Ex-Ante Evaluation (for Japanese ODA Loan)
South Asia Division 1, South Asia Department, JICA
1. Name of the Program
Country: India
Program: COVID-19 Crisis Response Emergency Support Loan
Loan Agreement: August 31, 2020
2. Background and Necessity of the Program(1) Current State and Issues of COVID-19 in India
COVID-19, which has been declared a global pandemic by WHO in March
2020, has been spreading rapidly beyond borders across the world. By August31, 2020, over 25 million cases were confirmed worldwide. The first case ofCOVID-19 in India was reported on January 30. COVID-19 cases have been
surging nationwide since the end of March. By August 31, around 3.54 million
people had been infected and about 63,000 people had died because of its
infection (WHO, 2020). In response to the spread of COVID-19, the Governmentof India implemented a strict lockdown policy throughout the country on March
25. From June 8 onward, lockdowns have been lifted in steps excluding regions
where COVID-19 were still spreading. Still, both the numbers of infection casesand deaths are on the rise, leaving the tense situation unabated. In India, morethan 1,400 Japanese firms are operating, with more than 5,000 branches andoffices across the country. The lockdown policy has caused decrease in sales,suspension and reduction of factory production, and disruption of supply chains.
A survey conducted by JETRO at the end of April shows that more than 80
percent of the Japanese firms were facing various troubles upon their activities,
suggesting that the spread of COVID-19, if it is prolonged, will have a further
serious impact on their economic activities. Such Japanese firms also haveconcern on the condition of local healthcare system which they have to rely incase of infection. Improvement of healthcare system in India is a crucial issue inorder to enable businesses to reopen or to continue their stable operations.
The Government of India has been engaged in improving the health sector
through the National Health Mission. The Mission involves development ofprimary healthcare facilities across the country and development of humanresources for healthcare. Nevertheless, India’s public spending for the healthsector has remained at around one percent of GDP (Government of India, 2019),
leaving the country’s healthcare system extremely vulnerable. For example, thenumber of hospital beds and physicians per 1,000 people were 0.7 as of 2011
and 0.857 as of 2018 respectively, which are far below the world averages of
2.704 beds and 1.565 physicians. The number of physicians per 1,000 people inIndia is even below 1, which is the recommended level by WHO (World Bank,2020). The spread of COVID-19 has also exposed several vulnerabilities ofhealthcare system in India, which has turned out to be significant issues to besolved. They include (i) insufficient numbers of medical institutions andphysicians; (ii) an inadequate implementation structure for testing andmonitoring of infectious disease; (iii) short supplies of ventilators and medicalequipment especially personal protective equipment; and (iv) lack of facilities
that provide appropriate care for the infected patients. In addition, theGovernment of India has also acknowledged the necessity to develop anaffordable, efficient, and transparent healthcare system with the use of ICT,
which would contribute to improving the situation in the rural areas where people
have been suffering from the poor accessibility to healthcare service.
To control the rapid spread of COVID-19, the Government of India announced
India COVID-19 Emergency Response and Health System Preparedness
Package and its plan to provide about 150 billion rupees (approx. 210 billionyen) to each state government as emergency response funds for the healthcare
sector in March. Furthermore, in response to various issues in the healthcare
sector, especially with respect to infectious disease control, the Government ofIndia has developed a new healthcare scheme with around 900 billion rupees(approx. 1.3 trillion yen) named Pradhan Mantri Atmanirbhar Swasth Bharat
Yojana (PM-ASBY), which is to be announced soon (after Cabinet approval).
The bulk of the budget for the India COVID-19 Emergency Response and Health
System Preparedness Package has been allocated for the emergency response
in FY2020. PM-ASBY, on the other hand, will focus on additional emergency
responses in FY2020 and beyond as well as on mid-term improvements of thehealthcare sector. The total budget of the India COVID-19 Emergency Response
and Health System Preparedness Package (approx. 150 billion rupees) has
already been financed with the loans from several donors including World Bankand ADB. As for PM-ASBY, however, support from donors has not been
confirmed as of July 22, leaving a huge financing gap. To fill the gap, theGovernment of India is requesting external funding support for PM-ASBY, at theoccasion of donor meetings.
PM-ASBY, which is to be implemented by various government agencies underthe Ministry of Health and Family Welfare (MoHFW), is aimed for tackling
COVID-19 crisis as well as strengthening India’s healthcare sector to prepare for
future pandemics. The main components of PM-ASBY are; (1) Procurement of
medical equipment and supplies for the emergency response to COVID-19; (2)Establishment of health centers in both urban and rural areas; (3) Setting up ofhospitals for communicable diseases; (4) Augmentation of implementation
structure for healthcare surveillance; (5) Reinforcements of the research
structure for infectious diseases; and (6) Promotion of National Digital HealthMission for digitalization of the healthcare sector in India.
Given these issues in healthcare sector in India, COVID-19 Crisis Response
Emergency Support Loan (“the Program”) provides budget support to theGovernment of India engaging in emergency response to COVID-19 among
other healthcare challenges facing the country.
(2) Japan and JICA’s Cooperation Policy for COVID-19 and the Positioning ofthe Program
In Country Assistance Policy for India (March 2016), the Government of Japanhighlights “health and sanitation sector” as one of the priority areas andaddresses these sectors as part of its assistance in improving India’s basicsocial services for the purpose of supporting sustainable and inclusive growth inIndia. The JICA Country Analysis Paper for India (March 2018) points out theimportance of giving priority to major development issues with strong financial
needs for which Japan and JICA’s strengths can be applied, while
comprehensively assisting India's efforts in achieving SDGs. The analysis paper
also mentions that JICA will focus on strengthening of the management ofinfectious diseases and on improving access to healthcare services that candirectly benefit the economically challenged as part of “the Basic Social ServiceImprovement Program” under the pillar of “Supporting Sustainable and InclusiveGrowth”. The Program is consistent with these policies and analyses.
(3) Other Donors’ Activities
On April 2, the World Bank committed one billion US dollars as a project loan
to assist the Government of India in implementing the India COVID -19
Emergency Response and Health System Preparedness Package. The AsianInfrastructure Investment Bank (AIIB) pledged 500 million US dollars as
co-financing with the World Bank on May 8. At its Board of Directors meeting onApril 28, the Asian Development Bank (ADB) committed 500 million US dollarsas loans to support the same package as part of its assistance in tackling

