Japanese ODA loan

Ex-ante Evaluation

1.

Name of the ProjectCountry: The People’s Republic of Bangladesh
Project: Maternal, Neonatal and Child Health Improvement Project (Phase 1) (Health,Population and Nutrition Sector Development Program)L/A signed on: January 25, 2012
L/A Amount: 5,040 million yen
Borrower: The Government of the People’s Republic of Bangladesh
2. Background and Necessity of the Project(1) Current state and Issues of the Health Sector in Bangladesh
Major improvements have been made in Bangladesh’s health sector, particularly in the areaof infectious disease control such as immunization programs and the battle against
tuberculosis. In the area of maternal and child health, advances have been made such as theimprovement of the infant mortality rate (per 1,000 live births, 92 in 1990 and 45 in 2009),
the under- five mortality rate (per 1,000 live births, 146 in 1990 and 67 in 2009), and thematernal mortality ratio (per 100,000 live births, 574 in 1990 and 194 in 2010). However,further efforts are needed to achieve the Millennium Development Goals (MDGs), for which
major challenges including the low proportion of births attended by skilled health personnel,
nutritional problems, and low service usage rate of impoverished groups, remain unsolved.
The proportion of births attended by skilled birth attendants is quite low (24.4% in 2009) incomparison with the averages for South Asia (48%) and other developing countries (64%). In
particular, the access to maternal and child health services are very limited among the poorest
in the society. While the proportion of stunting children is steadily decreasing, the progress indecreasing the proportion of underweight children has been slow. Thus, further efforts areneeded to ensure sufficient nutritional status. To improve these health indicators, services
provision must be improved in the health, nutrition and population sectors and at the sametime, the use of these services must be encouraged through awareness raising.
Improving service provision requires further efforts to establish a more consistent healthsystem that extends from local community to tertiary levels including the appropriate
allocation and management of facility development, human resources, materials, budgets, andother data and information. Further initiatives have to be taken to enhance the stewardshiprole and capacity of the Ministry of Health and Family Welfare, appropriately develop andallocate health personnel, enhance planning and budget allocation based on local needs, andimprove referral systems.
(2) Development Policy for the Health Sector in Bangladesh and the Priority of the Project
The Government of Bangladesh has defined health, nutrition and population issues asmajor challenges and aims to achieve MDGs under the 6th Five-Year Development Plan

(2011-2015) and the long-term strategy of the current government (Outline Perspective Plan
(OPP) of Bangladesh 2010-2021: Making Vision 2021 A Reality). The Government ofBangladesh is aiming to expand high-quality, user- friendly basic health service provision anda sustainable health system that responds to people’s needs under its National Health Policy(currently under formulation) by enhancing service provision and strengthening thestewardship role of the government.
A national strategy for maternal health has been formulated in the maternal and child healthsector with following basic principles: (1) strengthening emergency obstetric care to reducematernal deaths, (2) providing basic obstetric care for early detection of complications andappropriate referrals, (3) promotion of women’s rights, and (4) ensuring service quality.
To implement these policies, the Government of Bangladesh formulated the Health,Nutrition and Population Sector Programme (HNPSP, 2003-2011), defining priority issues
such as reducing maternal/infant mortality rates, preventing epidemic infectious diseases,
reducing malnutrition, and family planning. The government has been working on raising thequality of healthcare throughout the country while obtaining support from development
partners based on a framework of Sector-Wide Approaches (SWAps). A subsequent program,the Health, Population and Nutrition Sector Development Program (HPNSDP, started in July
2011, 2011-2016) has now been launched. The major challenges for Bangladesh are still
almost the same as in HNPSP; however, action plans for maternal and child health services
are being more explicitly formulated in HPNSDP to enhance the quality of measures taken
through more coordinated action among relevant departments within the Ministry of Healthand Family Welfare.
(3) Japan’s and JICA’s Policy and Operations in the Health Sector
In light of Japan’s Country Assistance Program for Bangladesh (May 2006), JICA haspositioned the health sector as one of the priority development issues under “socialdevelopment and human security,” one of the priority areas for assistance. This project isconsidered as a part of the “Maternal, Newborn and Child Health Program” under the Rolling
Plan for Bangladesh. JICA has provided technical assistance to reinforce the maternal andchild health, infectious disease control, and health system in order to achieve the MDGs incollaboration with other development partners. Further, JICA actively participates in various
meetings within the sector program framework to disseminate the outcome of technicalcooperation and propose policy recommendations based on field level knowledge andexperiences.
(4) Other Donor’s Activities
Sixteen development partners provide assistance under the HPNSDP framework, including
eight development partners that provide financial assistance through the trust fund managed
by the World Bank. In particular, a number of development partners, such as UNICEF,UNFPA, USAID, and WHO, provide assistance in the maternal, neonatal and child healthsector. The World Bank provided assistance of 300 million dollars to HNPSP and another 350
million dollars to HPNSDP.

