Japanese ODA Loan

Ex-Ante Evaluation (for Japanese ODA Loan)
1. Name of the ProjectCountry: The People’s Republic of Bangladesh
Project: Health Services Strengthening Project
Loan Agreement: June 14, 2018
2. Background and Necessity of the Project(1) Current State and Issues of the Health Sector and Priority of the Project inBangladesh
Having adopted sector-wide approaches (SWAps) since 1998, the Government ofthe People’s Republic of Bangladesh has developed and implemented
comprehensive health sector programs for health, population and nutrition with thesupport of donors under an assistance coordination framework in order to raise thelevel of healthcare standards nationwide. The Health, Population and Nutrition Sector
Program (2011–2016) implemented initiatives intended to achieve the Millennium
Development Goals in the health sector, such as reducing child mortality (Goal 4),
improving maternal health (Goal 5), and combatting HIV/AIDs, malaria and otherdiseases (Goal 6). As a result, compared to 1990 levels, goals related to the mortality
rate of children under five years old, the HIV prevalence rate, and the malaria mortality
rate have been achieved, while the maternal mortality ratio has also fallen significantly
toward the target (United Nations Development Program, 2015).
In the meantime, the number of deaths from non-communicable diseases (NCDs),
including cardiovascular disease, cancer, chronic respiratory disease and diabetes,
increased from 0.399 million in 2000 to 0.58 million in 2015 (World HealthOrganization, 2017) due to factors such as changes in dietary habits and lifestyle aswell as tobacco use. According to the Disability-Adjusted Life Year (which measuresthe disease burden expressed as the number of years lost due to early death orillness), the disease burden from cardiovascular disease almost tripled between 1990
and 2013, while the disease burden from diabetes increased by almost 150% during
the same period (Institute for Health Metrics and Evaluation, University of Washington,2013). This means that NCD control is an urgent issue.
Additionally, the number of people moving into cities has been rapidly increasing
due to the economic growth and loss of land and property caused by natural disasters
in recent years. As of 2010, 30.5% of the total population live in cities, of which 21.3%
live at or below the poverty line (World Bank, 2017). The population of slum areas inDhaka is the highest in Bangladesh at 3.4 million (37.4% of the city’s total population)and its population density is 0.22 million people per square kilometer (NationalInstitute of Population Research and Training, 2005). About 60% of residents have noaccess to running water, and about 10% have no access to clean toilets (Institute ofHealth Economics, University of Dhaka, 2015). Under these circumstances, 69.5% ofresidents go to the pharmacies as a first step, while only 13.9% use public healthcare
facilities that generally provide healthcare services free of charge (Institute of Health
Economics, University of Dhaka, 2015). This means that improved access to publichealthcare facilities is urgently required by the urban poor population.
In terms of healthcare services in Bangladesh, primary healthcare, including
screening and control of diseases, is provided at the primary healthcare facilities thatare closest to the residents (community clinics; hereinafter referred to as “lower-level
primary healthcare facilities”). Diagnoses and treatments are provided at upper-level
primary healthcare facilities (upazila health complexes) and secondary healthcare
facilities (district hospitals, etc.), while more specialized diagnoses and treatments areprovided through tertiary healthcare facilities (university hospitals, etc.). However, thescreening systems required for early detection and diagnosis have not yet been
sufficiently established, and residents still have a low level of awareness about theimportance of disease prevention. Furthermore, as the systems at primary healthcare
facilities in urban areas have not yet been sufficiently established, the urban poor
population only has limited access to healthcare services. The Health Services
Strengthening Project (hereinafter referred to as the “Project”) is intended to establish
a system for strengthening NCD control and access to health services by the urban
poor population in Dhaka by improving the quality of health services at primary andsecondary health facilities in all divisions, thereby contributing to improved health forthe people of Bangladesh. Bangladesh’s 7th Five-Year Plan (FY2016/17–FY2020/21)
and the 4th Health, Population and Nutrition Sector Programme (2017–2022;
hereinafter referred to as the “4th Health Sector Programme”), which is acomprehensive health sector development program, identify the following asimportant new issues in the health sector: preventing and controlling NCDs; achieving
universal health coverage through the provision of healthcare services to the urban
poor population; and enhancing access to healthcare services.
(2) Japan and JICA’s Cooperation Policy and Operations in the Health Sector
The JICA Country Analysis Paper for Bangladesh (May 2014) states that it isnecessary to strengthen health systems in a comprehensive manner by improving theseries of public health services provided by primary to tertiary healthcare facilities andby improving reliability. In addition, Japan’s Country Assistance Program for
Bangladesh (February 2018) states that, through a cooperation program forovercoming social vulnerabilities, which is one of the priority areas for assistance,
Japan will contribute to achieving universal health coverage by improving publichealth services, especially for maternal and child health, implementing measures for
NCD control, and strengthening health systems. Furthermore, the ProjectDevelopment Plan (April 2014) also states that Japan will, in response to demand forimproved hospital facilities and equipment, provide support by participating in SWAps
in order to strengthen health systems and enhance the quality and quantity of basic
healthcare services. The Project is, therefore, consistent with these policies and theanalysis. The Project is intended to contribute to improving public health inBangladesh by strengthening the referral system for NCDs and enhancing the urban
poor population’s access to healthcare services, thereby contributing to Goal 3 ofSDGs (“Ensure healthy lives and promote wellbeing for all at all ages”).
(3) Other Donors’ Activity
In Bangladesh’s health sector, with the aim of promoting the implementation of the
4th Health Sector Programme, all 14 donors have been providing support under theframework of SWAps by using numerous methods, such as contributing to a pool fundcalled a multi-donor trust fund as well as providing bilateral and multilateral aid. The
World Bank has supported the 4th Health Sector Programme as a primary donor andhas been responsible for managing the multi-donor trust fund. In partnership with theLocal Government Division of the Ministry of Local Government, Rural Developmentand Cooperatives (LGD), the Asian Development Bank has supported thedevelopment of primary health care in cities by providing support for healthcare
facilities under the LGD’s jurisdiction. No duplication of work has occurred as theProject provides support for healthcare facilities under the jurisdiction of the Ministry ofHealth and Family Welfare (MoHFW), which are different from healthcare facilities
under the jurisdiction of the LGD.
3. Project Description(1) Project Objective(s)The objective of the Project is to establish a system for strengthening NCD control
and access to health services by the urban poor population in Dhaka by improving thequality of health services at primary and secondary health facilities in all divisions,
thereby contributing to improved health for the people of Bangladesh.
(2) Project Site / Target Area
Throughout Bangladesh(3) Project Component(s)1) Strengthening NCD Control: To strengthen the screening systems for NCDs atprimary and secondary healthcare facilities, improve equipment, provide training,and expand and reconstruct facilities.
*To strengthen the referral system, the Project’s target facilities will be selectedfrom primary and secondary healthcare facilities throughout Bangladesh basedon health-system enhancement scores, which are determined by the MoHFW
from the perspective of the provision of healthcare services and the operationand maintenance management.

