Japanese ODA Loan
Ex-Ante Evaluation (for Japanese ODA Loan)
South Asia Division 1, South Asia Department
Japan International Cooperation Agency
１．Name of the Project(1) Country: India(2) Project: Project for the Establishment of Mizoram State Super-SpecialtyCancer and Research Centre(3) Project Site / Target Area: State of Mizoram（total population: about 1.1
million（2011 India Census））
Loan Agreement: February 27, 2023
２．Background and Necessity of the Project(1) Current State and Issues in the Health Sector/Area and the Priority of theProject in India
Non-communicable diseases (NCDs) such as cancer, diabetes, andcardiovascular diseases are a major issue in India across the country, mainly
due to changes in lifestyle with increasing economic development. It has
become a major challenge in the health sector. The proportion of deaths due toNCDs in India exceeds 60% of all deaths (Government of India, 2016), andamong NCDs, the annual incidence of cancer has nearly doubled from about
550,000 in 1990 to about 1.1 million in 2016 (The Lancet, 2018).
State of Mizoram has the second highest incidence of cancer in the country(129.6 females and 113.4 males per 100,000 of the population) after State ofKerala (137.3 females and 133.4 males per 100,000) as of 2016 (The Lancet,2018), and the mortality rate (number of deaths/number of patients) of cancer
patients is 52.4% for men and 39.7% for women as of 2016, the highest in thecountry (ICMR-NCDIR, 2021). The state government has identified this as thebiggest challenge in the state's health sector, and has stated in the Mizoram
Health Policy, which is being formulated, that cancer treatment should becompleted within the state. The state government also addressed that Mizoram
should be a model state for developing a comprehensive cancer control systemthat includes cancer prevention, screening, treatment, human resource
development, and research. At present, however, there is only one tertiary-level
public medical facility, the State Cancer Hospital, which faces issues such as
the shortage of medical facilities, equipment, and specialized personnel, as well

as a lack of a system for training medical personnel, and thus a comprehensive
cancer control system is required.
The objective of the Project is to improve access to cancer prevention,detection, and treatment as well as human resource development and researchthat support cancer control system, by developing Mizoram State’s cancercontrol system through the establishment of the Mizoram State Super Specialty
Cancer and Research Centre in Mizoram state thereby contributing to achieving
Universal Health Coverage through strengthening the healthcare systempertaining to cancer in the state.
(2) Japan’s and JICA’s Cooperation Policy and Operations in the Health
Sector/Area
The country-based Development Cooperation Policy for India (March 2016)
identifies "support for sustainable and inclusive growth" as a priority issue, and"health and sanitation" is among these key areas. In addition, the key
development issue in the JICA Country Analytical Work for India (March 2018)
is "inclusive growth in rural areas." Here, the analysis indicates that further
expansion of health services is needed to improve the living conditions of thepoor. This project is consistent with these policies and analysis. Furthermore,
the project will contribute to the strengthening of prevention and treatment
systems as stated in the JICA's Initiative for Global Health and Medicine, and isin line with the JICA Global Agenda for Health emphasis on “strengthening
diagnosis and treatment capacity in core hospitals”.
(3) Other Donors’ Activities
The World Bank is implementing the "Mizoram Health Systems Strengthening
Project" (loan amount: US$32 million) in Mizoram for the period from 2021 to2026. One of the components of the project is "strengthening the quality ofhealth services and support through innovations," which will include therenovation of secondary and primary health care facilities, collaboration with theprivate sector in medical waste disposal and testing, and strengthening humanresource development and management. In addition, the Bank will work on
home-based palliative care and screening for NCDs (including cancer) throughlocal communities, etc., and establish comprehensive primary health careservices, and so on.
The Asian Development Bank has been implementing a public financeimprovement management program (loan amount: US$94 million) from 2009 to2015 in Mizoram, under which the state has established its own healthinsurance system. In addition, the Bank has provided financing to the National
Urban Health Mission, an initiative of the Indian government to improve accessto healthcare for the urban poor (amount of financing: US$300 million).
３．Project Description(1) Project Description① Project Objective
The objective of the Project is to improve access to cancer prevention,detection, and treatment as well as human resource development and researchthat support cancer control system, by developing Mizoram State’s cancer
control system through the establishment of the Mizoram State Super Specialty
Cancer and Research Centre in Mizoram state thereby contributing to achieving
Universal Health Coverage through strengthening the healthcare systempertaining to cancer in the state.
② Project Components
1) Building Mizoram state Super-Specialty Cancer and Research center2) Installing medical and training equipment at the Cancer ResearchCentre.
3) Support of Cancer Control System Establishment (strengthening ofoperational management and medical safety at the Cancer ResearchCentre, strengthening of diagnostic and surgical capacity,strengthening of facility and equipment maintenance andmanagement capacity, strengthening of prevention and screening
capacity for state government officials, school teachers, and medicalpersonnel)
4) Consulting services (detailed design, bidding assistance, construction
supervision, support for environmental and social considerations)(2) Estimated Project Cost
12,515 million Yen (including Japanese ODA loan: 9,918 million Yen)
(3) ScheduleFebruary 2022 to August 2033 (127 months). The project will be completed
upon the commencement of service of the hospital and university facilities(August 2028).
(4) Project Implementation Structure1) Borrower: President of India
2) Guarantor: N/A

