Ex-Ante Evaluation

1. Name of the ProjectCountry: Republic of India
Project: Tamil Nadu Urban Health Care Project
Loan Agreement: March 31, 2016
Loan Amount: 25,537 million yen
Borrower: The President of India
2. Background and Necessity of the Project(1) Present State of Development and Problems of the Health Sector in India
While India is enjoying rapid economic growth in recent years, its health sector has
undertaken the National Rural Health Mission (hereinafter referred to as the “NRHM”)
under the leadership of the government since 2005, along with individual programs tofight tuberculosis, HIV/AIDS, and other diseases. As a result, India has seenimprovements in its health indicators, such as reductions in the prevalence ofinfectious diseases. Meanwhile, due to lifestyle changes along with economic growth,
the prevalence of non-communicable diseases (hereinafter referred to as “NCDs”),
such as cardiovascular diseases and cancers, has been on the rise. Deaths fromNCDs have overtaken deaths from infectious diseases, and NCDs have become themost common causes of death in urban areas (According to the WHO’s 2012 statistics,
the top three causes of death are ischemic heart disease, chronic respiratory disease,and cerebral and myocardial infarction, in descending order). NCDs are estimated toaccount for 60% of all deaths and carry a 26% risk of death in people aged between
30 and 70 years old (WHO, 2015). As the prevalence of these diseases is expected tocontinue to increase, NCD interventions (prevention and control) have become an
important issue that will require long-term efforts, along with primary health care suchas maternal and child care and infectious disease control.
(2) India’s Development Policies for the Health Sector and the Role of the Current
Project
Most of poor people can only afford public health care services though they are
limited both in quality and quantity. In light of this, the Twelfth Five Year Plan (fromApril 2012 to March 2017) identifies the strengthening of public health care services
for the urban poor including slum dwellers as a national priority issue. The National
Urban Health Mission (hereinafter referred to as the “NUHM”), launched in 2013 toimprove public health care services mainly for the urban poor, proposes to achieve its
objectives by strengthening the existing medical facilities and developing the capacityof health care personnel. The NUHM has been integrated with the NRHM into theNational Health Mission (hereinafter referred to as the “NHM”), under which measuresare being taken to strengthen primary medical facilities across the country to deal withNCDs.
Tamil Nadu State (with a population of 72 million according to the 2011 census) isthe most urbanized in India (with an urban population accounting for 48.5% of the total
population). It is estimated that around 8.64 million (2011 census) poor people areliving in slums, and the number is expected to continue to increase. The urban poor
can only afford public health care services, but the supply cannot meet the demand
which is growing along with the continuous inflow of population into cities. Therefore, it
is becoming increasingly urgent to improve the access of the urban poor to publichealth care services. Meanwhile, the prevalence of NCDs has been on the rise due tolifestyle changes. Especially, the incidence of cancer and diabetes in Tamil Nadu hasreached a higher level than the national average. Thus, the demand is growing for
NCD interventions (including early identification and treatment), in addition toconventional maternal and child health and infectious disease control mainly targetedat the poor. To be more specific, there is a growing need for the development of
secondary medical facilities to provide emergency treatment and perform tests for thediagnosis of NCDs as well as the development of tertiary medical facilities andequipment to provide an accurate diagnosis of cardiovascular and other diseases andcarry out treatment, surgeries, and other medical interventions. In light of the above,
the Tamil Nadu Urban Health Care Project (hereinafter referred to as “this Project”)
will be implemented, mainly aiming to develop secondary and tertiary medical facilities.
Designed to raise the quality of urban health care systems to provide public healthcare services for the urban poor and control NCDs prevailing in Tamil Nadu, thisProject is positioned to promote the NUHM.
(3) Japan and JICA’s Policy and Operations in the health Sector in India
The Government of Japan released its Strategy on Global Health Diplomacy in May
2013, emphasizing the importance of support for the health sector to achieve
universal health coverage (UHC). The Country Assistance Program for India (May2006) also identifies the “Health and Sanitation Sector” as a priority target. Moreover,JICA’s Country Analysis Paper for India (March 2012) identifies support for the “HealthCare and Sanitation Sector” as a priority issue. Thus, this Project is in line with thesepolicies and analysis results. Meanwhile, no ODA loans have been approved for thehealth sector in India. As of the end of January 2015, Japan has implemented seven
grant aid projects amounting to 16,010 million yen and four technical cooperation
projects worth 1,011 million yen in total.
(4) Other Donors’ Activity
The Asian Development Bank is planning to provide the Government of India with aloan of 500 million USD to support the NUHM. The World Bank implemented a projectto strengthen health systems in Tamil Nadu (Phase 1 from 2005 to 2010 with a cost
amounting to approx. 110 million USD; Phase 2 from 2010 to 2014 with a cost
amounting to 210 million USD).
(5) Necessity of the ProjectThis Project is highly urgent as it aims to improve the quality of urban healthsystems to provide public health care services and control NCDs in Tamil Nadu in theface of a growing urban poor population and changing disease patterns. This Projectis also consistent with the development policies of the Government of India and theassistance policies of Japan and JICA. Therefore, it is highly necessary and relevant
for JICA to implement this Project.
3. Project Description(1) Project Objective
By developing health care facilities and equipment and building the capacity of
medical personnel for NCD interventions in Tamil Nadu State, this Project aims toimprove urban health care systems, thereby contributing to the health promotion ofresidents in the state.
(2) Project Site/Target Area
The state of Tamil Nadu
(3) Project Components
1) Development of health care facilities (renovation of three tertiary medicalinstitutions and construction four new secondary medical institutions)2) Procurement of medical equipment (MRIs, CT scanners, x-ray equipment,
angiography equipment, hemodialyzers, endoscopes, etc.)
3) Capacity building of health care personnel (training on hospital facilities
management, medical equipment maintenance, NCD screening, etc.)
4) Consulting services (detailed design, bidding assistance, construction
supervision, etc.)(4) Project Cost
30,060 million yen (Loan amount: 25,537 million yen)
(5) Project Implementation Schedule
March 2016 – September 2021 (67 months in total). The project completion isdefined as the commencement of the service (September 2020)(6) Project Implementation Structure