COVID-19 employing its Countercyclical Support Facility (CSF). PM-ASBY isalso attracting attention from multilateral donors such as the World Bank, ADB,and AIIB as well as bilateral donors such as the German Development Bank(KfW). These donors attended a donor meeting organized by the Government ofIndia to call for financing for the package. On the other hand, a number of donors
have decided to provide budget support for the Prime Minister’s Poor Welfare
Scheme (Pradhan Mantri Garib Kalyan Yojana (PMGKY)) whose total amount isaround 1.7 trillion rupees (approx. 2.4 trillion yen). The scheme was announced
by the Government of India in March as a part of its social protection scheme tosupport the economy amid the spread of COVID-19. The World Bank and AIIB
committed 750 million US dollars, ADB committed one billion US dollars andthe French Development Agency (AFD) committed 200 million euros for PMGKY.
KfW is also considering lending 460 million euros as financial support. The New
Development Bank (NDB) committed one billion US dollars to support bothhealth sector and social protection.
3. Program Description(1) Program Objective
The objective of the Program is to contain COVID-19 and mitigate adverse
socioeconomic impacts in India, by extending budget support to Government ofIndia implementing emergency response programmes for health sector as
countermeasures against the COVID-19, thereby contributing to promoting thesocial and economic stabilization and development efforts of India.
(2) Program Site/Target Area
India
(3) Program Components
The Program will provide budget support to the Government of India engaging
in the emergency response for the healthcare sector. Policy matrix is prepared,
against which JICA and the Government of India will monitor the achievement ofthe policy actions. The Program will focus on three core policy agendas ofPM-ASBY. The Program’s agendas and policy actions are shown below:

Policy agenda

Policy action
Emergency Care andDisaster Preparedness
Strengthening district
capacity for disease
surveillance and early
identification of emerging
infectious diseases
Developing Digital HealthTechnology Eco-System

Cabinet approval of Pradhan Mantri Atmanirbhar
Swasth Bharat Yojana (PM-ASBY)
Implementation of at least 10 million COVID-19 tests
Development of training curriculum for doctors andnurses



Development of guidelines on the construction of new
infectious disease hospitals



