Ex-Ante Evaluation (for Japanese ODA Loan)
South Asia Division 1, South Asia Department, JICA
1. Name of the ProjectCountry: India
Project: Project for the Setting-up of All India Institute of Medical Sciences
Madurai
Loan Agreement: March 26, 2021
2. Background and Necessity of the Project(1) Current State and Issues in the Heath Sector/in Tamil Nadu, India
In India, there is a serious shortage of medical human resources and there isjust 0.86 doctors per 1,000 population (WHO, 2018), falling below the World
Health Organization recommended level of at least 1 doctor per 1,000
population. One of the reasons for the shortage of doctors is a shortage of
medical education and research institutions. According to the Ministry of Healthand Family Welfare (hereinafter “MoHFW”), there are about 554 medical
universities in the country with an annual enrollment capacity for Bachelor of
Medicine courses of about 80,000 students (MoHFW, 2019), but this is not a
sufficient number to educate enough doctors to satisfy demand for medical
service due to the rapid population growth in India. The government of India(hereinafter “GoI”) is developing medical universities in the country from 2012
to 2021 to increase enrollment capacity by 4,000 students per year. This
shortage of medical human resources all over India has led to an insufficient
distribution of medical human resources in the public health sector particularly
in primary and secondary health care institutions, where the salary is relatively
low compared to private medical institutions. In addition, there are issues suchas inadequate facilities and equipment. These issues have led to a lack ofadequate quality medical services. As a result, middle/low-income patients thatare not able to visit private medical institutions with high medical costs still haveto rely on public medical services. However, these patients are not able toreceive adequate medical services at public primary and secondary health careinstitutions due to the serious shortages of both medical human resources andequipment and this has led to excessive congestion of patients in tertiary healthcare institutions. Patients who want to receive adequate medical treatment at
the limited number of tertiary health care institutions are forced to travel long
distances to visit the hospital and to encounter problems such as long waitingtimes due to the extreme congestion of patients, causing issue such as delays
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in the provision of medical treatment to patients in need of advanced medicalcare which only tertiary health care institutions can provide. Given suchchallenges, it is extremely difficult to achieve Universal Health Coverage(hereinafter “UHC”) where all individuals and communities can receive thehealth services they need.
In order to address this situation, GOI implemented the “Prime Minister’s
Health and Safety program (Pradhan Mantri Swasthya Suraksha Yojana,
hereinafter “PMSSY”) starting in 2003, aiming to improve access to advanced
public medical services and the quality of public health care, to correct regional
disparities and to establish international standard medical universities andeducational institutions. GOI is constructing the “All India Institute of Medical
Sciences” (hereinafter “AIIMS”) nationwide in selected areas in which access to
medical care is limited. AIIMS is a public medical institution which has three
aspects (1) function of providing the highest level medical services in the country,(2) function of educating 4,000 like doctors and nurses every year, and (3)function of medical study and research. The first AIIMS was established in Delhi
in 1956 and there about 4 million outpatients annually from all over the country
can receive international standard medical services with affordable prices
considering the income level of each patient. In addition, AIIMS is carrying out
cutting-edge medical education and research. PMSSY set AIIMS Delhi as areference institution for other AIIMS and plans to establish AIIMS in 23 locations
nationwide as regional centers for clinical studies and advanced medical
research in community health care in addition to regional centers for medical
human resource development. As of 2021, seven new AIIMS have been
established and are in operation. AIIMS is expected to not only provide
advanced medical services, share knowledge from medical research and supply
medical human resources as an educational institution, but also work with thestate government and tertiary hospitals in the region, enhancing the capacity ofregional medical systems through direct human resource distribution such as
the dispatch of medical interns and medical students as part of internshipprograms etc. to primary and secondary health care facilities.
The state of Tamil Nadu, one of the planned states for the establishment of a
new AIIMS under PMSSY, has a population of about 72 million (2011 Census)
and it is one of the most urbanized states in the country. As the urban population
grows in cities such as Chennai in Tamil Nadu, the low income population is also
increasing and the low income population is reaching about 20% of the total
