(Field survey: June 12-23, 2007)

Ex-post monitoring of Completed ODA Loan Projects Report
Evaluator: Kenji Momota (IC Net Limited)
Project Name: Peru Health Service Strengthening Project (L/A No. PE-P10)
Loan Outline
Loan Amount/Disbursement Amount
Loan Agreement
Loan Completion
Ex-Post Evaluation
Executing Agency:::::

2,240 million yen/2,221 million yen
April 1994
July 1999
FY2002
Ministerio de Salud (MINSA) (Ministry of Health)

Project Objective
The project provided medical care equipment and medical supplies to healthcare facilities in the poorest regions, with the aim of improvingmedical care services for the low income classes, and thereby contributing to improvement of health in Peru.
Consultants: Contractors: Compañía Industrial Peruana Monfer S.A.(Peru), Dent Import S.A. (Peru), and others
Overview of Results
Item
At Time of Ex-Post Evaluation

At Time of Ex-Post Monitoring

Effectivenessand Impact

Expansion and qualitative improvements in medical careservices are continuing, and equipment and supplies
introduced by the ODA loan project are also playing acertain role as the basic infrastructure of medical carefacilities in poor regions.

Effectiveness1In Peru’s healthcare sector, various efforts were also
implemented after the project, by donors such as the WorldBank, IDB, and USAID, and the government under thehealthcare sector strategic plan (2001-05) of the Peru Ministryof Health (MINSA). With a focus on improvements in motherand child healthcare services for the impoverished class,improving capabilities of the Ministry of Health, etc., theactivities advanced the provision of free insurance, etc. Manyof the improvements in services of medical care institutions,and improvements in health indices described below are theresult of these coordinated efforts, and it is difficult toaccurately measure the effects of the ODA loan project alone.
But in interviews with the Ministry of Health and the person in
charge of policy at that time (Vice Minister of Health), it washeard that the Program to Strengthen Health Services throughthe IDB and ODA loan project is ranked as important in these
efforts, and is especially valued as playing a large role indeveloping infrastructure. Considering such positioning of thisproject, and the following various survey results oneffectiveness, one can say that the ODA loan project played acertain role in improvement of the health sector’s services andhealth indices.

2

<Table 1: Major healthcare sector projects implemented after
this ODA loan project>
Project Name

Main Activities

Program to Strengthen
Health Services(PFSS/1994~2000)

Support to improvecapabilities of healthcare
facilities and the Ministry ofHealthExpansion of basic healthcare
services, improve capabilitiesof healthcare facilities
Improve healthcare services formothers and children
Provision of healthcare
insurance for mothers andchildren (some of it free)
Improve healthcare services formothers and children of thepoor classes, improvecapabilities of the Ministry ofHealth

Programa Salud Básica
para Todos (1994 onwards)
Proyecto 2000 (1994-2002)
SMI/Seguro Materno
Infantil(from 1999 onwards)
PARSALUD (2001-2006)

Mainexecutors
IDB/JBIC/government

Government

USAID
World Bank,IDB,government
IDB,government

Source: Made based on MINSA responses(1) Situation of effective provision of welfare services in
the poorest regions(i) As shown in the table below, of the 3,516 facilities(1,684 via the ODA loan) which were provided withmedical care equipment, supplies, etc., about 76% (about75%) were 2,686 health posts (1,257 health posts). These
health posts are generally in rural areas with high poverty
rates, so it is thought to be contributing to the effective
provision of welfare services in the poorest regions.
<Table 1 Number of healthcare facilities which received

3(1) Situation of the effective provision of welfare services in
the poorest regions(i) Current situation of use of the equipment supplied
The equipment provided covered a wide range, from general
office goods to centrifuges used in blood tests, and incubatorsfor obstetrics. The table below shows the results of a sample
survey of the usage situation by type of equipment.

equipment & supplies provided through this project>
Institution
Total for thisODA loanproject
Hospital
117
62
Health center
713
365
Health post
2,686
1,257
Total
3,516
1,684
Source: Peru Ministry of Health (MINSA)

4<Table 2: Usage situation of equipment provided>
Type offacility

Status ofequipment

Medical careequipment(Precision
machinery)

Generalmachinery(Communi-cations &transport)
72.6%

Otherinfrastructure,
fixtures,
etc.
73.5%

In use38.7%
Broken* or
55.5%
27.4%
24.0%
damagedHospitals
Lost orcannot
5.8%
0.0%
2.5%
confirm
In use
45.8%
72.5%
80.0%
Broken* or
50.8%
27.5%
19.2%
Healthdamagedcenters
Lost orcannot
2.5%
0.0%
0.8%
confirm
In use
45.8%
57.5%
81.7%
Broken* or
53.7%
42.5%
16.7%
Healthdamagedposts
Lost orcannot
1.7%
0.0%
1.7%
confirm
In use
43.4%
67.5%
78.4%
Broken* or
53.3%
32.5%
19.9%
damagedAverage
Lost orcannot
3.3%
0.0%
1.7%
confirm
Source: Site questionnaire surveys. (They were implemented in the threeprovinces of Ica, Junín, and Lambayeque. They were implemented at 10hospitals, 10 health centers, and 30 health posts)* Some partially broken items which could be operated but for which 100%

of functions could not be used were included in “Broken.”