Development of guidelines for the introduction ofTeleconsultation for implementation
Presentation of operational guidelines and directives
for use of National Health Information Platform forsurveillances to all the implementing states(4) Estimated Program Cost
Loan amount: 50,000 million yen(5) Schedule
From July 2020 to March 2022 (21 months). The Program will be completed
upon the completion of loan disbursement, which will be conducted as soon as
the achievement of policy actions are confirmed.
(6) Program Implementation Structure1) Borrower: The President of India
2) Executing Agency: The Ministry of Health and Family Welfare (MoHFW) ofIndia(7) Collaboration with Other Schemes and Donors
1) Japan’s Assistance Activity: None in particular2) Other donors’ Assistance Activity: None in particular(8) Environmental and Social Consideration/ Cross-Sectoral Issues/ GenderCategory
1) Environmental and Social Consideration① Category: C② Reason for Categorization: As the Program is a budget-support loan,
the negative impact on the environment from this Program is likely tohave minimal or little adverse impact on the environment under the‘JICA Guidelines for Environmental and Social Considerations (April2010)’.
2) Cross-Cutting Issues:① Relevance to climate action: N/A② Poverty reduction and considerations: The Program is expected toimprove the access of the poor to public healthcare services which
deals with COVID-19 and other infectious diseases.
③ HIV/AIDS and Other Infectious Disease Control: N/A④ Participation-type development: N/A⑤ Disability Consideration, etc.: N/A
3) Gender Category: ■GI (Gender Informed)<Reason for Categorization>
The assessment of gender mainstreaming was conducted in the appraisal
process, however, it did not result in formulating specific components that would
specifically focus on gender equality or women's empowerment.
(9) Other Important Issues: N/A
4. Targeted Outcomes(1) Quantitative Effects
1) Outcomes (Operation and Effect Indicators)
Baseline(May 2020)

Target (2022)

No. of the COVID 19 tests carried out

3,800,000

15,000,000

No. of Doctors and nurses trained following MOHFW
guidelines consistent with WHO standards of clinicaltreatment for COVID- 1910,000

75,000No. of districts with approved construction anddevelopment plan of 100/50 Infectious disease hospital
block in accordance with issued guidance

070

Percentage of districts with COVID-19 isolation facility inat least one hospital (%)-85

No. of district hospitals equipped for teleconsultation inaccordance with issued guidance

1273

Percentage of states using a national health information
reporting platform for surveillance that unifies multiple
pre-existing data sources (%)

3350Indicator(2) Qualitative Effects
Mitigation of adverse socio-economic impacts due to COVID-19(3) Internal Rate of ReturnNot calculated as it is a program loan.
5. External Factors and Risk Control(1) Preconditions
None in particular(2) External Conditions
The trend of recovery in spread of COVID-19 shall be maintained globallyand the rapid deterioration of the situation shall be avoided.
6. Lessons Learned from Past Programs
Two major lessons have been drawn from the ex-post evaluation of the“Emergency Budget Support Japanese ODA Loan” program for the Philippines.
Firstly, this particular loan, which was built on the framework of existing programloans, was provided in a flexible and timely manner in the midst of the financial
crisis of 2008, thus enhancing the effectiveness of the intervention. Secondly,
since one of the objectives of emergency budget support was to extend
financing in a timely manner to facilitate crisis responses, the procedures for theloan disbursement should be as simple and flexible as possible.
Having learned the lessons above, the Program makes the most of theframework of COVID-19 Emergency Response and Health System
Preparedness Package—a scheme that has been already drawn up by theGovernment of India and is implemented with the support of ADB and other
donors--in identifying the policy actions and evaluation indicators. In fact, four ofthe six operation and effect indicators for the Program were employed from theabove framework. The four indicators are: (i) No. of the COVID 19 tests carriedout; (ii) No. of Doctors and nurses trained following MOHFW guidelines
consistent with WHO standards of clinical treatment for COVID- 19; (iii)
Percentage of districts with COVID-19 isolation facility in at least one hospital;and (iv) Percentage of states using a national health information reporting
platform for surveillance that unifies multiple pre-existing data sources. Thisarrangement enables the timely provision of loans to meet the urgent financialneeds.

7. Evaluation Results
The Program, which is designed to support emergency responses of theGovernment of India for health sector amid the COVID-19 crisis, is consistent
with the development issues and policies of India as well as Japan's and JICA'scooperation policies and analyses. Also, the Program will likely contribute tothree of the SDGs: Goal 1 (No Poverty), Goal 3 (Good Health and Well-being),and Goal 8 (Decent Work and Economic Growth).
8. Plan for Future Evaluation(1) Indicators to be Used
As indicated in section 4.
(2) Timing
Ex-post evaluation: two years after the program completion
End