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urban population or 7.3 million. This has led to the same problems of patientcongestion and dysfunction in public tertiary health care institutions as observed
around the country. In particular, the second largest city in the state, Madurai(population of about 1 million, 2011 Census), where the new AIIMS will beestablished only has one tertiary medical institution, Rajaji Hospital, which
receives middle and low income patients who are not able to access private
medical services due to the high cost. However, the bed occupancy rate of thehospital is always in excess of 95% (the average in Japan is about 80%, MHLW
2019) and issues such as patient congestion and dysfunction as a public tertiary
hospital can also be observed. There is also a serious shortage of medical staff
in Tamil Nadu, with just 2.2 healthcare workers per 1,000 population, less thanhalf of the standard recommended by WHO (4.5 per 1,000 population) (WHO,2016). Many patients are forced to travel long distances and wait for a long timeat the hospital etc., and they are not able to receive timely and appropriate
medical services. In addition, it is considered that more patients potentially may
not be receiving medical services, making it difficult to realize UHC. In thisrespect of COVID-19, it has seen a cumulative number of infected people in thestate of about 850,000 as of March 1, making the state one of the hotspots in
the South Indian region and the number of infected in the state is the fifth highest
in the country. From this perspective as well, it is an urgent issue to strengthen
the capacity of receiving patients, and the GOI is proceeding in newly
established AIIMS with developing infectious disease wards that can also
handle COVID-19.
The Project for Setting-up of All India Institute of Medical Sciences Madurai(Hereinafter “the Project”) will contribute to improving the quality of medical
services including for infectious diseases such as COVID-19 and noncommunicable diseases, and contribute to the development of medical
personnel and the enhancement of a medical personnel supply system for thecommunity through the construction of hospital and university facilities and theinstallation of related equipment enabling the provision of advanced public
medical services and human resource development as well as capacity
development for hospital management and the enhancement of humanresource development systems through the establishment of AIIMS Madurai
which will operate as a regional medical center in Tamil Nadu. The Project aims
to enhance the health care system in the region and promote UHC, and it istherefore positioned as an important project for India’s health sector.
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(2) Japan and JICA’s Health Sector Policy and the Positioning of the Project
It is the Country Assistance Policy for India (March 2016) formulated by theGovernment of Japan establishes “Health and Hygiene” as a priority area andstates its support for the health and hygiene sector as part of efforts to develop
basic social services. In addition, the JICA Country Analysis Paper for India(March 2018) mentions the strengthening of measures against infectious
disease and broadly improving direct access to health services for the poor asa one of the prioritized efforts under the “basic social service improvement
program” as a part of “support for sustainable and inclusive growth”. Thus, theProject is consistent with this policy and analysis.
The Project plans to develop an infectious disease ward (planned to be 150beds), and it is also in line with some of the effort to “establish and strengthen
systems for infectious disease diagnosis and treatment” as a part of the “JICA’s
Initiative for Global Health and Medicine” supporting Prime Minister Suga’s
speech at the United Nations General Assembly on September 25, 2020.
Furthermore, the Project will contribute to the achievement of Goal 3 of the
Sustainable Development Goals (ensure healthy lives and promote well-being
for all ages). Therefor JICA’s support for the implementation of the Project ishighly necessary.
(3) Other Donor’s Activities
The World Bank provided support for the health sector in India with a policythat places importance in improving the quality of health care services, and asof October 2020 The World Bank has approved 11.421 billion dollars for 61
projects, including a loan project to strengthen the health system in Tamil Nadu
(Phases 1 and 2: 2005-2014). The Asian Development Bank (hereinafter “ADB”)
has a record of implementing loan projects under the National Urban HealthMission (NUHM) with the Indian government for the purpose of improving
medical care access to the poor (2015-2019).
Further, for the COVID-19 pandemic, the World Bank provided a 1 billion USD
loan and the ADB separately provided a 500 million USD loan to the “COVID19 Emergency Response and Health System Preparedness Package”
announced by the Indian government as a roughly 2 billion USD health program.
3. Project Description(1) Project Objective
The objective of the Project is to establish All India Institute of Medical Sciences4