1) Borrower: The President of India
2) Executing Agency: Health and Family Welfare Department, Government of Tamil
Nadu3) Operation and Maintenance System: The Health and Family Welfare Department
will operate and maintain as planned all medical facilities provided and medicalequipment procured in the Project in accordance with the standard maintenanceprocedures.
(7) Environmental and Social Considerations/Poverty Reduction/Social Development
1) Environmental and Social Considerations① Category: B② Reason for Categorization: This project is classified as Category B because it
is not in a sector nor does it have characteristics likely to exert impact, nor is it
in a sensitive region, and so no significant adverse impact on the environment
is considered likely, under JICA guidelines for environmental and social
considerations (April 2010).
③ Environmental Permit: The Environmental Impact Assessment (EIA) report isrequired for this Project under the Indian laws. The report is expected to beapproved by the state authorities (State Environmental Impact Assessment
Authority of Tamil Nadu) by July 2016.
④ Anti-Pollution Measures: During the construction period, air, water, noise, andvibration pollution will be reduced to meet the legal standards of India by suchmeasures as sprinkling water to prevent dust emissions and limiting the speedof construction vehicles. Moreover, in order to reduce the impact of waterpollution and waste disposal, the design and construction supervisionconsultants will supervise appropriate treatment. These measures areexpected to prevent significant negative impacts on the natural environment.
After the commencement of services, the medical waste is to be separated into
infectious, physiological, and sharp-edged wastes and collected by licensed
waste collectors; therefore, this Project is not likely to cause environmentalimpacts.
⑤ Natural Environment: The Project sites are not located in or around susceptible
areas, such as national parks. Moreover, this Project is designed to constructbuildings in lands owned by the State Government. Therefore, this Project islikely to have a minimal adverse impact on the natural environment.
⑥ Social Environment: This Project will not involve involuntary resettlement orland acquisition from private owners as it will be implemented within existing
facilities, using lands owned by the State Government.
⑦ Other/Monitoring: During the construction, the contractors will monitor thequality of air and water, the level of noise and vibration, and waste disposal,and after the commencement of services, the implementing agencies will
monitor waste disposal on a regular basis.
2) Promotion of Poverty Reduction:
The Project is expected to improve the access of the poor to public health careservices.
3) Promotion of Social Development
Barrier-free considerations: The hospitals to be constructed will be designed
according to the principles of universal design. For example, the hospitals are tobe equipped with slopes, handrails, wide passages, and spacious restrooms forwheelchair access.
Gender considerations: Although this Project mainly aims to control NCDs, it isexpected to improve health care services for pregnant women and infants bystrengthening the capacity of medical personnel and renovating secondarymedical facilities which serves as hubs to provide health care services for
expectant and nursing mothers. Moreover, it is generally said that women tend totake care of NCD patients at home, and this Project is expected to reduce theburden of women’s domestic labor by improving prevention, treatment, and other
health care services for NCDs. Therefore, this Project is classified as agender-integrated project.
Prevention of HIV/AIDS and other infectious diseases: During the construction
period, the contractors will take HIV/AIDS prevention measures for theconstruction workers.
(8) Collaboration with Other Donors
The World Bank implemented the Tamil Nadu Health Systems Project until 2015 tostrengthen health systems in Tamil Nadu. The project implementation unit establishedby the project will be utilized for this Project.
(9) Other Important Issues:
None in particular
4. Targeted Outcomes(1) Quantitative Effects
1) Performance Indicators (Operation and Effect Indicator)
Indicators

