Private Sector Investment Finance
Ex-Ante Evaluation

1. Name of the ProjectCountry: People's Republic of Bangladesh
Project: East-West Medical College Hospital ProjectSigning Date: July 3, 2018
Investee : Ship Aichi Medical Service Limited

2. Background and Necessity of the Project
In Bangladesh, the lack of sufficient medical infrastructure and the shortage of medical
human resources are major issues in the field of healthcare. The number of hospitalbeds in Bangladesh per 10,000 population is extremely low at only 6 (World HealthStatistics 2014) (The global average is 27 beds, and the average for lower
middle-income countries including Bangladesh is 10). There is also a serious deficit ofhealthcare workers, as the total number of physicians, nurses, midwives, dentists andpharmacists per 1,000 population is 0.66. (WHO defines a country with fewer than 2.28
healthcare workers per 1,000 population as having a critical shortage) (The World
Health Report 2016).
In addition, the structure of diseases is currently in transition due to factors such aschanges in dietary habits and lifestyle, with Non-Communicable Diseases (NCDs)
becoming a major challenge in Bangladesh. NCDs, including cardiovascular diseases
and cancers, account for 61% of all diseases (Health Bulletin 2016) and 59% of deaths(NCDs Country Profile 2014). The number of patients admitted to the National Instituteof Cardiovascular Diseases increased three-fold between 2002 and 2014 (HealthBulletin, 2014). However, few hospitals are in charge of high-level medical care,including definite diagnoses and treatment of NCDs. Among public hospitals, only about
30% of upazila health complexes and about 50% of district hospitals offer definite
diagnoses of diabetes (Health Facility Survey 2014). Also, only 0.3% of health facilities
nationwide have diagnostic functionality based on CT scans (Health Facility Survey2014). Under these circumstances, the improvement of medical infrastructure and thedevelopment of medical human resources, particularly in response to NCDs, havebecome challenges for Bangladesh.
Under the framework of donor coordination through a sector-wide approach, theGovernment of the People’s Republic of Bangladesh has set forth the development of
medical facilities (Physical Facilities Development) as part of its "4th Health, Populationand Nutrition Sector Programme (HPNSP) 2017 -2022" with the aim of ensuring fair andhigh-quality healthcare for all citizens. The Government will work to establish hospitals,
renovate and improve the quality of existing medical facilities, and strengthen humancapital. In addition, the Strategic Plan in the Programme aims to achieve universal
health coverage by improving and expanding medical services utilizing the private
sector in addition to the public sector.
Japan's "Country Assistance Policy for the People's Republic of Bangladesh" (February2018) identifies "overcoming social vulnerability" as a priority area in order to support
the country's "acceleration of economic growth that can benefit all citizens toward its1

transition to a middle-income country," and sets out "human development" as adevelopment issue. In the Assistance Policy, the overwhelming shortage of healthprofessionals at medical facilities, the management of hospitals, and the improvementof facilities and equipment were identified as issues to be addressed. Support toimprove the quality and quantity of health and medical services is listed as a responseto the issues. In addition, the JICA Country Analysis Paper for the People's Republic ofBangladesh (May 2014) points out that the absolute shortage of health workers and thestandardization of their quality (knowledge and technical level) are challenges in thecountry, and healthcare is positioned as a priority area.
To date, JICA has been providing support to improve the medical facilities andequipment for the early diagnosis of NCDs, and to improve the educational environment
at nursing universities through the ODA loan project titled "Maternal, Neonatal and Child
Health (MNCH) and Health System Improvement Project" (Signed in December 2015).
Furthermore, support has been provided to develop nurses on bachelor's courses
through the "Project for Capacity Building of Nursing Services (technical cooperationproject)" (July 2015 to June 2020). Support has also been provided for capacity building
to address the challenges of NCDs and for taking urban health measures at thecommunity level in the "Project for Strengthening Health Systems through Organizing
Communities (technical cooperation project)" (July 2017-). On the other hand, support
has not been provided for comprehensive and high-level medical services including
medical treatment, and this project complements the initiatives in the field of health andmedical care that have been implemented so far. In addition, the "Future Investment
Strategy" of the Government of Japan (Cabinet decision made in June 2017) aims toestablish about 20 Japanese medical care bases overseas mainly in emerging
countries by 2020. The "Healthcare Policy" (Cabinet decision in July 2014) calls for theactive use of JICA's Private Sector Investment Finance to expand exports of medicalservices.

3. Project Description(1) Project Objectives
The Project aims to provide medical services based on the expertise of Japanesehospital administration through expanding the facilities, constructing a new wing toincrease the number of hospital beds, and establishing new medical departmentswith a high degree of specialization at East-West Medical College Hospital, thereby
improving medical care standard in Bangladesh..
(2) Project Site/Target Area
Dhaka, the People’s Republic of Bangladesh(3) Project Components
Extension (1st floor) and reinforcement work (1st to 4th floor) to the existing wardsof East-West Medical College Hospital (EWMCH), construction of an Annexbuilding (10 stories) and a Service building on the premises, and management of allhospital facilities including the existing wards. The number of beds after theextension will be 584 (currently 280).
(4) ScheduleApril 2019 Partial opening of the hospital2

April 2020 Opening of all medical departments(5) Project Implementation Structure1) Investee: Ship Aichi Medical Service Limited (SAMSL)
2) Executing Agency: SAMSL
3) Operation and Maintenance Agency: SAMSL(6) Environmental and Social Consideration/Poverty Reduction/Social Development
1) Environmental and Social Consideration(i) Category: C(ii) Reason for Categorization: Under the JICA Guidelines for Environmentaland Social Considerations (April, 2010), the project is likely to have minimal
adverse impact on the environment.
2) Cross-Cutting Issues: None
3) Gender Category: Gender Activities Integration Project<Description of activities and reason for classification>
The purpose of this project is to contribute to improving the standards of medicalcare in Bangladesh by investing in the extension work and operation, etc. of theprivate general hospital, which includes the department of obstetrics andgynecology.

4. Lessons Learned from Past Projects and Application to the Project
The ex-post evaluation of the ODA loan project in Vietnam "The Regional and Provincial
Hospital Development Project" (approved in March 2006) identified that capacity
building through technical assistance such as human resource development is usefulfor more effective use of the provided equipment and for improving medical services. In
this project, medical human resources will be developed with support from both local
and Japanese hospitals.
The ex-post evaluation of the Japanese Grant Aid project in the Philippines "The Projectfor Improvement of the Aurora Memorial Hospital" (approved in March 2010) identified
that when procuring equipment and materials, it is important to introduce a system
which enables the parties concerned to easily contact suppliers and distributors in orderto ensure stable equipment repair and purchase of spare parts, which will enable
continued and effective use of the equipment and materials. In this project, Green
Hospital Supply, Inc. (GHS) will play a central role in constructing a system in which alocal agency will conduct the maintenance. Since some of the medical equipment isplanned to be procured from GHS's group companies, a framework will be establishedwhich enables the local agency to contact the suppliers.

5. Evaluation Results
This project is in line with Bangladesh's development issues and policies, as well asJapan's and JICA's assistance policies. In addition, it is expected to contribute to SDGs
Goal 3 (healthy lives and well-being). Therefore, it is highly necessary for JICA tosupport the implmentation of this project.

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