in Madurai, Tamil Nadu, as a signature medical institution in South India
including both health care and medical education (i) to improve access to highquality medical services, (ii) develop healthcare professionals and researchersof high standards, thereby augmenting human resource in the region as well as
across the country to contribute to universal health coverage in India.
(2) Project Site/Target Area
Madurai, State of Tamil Nadu (Population of about 1 million, 2011 Census)(3) Project Componentsa) Construction of hospital facilities (about 900 beds) and university facilities(total number of students: about 1,500), installation of medical equipment
and training equipment etc., and operation & maintenance servicesb) Consulting Services (detailed design, bidding assistance, construction
supervision, hospital management and human resource capacity
development and system enhancement, regional medical systemstrengthening, promotion of networking between Japanese and Indian
medical communities, support for environmental and social consideration,etc.)(4) Estimated Project Cost
27.690 billion yen (ODA loan amount: 22.788 billion yen)(5) Schedule
March 2021 to May 2028 (86 months). The project will be completed upon
the commencement of service of the hospital and university facilities (October2026).
(6) Project Implementation Structure1) Borrower: President of India
2) Guarantor: None
3) Executing Agency: PMSSY Division of Ministry of Health and Family
Welfare4) Operation and Maintenance Agency: AIIMS Madurai(7) Collaboration with Other Schemes and Donors
1) Japan’s Assistance Activities
With the ODA loan, “Tamil Nadu Urban Health Care Project” aims topromote joint training, research and cooperation between the hospital andthe medical facilities established in the state (mainly secondary and tertiary
health care facilities) and to strengthen the regional medical referral system.
In addition, ODA loan project “The COVID-19 Crisis Response Support Loan
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for Social Protection” is expected to provide synergistic effect with this projectin support the Indian government’s COVID-19 response.
In addition, through the “Technical Cooperation Project on Non
Communicable Diseases” to be implemented in the state, training programs
are planned to be conducted in Japan for the purpose of handling the noncommunicable disease issue in the state, and this is also expected to havesynergistic effect with the Project. Also, a request has been received from
GOI for Country-Focused Training for “Advanced Training in the field of
Medical Science & Management for AIIMS-like Institutes,” requesting training
to enhance the health system, hospital management, public health plans, andmeasures for infectious and non-communicable diseases for all AIIMS
officials including at AIIMS Madurai, and this is currently being considered by
the government of Japan and is expected to have a synergistic effect with the
Project.
2) Other Donors’ Assistance Activities: N/A(8) Environmental and Social Consideration / Cross Sectoral Issues / Gender
Category
1) Environmental and Social Considerations(i) Category: B(ii) Reason for Categorization: The Project is not located in a sensitive area,
nor has sensitive characteristics, nor falls into sensitive sectors under
the JICA guidelines for environmental and social considerations (April2010), and its potential adverse impacts on the environment are not
likely to be significant.
(iii) Environmental Permit: The reparation of an Environmental Impact
Assessment (EIA) report for the Project is mandated by local law, andapproval is expected to be obtained from the Tamil Nadu government
authorities at the State Environmental Impact Assessment Authority by
September 2023.
(iv) Anti-Pollution Measures: Measures such as watering to prevent dust,
limitation of construction vehicle speeds and other mitigation measures
will be taken during construction to ensure that the Project complies withlocal laws with respect to air quality, water quality, noise/vibration andwaste. While in service, medical sewage will mainly be reused after
processing in sewage treatment equipment, and medical waste will beseparated into infectious, living tissue and sharp objects and will be
6collected by a designated contractor based on local law.
(v) Natural Environment: The target area of the Project is not part of nationalparks and construction will be conducted on state government property,
and any undesirable impacts on the natural environment are assumed
to be minimal.
(vi) Social Environment: Given that the Project will be implemented on land
wholly owned by the state government, it does not involve any
acquisition of private land or the involuntary relocation of residents. It
has been confirmed that there is no particular objection to theimplementation of the Project from residents around the project site.
(vii) Other/Monitoring: Contractors monitor air quality, waiter quality,
noise/vibration, waste, etc. during construction and executing agency
monitor waste, etc. when in service.
2) Cross-Sectoral Issues(i) Climate Change: N/A(ii) Poverty Response/Consideration: Access of the poor to public medical
services is expected to be improved.
(iii) Consideration for Persons with Disabilities: The facilities in the Project
shall install slopes and handrails and shall be designed taking into
account universal design such as allowing sufficient space inpassageways and toilet design allowing the use of wheelchairs.
Consideration shall also be given to appropriate measures to securesmooth movement routes from the site entrance to destination buildings,
to ensure information security for the visually impaired, hearing impairedor persons with intellectual disabilities who need communication
assistance, and to provide appropriate measures to deal withemergencies such as fire, disaster and infectious disease.
(iv) Countermeasures against Infectious Diseases such as AIDS/HIV: The
contractor shall take appropriate measures against AIDS infection
during the construction stage. Moreover, at the time of appraisal, theexecuting agency agreed to a list of countermeasures (36 items) thatmust be taken when formulating and implementing the Project asmeasures against COVID-19 infections. Items include the formulationof and adherence to behavioral patterns for infection prevention andthorough implementation of contractual considerations for contractors
in the event that COVID-19 infection spreads.
73) Gender Category
Gender Project ■ Gender Informed (Significant) (Gender Activity
Integration Project)
Activity Description/Reason for Categorization: For the Project, it has been
agreed with GOI that toilets and other facilities shall be installed reflecting
the safety and gender needs of women, equality of schooling andemployment opportunities shall be ensured, equipment shall be introduced
based on the needs and ease of use of female healthcare professionals,
and public awareness activities for communities shall be carried out for
diseases that are common in women such as breast cancer.
(9) Other Important Issues: N/A
4. Targeted Outcomes(1) Quantitative Effects
Outcomes (Operation and Effect Indicators)
Baseline*