Looking at results from the sample survey, a wide range of
40% to 80% is seen in usage rates for equipment. There is still
effective utilization (70% to 80%) of simple medical caredevices (i.e. medical care utensils such as mirrors, forceps, andtooth extraction forceps), communications and transport
equipment (i.e. fax machines, vehicles, etc.), and basic
infrastructure for large hospitals such as generators andboilers. On the other hand, precision machinery such as
centrifuges for blood tests have a usage rate falling to about
40%. In interview surveys at each facility, the following weregiven as the background for the declining usage rates.
• Exceeded the useful life of the equipment• Lack of budget for proper maintenance• Due to progress in decentralization of the healthadministration, technical support from the center (MINSA)
ended, and regional disparities increased
Due to regional decentralization policy since the year 2000,
the carrying out of repairs and support for equipment, which
MINSA had been in charge of until then, was transferred toregional governments. This affected each region’s operationand maintenance situation of equipment. Disparities are arising
between regions, as regions with relatively strong economies
such as Ica Province have maintained up to 60% to 70% usageof precision equipment, etc.
(ii) Welfare services of health posts in rural regions inpoverty
Many health posts are in rural regions with high poverty

5(ii) Welfare services of health posts in poor rural regions
The number of medical care facilities increased slightly fromrates, and as shown in the table below, MINSA has
the time of ex-post evaluation, and the level at the time ofincreased the total number of healthcare facilities under its ex-post evaluation is being maintained.
control.
Table 3
Number of Healthcare facilities under MINSA control
Table 2Year
1996
2001
2006
Number of healthcare facilities under MINSA control
Year1990

1992

1996

Hospitals
Health centers
Health posts
Total
3,731
Source: MINSA

455
1,083
3,079
4,617

136
1,028
4,762
5,926

2001
(October)
132
1,169
5,316
6,617

(2) Increased number of medical examinations at MINSA
facilities
The number of medical examinations (number of visits tomedical care institutions?) at MINSA’s healthcare
facilities increased. Especially since 1994 when theproject began, the number has significantly increased. One
can conjecture that the equipment provided by the ODA
loan has improved the capability of health centers andhealth posts under MINSA to provide services to morepeople.
• Hospitals: About 5 million (1994) →• Health centers : About 8.5 million (1994) →• Health posts : About 3 million (1994) →About 8 million (1999)
About 19 million (1999)
About 19 million (1999)

6Hospitals
Health centers
Health posts
TotalSource: MINSA

136
1,028
4,762
5,926(October)
132
1,169
5,316
6,617

146
1,203
5,472
6,821

(2) Increased number of medical examinations at MINSA
facilities:
The number of medical examinations at MINSA’s healthcare
facilities increased from the time of the ex-post evaluation(about a 25% to 35% increase), showing that expansion ofhealthcare services is progressing.
As shown in Table 2 above, the absolute number of medicalcare institutions themselves is not increasing much, but it isthought that due to efficient provision of medical care services,
the number of medical examinations and number of patients
examined per facility are increasing. The efforts by thegovernment and donors towards strengthening of healthcare
services since the second half of the 1990s that werementioned above are seen to be in the background of this.

• Hospitals• Health centers• Health posts

Chart 1
Number of medical examinations at MINSA’s health facilities: About 8 million (1999) → About 10 million (2006): About 19 million (1999) → About 25.6 million (2006): About 19 million (1999) → About 24.3 million (2006)<Table 4: Number of patients examined and number of medical
examinations provided at MINSA’s healthcare facilities>(unit: millions)
Number of patients
examined(million people)

Number of medical examinations(million times)

Fiscalyear

Hospitals

Centers

Posts

Hospitals

Centers

20022003
2004
2005
2006

3.44
3.583.91
3.87
4.05

7.26
7.51
8.21
8.52
8.28

6.68
7.13
6.77
7.13
7.00

8.67
8.86
9.53
9.61
10.12

21.53
22.92
24.47
24.98
25.63

Posts

21.26
23.28
21.93
23.04
24.31

Source: MINSA
Source: MINSA, Office of Statistics (Oficina de Estadísticas)(3) Medical examinations at MINSA’s healthcare
facilities as a percentage of examinations at all medical (3) Medical examinations at MINSA’s medical care facilities
as a percentage of examinations at all medical care facilities
care facilities: 39% (1994) → 52.8% (2000)
1. Percentage of people who received
medical examinations of total
population
2. Percentage of people who received
medical examinations at MINSA’s
medical care institutions
3. Of people who received medicalexaminations, the percentage of people
who received examinations at