3) Executing Agency: Government of Mizoram, Health and Family Welfare(HFWD)
4) Operation and Maintenance System：HFWD(5) Collaboration and Sharing of Roles with Other Donors
1) Japan’s Activity
JICA’s Long-term Training for UHC program can provide training inoncology, pathology, and other fields related to cancer treatment, etc.
So, JICA and HFWD confirmed to seek the possibility of nominating
concerned officers/human resource to apply for JICA’s long term
training for UHC program.
Other Donors’ Activity
Consider collaboration with the Mizoram Health Systems Strengthening
Project (2021-2026), which is being implemented by the World Bank.
(6) Environmental and Social Consideration
2)① Category: B② 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 (April 2010), and its potential adverse impacts on theenvironment are not likely to be significant.
③ Environmental Permit: EIA Report of the Project will be prepared by
HFWD and the authorized consultant and approved by State Level
Environment Impact Assessment Authority (SEIAA) to get an
Environmental Clearance by the commencement of the construction.
④ Anti-Pollution Measures: Air quality, water quality, noise, vibration,
and waste during construction will meet domestic emission andenvironmental standards. Dust control through water sprinkling,
speed limits for construction vehicles, and other mitigation measureswill be implemented. At the time of commissioning, medical
wastewater will be discharged into the general sewage system after
being detoxified by wastewater and effluent treatment facilities
installed at each facility as a unit. Waste from medical facilities will beclassified and stored according to laws and regulations, collected bydesignated contractors, and disposed of at medical waste treatment
plants designated by the state government. Radioactive waste will
also be disposed of in accordance with the waste management planbased on the guidelines of the country.
⑤ Natural Environment: The project area does not fall in or nearsensitive areas such as national parks, etc., and undesirable effects
on the natural environment are assumed to be minimal.
⑥ Social Environment: Since this project will be implemented entirelyon the existing hospital site and land owned by the state government(HFWD), there will be no land acquisition or involuntary resettlement.
No particular opposition to the Project has been observed fromresidents in the vicinity of the Project site.
⑦ Other/Monitoring: Contractors will monitor air quality, water quality,
noise, vibrations, waste, and other factors during construction, andthe implementing agencies will monitor those factors after thecommencement of services.
(7) Cross-Sectoral Issues① Poverty Reduction Measures and Consideration for the Poor:
Access to cancer control medical services for the poor population is
expected to be improved through the establishment of cancer control
systems in the public medical institution in the state.
② Infectious Disease Control Measures: As an initiative to prevent thespread of COVID-19, a list of measures (36 items in total) to be takenby the implementing agencies at the time of project formulation andproject implementation was agreed upon approval. Based on the list,
the detailed items to conduct were clearly stated, such as
maintenance of quarantine equipment and materials, improvement of
the working environment including dissemination of the code ofconduct, construction supervision, and awareness-raising. The
impact of COVID-19 will be closely monitored throughout the project
phase, with the agencies reporting on the status of implementation
on a quarterly basis. The agencies will also be monitored so that theytake flexible and appropriate actions. In addition, HIV/AIDS
prevention measures for construction workers will be taken by thecontractor during the construction phase.
③ Consideration for Person with Disabilities: In accordance with theNational Building Code of India and the Building Ordinance of theAizawl Municipal Council, the facilities in the Project shall installslopes and handrails and shall be designed taking into accountuniversal design such as allowing sufficient space in passageways
and toilet design allowing the use of wheelchairs. The facility will also
be designed to guarantee providing information to visually impaired,hearing impaired, intellectual disabilities, and other people who needto take reasonable care of their communication needs.
(8) Gender Category■Gender Informed (Significant) (Gender activity integration project)<Details of Activities/Reason for Categorization>
It has been agreed with HFWD that facility design will incorporate genderspecific needs, the Project will ensure women’s participation on every
opportunity such as employment and training program and equipment will beselected based on gender-specific needs and usability by both men and women.
In addition, this Project has also been confirmed to improve quality of treatment
services for female-specific cancers, in collaboration with various clinicaldepartments.
(9) Other Important Issues: None
４. Targeted Outcomes(1) Quantitative Effects
1) Outcomes (Operation and Effect Indicators)
Indicator
Baseline
Target (2030)(Actual value in 2019) [2 years after project completion]
Number of treatment(persons/year)
Radiotherapy
12,082
17,03601,027
Surgery
Chemotherapy
Computed Tomography(CT scan)Outpatient Department(OPD) number
Inpatient Department (IPD)
numberAverage Number ofOccupied Beds
(beds/day)