Baseline(actual value in 2014)

Target (2023)[2 years after project completion]

Number ofsurgeries withcatheterinterventions(cases)Madurai Medical College
Hospital: 336
Kilpauk Medical College
Hospital: 0
Coimbatore Medical College
Hospital: 0

Madurai Medical College
Hospital: 700
Kilpauk Medical College
Hospital: 150
Coimbatore Medical College
Hospital: 150

Number ofsurgeries
performed in hybrid
operating rooms(cases)Madurai Medical College
Hospital: 46
Kilpauk Medical College
Hospital: 0
Coimbatore Medical College
Hospital: 5

Madurai Medical College
Hospital: 280
Kilpauk Medical College
Hospital: 200
Coimbatore Medical College
Hospital: 100

Number of

Vellore: 0
Tirunelveli: 10
District
hospitals: 0

mammography
examinations(cases)Number ofhemodialysis
treatments (cases)

Vellore: 1000
Tirunelveli: 1000
headquarters District headquarters hospitals:650<Tertiary medical facilities>
Tirunelveli: 460
Nagercoil: 62
Tuticorin: 202
Trichy: 294
All hospitals as listed on the left:<Secondary medical facilities> 600
Erode: 1,249
Cuddalor: 694
Other district headquarters
hospitals: 0

Inpatient bed
Avadi: 85.4
occupancy rate (%)
Other hospitals: NA
Number of seats in Madurai Medical College
Hospital: 2
a training course for
Kilpauk Medical College
cardiologists
Hospital: 0
Coimbatore Medical College(persons)Hospital: 0Madurai Medical College
Fill rate ofHospital: 100
cardiology positionsKilpauk Medical College(%)
Hospital: NA
Coimbatore Medical College
Hospital: NA
Number of certified Number of certified secondary
medical facilities: 0(*) tertiary andNumber of tertiary medicalsecondary medical facilities with certified
facilities (hospitals) cardiology, radiology,nephrology, andanesthesiology units: 0All hospitals as listed on the left:
90
Madurai Medical College
Hospital: 4
Kilpauk Medical College
Hospital: 2
Coimbatore Medical College
Hospital: 2All hospitals as listed on the left:
100

Number of certified secondary
medical facilities: 4Number of tertiary medical
facilities with certified cardiology,radiology, nephrology, andanesthesiology units: 3

(*) Refers to the third-party certification for quality assurance by the Government ofIndia.
(2) Qualitative Effects
Health promotion of local residents; poverty reduction through participation ineconomic activities as a result of health promotion(3) Internal Rate of ReturnNot calculated as the Project does not contain profitability.
5. External Factors and Risk Control
Political and economic instability and natural disasters will not occur in India orareas surrounding the Project sites.
6. Evaluation Results and Lessons Learned from Past Projects(1) Results Similar Past Projects
The ex-post evaluation of Rural Health Infrastructure Strengthening Project in theKingdom of Thailand extracted a lesson that in a project which provides equipment todifferent medical institutions, the enhancement of their hospital management capacity
can contribute to their effective use of the equipment to be installed because theircapacity levels are different.
(2) Lessons for the Project
In order to ensure the effective use of the equipment to be provided to differentmedical institutions, this Project is designed to examine the ability of those who will
use the equipment at the hospitals and then provide technical assistance to enhancetheir capacity so that they can operate and maintain the equipment properly and help
to make accurate diagnoses.
7. Plan for Future Evaluation(1) Indicators for Future Evaluation
1) Number of surgeries with catheter interventions (cases)
2) Number of surgeries performed in hybrid operating rooms (cases)
3) Number of mammography examinations (cases)
4) Number of hemodialysis treatments (cases)
5) Inpatient bed occupancy rate (%)6) Number of seats in a training course for cardiologists (persons)7) Fill rate of cardiology positions (%)8) Number of certified ertiary and secondary medical facilities (hospitals)(2) Timing
Two years after project completion