2) Urban Health Improvement: To strengthen the screening systems used at urban
dispensaries (primary healthcare facilities) in Dhaka, improve equipment,
provide training, and reconstruct facilities.
*The Project aims to enhance the capacity for accepting patients at primary
healthcare facilities in Dhaka and ease the concentration of patients at tertiary
healthcare facilities in urban areas, thereby contributing to more efficient
diagnosis and treatment systems at tertiary healthcare facilities.
(4) Estimated Project Cost (Loan Amount)
8,285 million Yen (Loan Amount: 6,559 million Yen)
(5) Schedule
June 2018–June 2022 (49 months in total). The Project will be completed uponcommencement of services at all facilities (June 2022). Because the Project
supports the 4th Health Sector Programme being implemented by the MoHFW, theProject will be completed in June 2022 at the same time as the programme iscompleted.
(6) Project Implementation Structure1) Borrower: The Government of the People’s Republic of Bangladesh
2) Guarantor: N/A
3) Executing Agency: The Ministry of Health and Family Welfare (MoHFW)
4) Operation and Maintenance System: The Project will be operated andmaintained by the MoHFW and the Public Works Department (PWD) of the Ministryof Housing and Public Works.
(7) Cooperation and Sharing of Roles with Other Donors
1) Japan’s Activity: Plans for improving the operation of urban dispensaries, which
will be developed under the technical cooperation project called the Project forStrengthening Health Systems through Organizing Communities (2017–2022), will
be utilized. In addition, screening and diagnosis systems at national university
hospitals, which are the top referral facilities in each jurisdiction, will be developed
under the Japanese ODA loan project called the Maternal, Neonatal and Child
Health and Health System Improvement Project (December 2015). Throughcollaboration with the latter project, the referral system connecting primary,secondary and tertiary healthcare facilities will be reinforced.
2) Other Donors’ Activity: Based on the 4th Health Sector Programme, aid activities
will be implemented, monitored and evaluated jointly by the Government of
Bangladesh and participating donors.
(8) Environmental and Social Consideration / Poverty Reduction / Social Development
1) Environmental and Social Consideration① Category: C② Reason for Categorization: Based on the JICA Guidelines for Environmentaland Social Considerations (published in April 2010), any undesirable impact

that the Project may have on the natural environment is likely to be minimal.
2) Cross-Cutting Issues: Considerations for poverty: The primary healthcare
facilities in Dhaka that will be supported by the Project provide healthcare services
mainly to the urban poor population living in neighboring slum areas. The urban
poor population’s access to healthcare services is expected to be improved throughthe strengthening of screening, diagnosis and treatment systems at these facilities.
3) Gender Category: [Gender Project] GI (S) (Gender Activities Integration Project)
Activity Components/Reason for Categorization:
It has been confirmed that the Project will be implemented according to genderequality strategies in order to promote the use of healthcare facilities by women.
For instance, the training to be provided under the Project will cover the issue ofgender equality. In addition, privacy-conscious screening areas andgender-segregated restrooms will be created when primary healthcare facilities arereconstructed or expanded.
(9) Other Important Issues: N/A
4. Targeted Outcomes(1) Quantitative Effects
1) Performance Indicators (Operation and Effect Indicators)
Baseline(Actual Value in 2017)