Indicator(2020 Actual)

Bed occupancy rate (%)
No. of inpatients/day (people)
No. of outpatients/day (people)
No. of emergency patients/day(people)No. of enrolled medical students(MBBS) (people/year)
No. of enrolled nursing college
students (people/year)
Staff sufficiency rate (%)

Target (2030)(two years after
Project Completion]

95
-

90
116
5,000

-

48

-

150

-

150

71

80

(*Regarding the baseline, bed occupancy rate is the figure from the only public tertiarycare hospital in Madurai, Rajaji Hospital, and staff sufficiency rate is the figure from the
AIIMS Delhi, the first established AIIMS in the country.)(2) Qualitative Effects
The promotion of UHC through the strengthening of the medical system in
Tamil Nadu state for non-communicable diseases and infectious diseases
including COVID-19, the enhancement of the regional center function foradvanced medical research and capacity development of medical humanresource, and the expansion of employment of young people, including women,
by strengthening the education system for doctors and nurses.
8(3) Internal Rate of Return
Based on the following assumptions, the economic internal rate of return(EIRR) of this project will be 25.1%. On the other hand, given that the Project is
not intended to be a for-profit project, the financial internal rate of return (FIRR)
is not calculated.
[EIRR]
Costs: Project costs, operation and maintenance costs (all excluding tax)
Benefits: Reduction of medical costs for patients in private hospitals by the
Project, economic growth by reducing the number of patient death,and increased lifetime income of educated doctors and nurses
Project Life: 38 years
5. Preconditions and External Conditions(1) Preconditions: None
(2) External Conditions: None
6. Lessons Learned from Past Projects and Application to the Project
From the ex-post evaluation results etc. of the “Rural Health Infrastructure
Strengthening Project” in the Kingdom of Thailand (2005), the lessons werelearned that it was necessary to select medical equipment after carefully
determining the capabilities of hospital staff involved in operation andmaintenance and the budget for operation and maintenance. In addition, from the
ex-post evaluation results of the grant aid “The Project for Improvement ofAnuradhapura Teaching Hospital” in the Democratic Socialist Republic of Sri
Lanka (2013), the lessons were learned that in higher-level medical facility setup projects in areas in which there is no adequately functioning referral system,
if the number of mildly ill non-referral patients was expected to increase following
the completion of construction, it was effective for increasing the effectiveness of
this project and maintaining its impact that priority initiatives be introduced forpatients in need of advanced treatment.
Under the Project, AIIMS is operated and maintained by government subsidy
and until now all necessary budget has been allocated to AIIMS from the central
government, but it will be necessary to keep an eye on whether this continues tobe the case with the Project. Also, as a part of the consulting services provided
by consultants employed at the construction supervision stage, it is planned that
according to the maintenance capabilities of hospital staff and maintenancebudgets, support will be provided for detailed maintenance plans to be formulated
9and related training conducted for correct operation and maintenance and theselection of appropriate medical equipment. In addition, the development of ahealth system in cooperation with the regional medical system including a
medical referral system is a role expected of AIIMS, and the initiatives of the
AIIMS Madurai will be supported through the consulting services of the Project.
7. Evaluation Results
The Project is consistent with the development issues and policy of India as
well as the policy of Japan and JICA. It will contribute to the improvement of
medical service quality, including infectious disease control, and theenhancement of medical personnel development and the supply system in Tamil
Nadu state through the construction of hospital and university facilities and theinstallation of related equipment for advanced medical care and human resource
development, and support for enhanced hospital management and humanresource development system. Moreover it will contribute to the achievement ofGoal 3 of the Sustainable Development Goals (ensure healthy lives and promote
well-being for all ages). Therefore JICA’s support for the implementation of the
Project is highly necessary.
8. Plan for Future Evaluation(1) Indicators to be Used
As indicated in section 4 above.
(2) Timing of the Next Evaluation
Ex-Post evaluation: two years after the Project’s completionEnd10