6,646

9,371

1,850

2,609

11,935

16,8392,776

3,9164171

Number of Referral Cases to1,000489
outside of the State related
to Cancer
50
Number of trained personnel
on cancer care under soft0(including 25 females）
component
Number of awarenessraising activities with a02
gender perspective
Development of gender1
based cancer patient0
counseling manual
Proportion of patient
37.5
diagnosed at early cancer
26.2
stage (stage I or II)
Screening coverage among
2.6
15
target population (average)* Baseline is the actual results at existing State Cancer Hospital.
Target is the number expected at the new Cancer Research Centre.
(2) Qualitative Effects
Improving accessibility to cancer prevention, screening, and treatment services.
Strengthening of quality of Human resource in the field of cancer treatment.
Stimulating cancer research. Raise awareness amongst residents regarding
cancer prevention measures.
(3) Internal Rate of Return
Based on the assumptions listed below, the economic internal rate of return(EIRR) for the Project is 17.4%. Cancer Research Centre to be developed
under this project will collect only actual costs from patients, such as the cost ofcancer tests and the cost of medicines necessary for the tests. Since the projectcosts are not at a recoverable level, the financial internal rate of return (FIRR)
has not been calculated.

【EIRR】
Cost：Project costs, Operation and Maintenance costs, etc. (All excludingtaxes)
Benefit：Benefit related to the ability to engage in productive activities dueto the extended life period; and Benefit from the reduced treatment costs
that would have been required if the project had not been implemented at
the private hospitals; and Benefits of reduced travel cost due to thedecrease of transport to out-of-state medical facilities.
Project Life：40 years
５. External Factors and Risk Control(1) Preconditions: None
(2) External Factors: None
６. Lessons Learned from Past Projects
From the results of the ex-post evaluation of the Japanese ODA loan
"National Islamic University Health and Medicine Project" for the Republic ofIndonesia (evaluation year: 2015), etc., we have learned the lesson that it isimportant to clarify as much as possible the utilization policy of procured
equipment including employment and operation plan of engineers at the time ofproject formulation for the equipment requiring special skills.
In this project, we have agreed with the HFWD on the staffing plans
necessary for the operation of the Cancer Research Centre to be established,
and the HFWD has confirmed that it will staff the Centre in accordance with theagreed plans. The staffing plan includes engineers who will manage the medical
equipment to be procured under the project. The budget required to implement
the staffing plan have also been confirmed with the Mizoram government at thetime of the appraisal. In addition, the project plans to manage the progress ofthe staffing plan and provide support for its implementation as part of theproject's support for the establishment of a cancer control system.
７. Evaluation Results
This project is in line with the country's development issues and policies, aswell as the cooperation policy and analysis of Japan and JICA, and willcontribute to the establishment of a comprehensive cancer control systems inthe state through the establishment of the Mizoram State Super-Specialty

Cancer and Research Centre, and support for human resource development
and research to support cancer control. The project will contribute to the SDGs'
Goal 3, "Ensure healthy lives and promote well-being for all at all ages", andtherefore, it is highly necessary 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