(5) Necessity of the ProjectThis project implements activities related to maternal, neonatal and child health as a part ofa comprehensive health program (HPNSDP). Further efforts are needed to achieve the MDGs
by the Bangladesh government, while more assistance from development partners is also
required. Since this Project is in line with Japan’s priority area and sector under its Country
Assistance Program for Bangladesh and, in particular, aims to disseminate the outcome of
JICA’s technical cooperation in the maternal, neonatal and child health sector, this Project istherefore considered highly necessary and relevant.
3.

Project Description(1) Project Objectives
The objective of the Project is to improve maternal, neonatal and child health (MNCH)
services and strengthen health system of Bangladesh, by implementing MNCH related
activities under the HPNSDP, thereby contributing to the improvement of MNCH status ofBangladesh.
(2) Project Site/Target Area: Throughout Bangladesh(3) Project Components
The Project implements activities that contribute to improving maternal, neonatal and childhealth services within the framework of HPNSDP (international/domestic competitive bidding,etc.). The Japanese ODA loan will be used for training, provision of equipment, andconstruction works related to maternal, neonatal and child health.
(4) Estimated Project Cost (Loan Amount)
23,690 million yen (the total amount of the Japanese ODA loan is: 9,758 million yen, of
which Phase 1 loan amount is: 5,040 million yen)(5) Schedule
It is scheduled to be carried out between January 2012 and June 2016 (54 months in total).
The Phase 1 loan covers FY2011/12 through FY2013/14. The Project will be completed
when HPNSDP is completed (June 2016).
(6) Project Implementation Structure1) Borrower: The Government of the People’s Republic of Bangladesh
Executing Agency: Ministry of Health and Family Welfare
Operation/Maintenance: Ministry of Health and Family Welfare and organizations

2)
3)

under supervision of the ministry(7) Environmental and Social Consideration/Poverty Reduction/Social Development
1) Environmental and Social Consideration:i.

Category: FIii.

Justification: The Project is designed to provide financing to financial
intermediaries. Sub-projects cannot be specified prior to JICA's approval for
financing, and they may have environmental impacts under the JICA guidelines
for environmental and social considerations(April, 2010).

iii.

Monitoring/Others: In this Project, the executing agency will prepare theenvironmental management plan and the social management framework and will
monitor measures for environmental and social considerations based on these planand framework.

2)

Promotion of poverty reduction: Activities will be implemented to improve the access3)

to health services among the impoverished group.
Promotion of Social Development: Consideration will be given to women and thesocially vulnerable people in community activities.

(8) Collaboration with Other Donors
This project will be financed within the framework of HPNSDP with other 15
development partners. The Project activities will be coordinated with the ongoing JICA
technical cooperation project and activities of the expert in the health sector and will also
contribute to the dissemination of the outcome of JICA’s assistance.
(9) Other important issues: None4.

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

Baseline

Target (2016)(2007)[at the time of projectcompletion]*

Infant mortality rate (1,000 live birth)52

31

Neonatal mortality rate (1,000 live birth)

3721

Maternal mortality ratio (100,000 live birth)

194 (2010)

143

Delivery by skilled birth attendant (%)

1850

Antenatal care coverage (at least 4 visits) (%)

20.6

50

Postnatal care within 48 hours (at least 1 visit) (%)

18.5

50

15.550―3,000120

204

Union level facilities providing basic emergency obstetricalcare services (%)
Additional providers trained in midwifery at Upazila healthfacilities
Number of comprehensive emergency obstetrical carefacilities with functional 24/7 services

Note: Since the indicators for maternal and child health in the HPNSDP were used as target indicators forthis Project, they were set for the time of project completion (2016). An ex-post evaluation of this Projectwill be conducted to confirm the performance by referring to the 2016 target indicators.

Internal Rate of Return: Not calculated.
(2) Qualitative Effects: Capacity development of health personnel.
2)5.

External Factors and Risk Control
Delay in civil engineering works due to natural disasters such as floods, appropriate

personnel deployment at health facilities.

6.

Lessons Learned from Past Projects

A lesson learned was that careful consideration is needed to ensure that common
recognition is shared for various matters in projects that involve collaboration with otherdevelopment partners, especially when the large number of development partners are involved.
In this Project, since a collaborative system to monitor overall HPNSDP progress isestablished, JICA plans to actively participate in various activities, including annual review
meetings (for policy discussion), development partners’ meetings, and task groups establishedfor each theme, to disseminate and share information, as well as coordinate and build
consensus for activities.
7. Plan for Future Evaluation(1) Indicators to be used
Infant mortality rate (1,000 live birth), neonatal mortality rate (1,000 live birth), maternalmortality ratio (100,000 live birth), delivery by skilled birth attendant (%), antenatal carecoverage (at least 4 visits) (%), postnatal care within 48 hours (at least 1 visit) (%), unionlevel facilities providing basic emergency obstetrical care services (%), additional providers
trained in midwifery at Upazila health facilities, number of comprehensive emergency
obstetrical care facilities with functional 24/7 services(2) Timing of Next Evaluation: Two years after the completion of the project