1997

2000

54.7%

55.9%

<Table 5: Percentage of medical examinations at
MINSA’s medical care facilities>
2000

2004

55.9%

N.A

29.5%

24.6%

52.8%

N.A

1. Percentage of people who received

25.0%
45.7%

29.5%
52.8%

7

medical examinations of total
population *1
2. Percentage of people who received
medical examinations at MINSA’s
medical care institutions
3. Of the people who received medicalexaminations, the percentage of people

who received examinations at MINSA’s
healthcare facilities (2/1)
Source: MINSA*1:There are no statistics for private medical care facilities, so this
could not be confirmed.

MINSA’s healthcare facilities (2/1)
Source: ENNIV (National Standard of Living Survey)

According to MINSA, the number of people examined andnumber of medical examinations by MINSA medical careinstitutions are increasing, but the percentage of such numbersof the total examinations at both public and private medicalcare facilities is decreasing since the time of ex-post
evaluation. MINSA believes that this is mainly due toincreases in the number of private medical care facilities andEsSalud and other public medical care institutions, which
resulted in a relatively low ratio at MINSA.

(4) Situation of improvement in quality of health services:
Due to equipment and supplies provided by this project, it (4) Situation of improvement in quality of healthcare services
became possible to provide health services which were (i) Questionnaire survey of medical care facilities
not possible to provide before. As such, this project made Regarding the situation of medical care services compared togreat contributions to improvements in quality. Also, before project implementation, the following viewpoints andaccording to an evaluation report of the MINSA, health opinions were heard often in interviews at medical carecenters referred 40% to 50% of patients to other facilities institutions in each region. From the responses, it isin 1994 due to lack of capabilities, but this has now understood that the overall capabilities of medical caredecreased to 12%.
facilities are improving, such as the number of medical
examinations per facility, variety of medical care services, andlevel of the medical care staff. On the other hand, factors
which inhibit the manifestation of project effect were alsoseen, such as the falling functions of some equipment due to alack of maintenance.
Through the effects of training for medical care employees
which was implemented as part of joint financing, and through8the use of equipment which was introduced through an ODA
loan, medical care technology and efficiency (reduced waitingtime, selection of proper medical treatment methods, etc.)
improved. MINSA believes that these are major reasons forthe improvements.
<Table 6: Outline of results of interviews with medical care institutions>
Points which improved compared toFacility
before project implementation
Quantitative data
• Number of medical examinations per day: Increased froman average of 100-130 before project implementation, to400.
Qualitative opinions
Hospita • Reduced surgery times, and ability to handle a greaterlvariety of medical care services• Improved techniques and expertise of medical care staff,etc.
Issue• Lack of operation and maintenance budgets, especiallyfor preventative maintenance.
Quantitative data• Number of medical examinations per day: Approximately
doubled compared to before project implementation
Qualitative opinions• Reduced surgery times and ability to handle a greater
variety of medical care services• Improved techniques and expertise of medical care staff,
Centeretc.
Issues• Lack of operation and maintenance budgets, especiallyfor preventative maintenance.
(Voices were head that precision equipment for blood tests
cannot be operated 100% in some facilities, so some test
aspects cannot be done)

9Points which improved compared tobefore project implementation
Quantitative data• Number of medical examinations per day:Increased from an average of 10-15 before project
implementation, to 35-40.
・ Number of referrals per month*: Decreased from anaverage of 30-35 before project implementation, to 10-15
after (because of an increase in the services and numberof medical treatments which can be handled at posts)
Post
Referral services: Referral of patients who require medical
treatments which lower medical care institutions (healthcenters, posts, etc.) cannot handle
Qualitative data
Mutual assistance relations and networking between
facilities improved. For example, staff from centers
participate in times of emergency.
Issue• Lack of operation and maintenance budgets, especially forpreventative maintenance.
Source: Field questionnaire surveys. (They were implemented in the threeprovinces of Ica, Junín, and Lambayeque. They were implemented at 10
hospitals, 10 health centers, and 30 health posts)
Facility(ii) Beneficiary survey: A beneficiary survey was done ofusers of healthcare facilities on the situation of improvements
in healthcare services since the time of ex-post evaluation(2001). (Total 1,000 people in three provinces). Those results
are summarized below.

10