR]
Cost: Business, management, maintenance and operation expenses (allexcluding tax)
Benefit: Reduction of opportunity cost/travel expenses for patients andattendants, reduction of NCD-related cost, reduction of newborn
infant/maternal mortality rate, added value produced by healthworkers
Project Life: 38 years[FIRR]
Cost: Business, management, maintenance and operation expenses
Benefit: Medical care revenue, government budget
Project Life: 38 years

5. External Factors and Risk Control(1) Preconditions
N/A(2) External Factors:
N/A

6. Lessons Learned from Past Projects
From the ex-post evaluation of the Rural Health Infrastructure Strengthening
Project for the Kingdom of Thailand (evaluation year: 2005), the level of hospitals’
management capacity is connected to effective use of the equipment provided,indicating that enhancement of management capacity is a useful endeavor. Also,
the ex-post evaluation of the Regional and Provincial Hospital Development
Project for the Socialist Republic of Vietnam (evaluation year 2014) has taught
us that achieving project outcomes at an early stage requires systematic training

on the use of equipment provided. Based on these lessons, this Project aims toenhance the management capacity of the target hospitals through a consulting
services and technical cooperation, and to plan and implement systematictraining on the use of equipment by applying existing resources of the nationalhospitals that have been providing advanced medical care.

7. Evaluation Results
This Project is consistent with Cambodia’s development issues and policies
as well as Japan and JICA’s cooperation policy and analysis. By developing
medical facilities and equipment necessary for upgrading the provincial hospitalsin Siem Reap and Kampong Cham provinces to regional hospitals, the Project
aims to improve access to advanced healthcare in the provinces and contributeto the health of the local population, thereby contributing to the SDGs Goal 3,“Ensure healthy lives and promote well-being for all at all ages”. Therefore, there
is a strong need to support the implementation of this Project.

8. Plan for Future Evaluation(1) Indicators to be Used
As indicated in Sections 4.
(2) Future Evaluation Schedule
Ex-post evaluation: 2 years after the project completion
END
Attachment: Regional Hospital Development Project MapAttachment
Regional Hospital Development Project Map

Stung Treng
Provincial Hospital

Siem Reap
Provincial Hospital

Battambang Provincial
Hospital

Kampong Cham
Provincial Hospital
Phnom penh
Municipal Hospital

Legend:Candidate regional
hospitals

Kampot Provincial
Hospital

Provincial hospitals
Svay Rieng
Provincial Hospital

Hospitals subject tothis Project
Hospitals not coveredby this Project

Source: JICA “The Data Collection Survey on Project for Upgrading Quality ofHealth Services of Selected Provincial Hospitals”