Target (2024)(Expected value 2 years
after project completion)

No. of lower-level primary
healthcare facilities that
implemented referrals toupper-level primary healthcare
facilities after a pilot referral
network was established(cumulative total)*1―2,273

No. of upper-level primary
healthcare facilities that
implemented referrals tosecondary healthcare facilities
after a pilot referral network wasestablished (cumulative total)*2―85

Indicatora) NCD control

No. of healthcare workers fromlower-level primary healthcare
facilities who participated intraining on NCD control(cumulative total)*10

No. of doctors and nurses who
participated in training on NCD
control (cumulative total)*202,273*45,525*5b) Improvement of urban healthNo. of doctors and nurses whoparticipated in training on NCD
control (cumulative total)*3096*6*1: 2,273 community clinics supported by the Project*2: 85 upazila health complexes supported by the Project*3: 16 urban dispensaries supported by the Project*4: Healthcare workers located at 2,273 community clinics supported by the Project(one worker per facility)*5: Total of 45 doctors per facility (participating in three types of training) and total of
20 nurses (participating in two types of training) at 85 upazila health complexes
supported by the Project*6: Total of six doctors and nurses per facility (three types of training) at 16 urban
dispensaries supported by the Project(2) Qualitative Effects
・ Understanding of NCDs at primary healthcare facilities will improve and workers
at these facilities will be able to provide lifestyle guidance to prevent NCDs.
・The number of outpatients and urban poor visiting urban dispensaries will
increase.
・ The number of outpatients at the primary health care level will decrease at
tertiary healthcare facilities in Dhaka.
・The lifestyle guidance provided at primary and secondary healthcare facilities will
improve residents’ awareness about NCD prevention and change their lifestyles.
・ The system for referring NCD patients from upazila health complexes tosecondary healthcare facilities will be strengthened.
・The system for referring NCD patients from secondary healthcare facilities totertiary healthcare facilities will be strengthened.
・ The system for making referrals from urban dispensaries to higher-level
healthcare facilities will be strengthened.
(3) Internal Rate of ReturnSince healthcare facility users will not be charged fees under the Project, theFinancial Internal Rate of Return (FIRR) will not be calculated. In addition, theEconomic Internal Rate of Return (EIRR) will not be calculated because estimatingthe number of people who contract diseases due to a failure to implement disease
prevention measures or screening is impossible and quantifying the benefits
generated by improving medical services and convenience is extremely difficult.
5. Preconditions / External Conditions(1) Preconditions: N/A(2) External Conditions: N/A
6. Lessons Learned from Past Projects
The results of the ex-post evaluation of the Regional and Provincial Hospital
Development Project in Vietnam revealed the following: (1) when the procurement ofequipment and training on its usage is planned, training must be scheduled to becompleted prior to the procurement of the equipment and materials so that thetargeted outcomes are realized at an early stage; and (2) it is important to establish
project objectives that are consistent with the output and the appropriate operationand effect indicators.
The schedule for the Project has been developed to provide as much training as
possible prior to the procurement of the equipment and materials so that the targeted
outcomes will become visible after the equipment and materials are installed. This
training is for healthcare workers engaged in screening and those responsible formaintaining the equipment and materials used for the screening of NCDs at primaryand secondary healthcare facilities. Additionally, the Project aims to establish asystem that will contribute to the strengthening of NCD control and to improved
access to healthcare services for the urban poor population in Dhaka. Therefore, inthe first stage, the outputs of NCD prevention and an increase in the number of urban
poor using primary healthcare facilities will be examined as qualitative effects.
Subsequently, operation and effect indicators will be established based on the outputs,
including improvements to the screening equipment and facilities, as well as theimplementation of training.
7. Evaluation Results
The Project is consistent with Bangladesh’s development issues and policies andwith the cooperation policies and the analysis of the Government of Japan and JICA.
The Project is expected to contribute to improved public health in Bangladesh bystrengthening the referral system for NCDs and by enhancing the urban poor
population’s access to healthcare services, thereby contributing to SDG 3 (“Ensurehealthy lives and promote wellbeing for all at all ages”). Thus, the necessity for JICA tosupport the Project is substantial.
8. Plan for Future Evaluation(1) Indicators to be Used
As described in (1)-(3) of Section 4.
(2) Timing
Ex-post evaluation: Two years after the project completion