Mongolia: Fifth Health Sector Development Project

Sovereign Project | 45009-002 Status: Approved


The project will improve patients' and health workers' safety in hospitals in Mongolia. It will (i) improve the safety of blood transfusions, (ii) strengthen medical waste management, and (iii) prevent and control hospital acquired infections. It complements previous Asian Development Bank (ADB) initiatives in the health sector in Mongolia.

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Project Name Fifth Health Sector Development Project
Project Number 45009-002
Country Mongolia
Project Status Approved
Project Type / Modality of Assistance Loan
Source of Funding / Amount
Grant: Fifth Health Sector Development Project
World Health Organization US$ 480,000.00
German Federal Ministry of Health US$ 186,000.00
Loan 2963-MON: Fifth Health Sector Development Project
Asian Development Fund US$ 30.00 million
Strategic Agendas Inclusive economic growth
Drivers of Change Governance and capacity development
Sector / Subsector

Health - Health sector development and reform

Gender Equity and Mainstreaming Effective gender mainstreaming
Description The project will improve patients' and health workers' safety in hospitals in Mongolia. It will (i) improve the safety of blood transfusions, (ii) strengthen medical waste management, and (iii) prevent and control hospital acquired infections. It complements previous Asian Development Bank (ADB) initiatives in the health sector in Mongolia.
Project Rationale and Linkage to Country/Regional Strategy

Mongolia's economic outlook is bright, but the country is experiencing severe shortages in the provision of social services despite increasing budgetary resources. There is inadequate capacity to implement reforms to improve accessibility and service quality of hospital services. Poorer segments of the population have limited access to private hospitals due to high cost of care and limited health insurance coverage. At the same time, international support to the health sector is shrinking. The cost of reforming the hospital sector in Ulaanbaatar alone is estimated at $450 million. Patients' and health workers' safety is currently compromised by lapses in hospital hygiene, blood transfusion practices, and medical waste management in the public and private sector.

The government seeks to strengthen blood safety in hospitals and improve preparedness for emergencies in case of natural disasters. Deficiencies in aimag (province) blood banks impact on patients' and health workers' safety. Inadequate facilities, equipment, and testing materials; inadequate capacity of personnel involved in blood safety; lack of confidentiality; poor registration and reporting of adverse reactions; lack of readiness for emergencies; and lack of measures to reduce inappropriate blood transfusions are among the major deficiencies, which can result in unintentional transmission of HIV, syphilis, and hepatitis B and C.

Efforts are underway in Ulaanbaatar and in medium-sized cities such as Darkhan and Erdenet to improve hospital medical waste treatment and disposal, but the situation in the aimags is far from ideal. There is inadequate management of liquid hazardous waste produced by hospitals and laboratories. Liquid hazardous waste when poorly disposed causes harm to people and the environment, as it contains chemical substances, drugs, and pathogens. Hospital sewerage systems are not always of good quality, resulting in environmental and public health risks.

Infection control in Mongolian health care facilities is poor and hospital acquired infections are thought to be underreported. In March 2010, Mongolia experienced 28 hospital acquired infections among newborns, of whom five died, as a result of poor infection control clinical practices. Prevalence of hepatitis B and C of health care workers in Mongolia is among the highest in the world and points to breaches in health care safety. Sterilization facilities and practices in hospitals are poor, and basic hygiene measures, such as hand washing, are not commonly implemented. The surveillance system currently implemented in hospitals consists of passive reporting of hospital acquired infections. Several aspects prevent the current passive surveillance system in hospitals from being effective: (i) the disincentive associated with reporting of hospital acquired infections cases; (ii) the widespread preventive use of antibiotics for surgery and other procedures, including for newborn babies; and (iii) the lack of microbiology capacity to detect infections and sensitivity to treatment.

The government has established a legal and regulatory framework to address the above shortcomings. But it lacks investment funding; financing of operational costs; and human resources capacity to implement regulatory measures, guidelines, and plans. Several international partners are supporting the government in these areas but there are still significant gaps, primarily investments, development of monitoring and surveillance systems, and institutional and human resources capacity development. Private investors are entering the hospital market intending to offer higher standards of care for more affluent patients. Public hospitals (with a greater bed capacity) lag behind and remain a serious threat to patient and health workers' safety. This perpetuates discrimination between poorer and more affluent population groups. A central facility for the treatment and disposal of medical wastes was established as a public-private partnership in Ulaanbaatar in 2007 and has been operational since 2010. This initiative, although requiring major investments, represents a solid foundation for improved medical waste management in the capital where almost half of the Mongolian population lives. Ulaanbaatar's National Transfusiology Center (NTC), which provides blood transfusion services of acceptable quality, can play an important role in capacity development and monitoring of hospital transfusion activities in Ulaanbaatar and in the aimags.

The project builds on hospital sector reforms initiated under previous ADB-funded operations in Mongolia, including the Fourth Health Sector Development Project to strengthen hospital services. ADB sector recommendations emphasize the need for structural changes in health care delivery by rationalizing excess hospital capacity at the secondary and tertiary levels, particularly in Ulaanbaatar. The Fourth Health Sector Development Project is engaged in reforming the hospital sector but hospital rationalization needs to be complemented with increased quality and safety of hospital services to provide effective care and lower resistance to sector reforms. The project will deliver tangible benefits to women by ensuring higher safety standards to protect staff, the majority of whom are women, against hospital acquired infections and improving safety of blood transfusions in hospitals.

ADB is the largest external financier of the health sector in Mongolia, and plays a key role in assisting the government to formulate and implement health sector reforms. Support from other partners tends to focus on assisting the government to address particular diseases or develop certain programs. ADB works in close consultation with these partners to support the coordinated implementation of the Health Sector Master Plan (2006-2015). The World Health Organization, with global expertise in all three focus areas of the project, will assist the project mainly by providing consulting services. The German Federal Ministry of Health, which is supporting a small scale hospital hygiene project in Mongolia, will support the project by providing advisory services for policy development, monitoring and evaluation, and training activities in Mongolia and Germany.

The project builds on previous ADB health sector development initiatives and policy reforms under the Social Sectors Support Program to continue reforming the Mongolian health sector in line with (i) the National Development Strategy in achieving the Millennium Development Goals (MDGs), MDG 4 (Child Health) and MDG 5 (Maternal Health), and more directly MDG 6 (HIV/AIDS and tuberculosis), and MDG 7 (environmental health and sanitation); and (ii) the government's Health Sector Master Plan (2006-2015) for improving hospital services. The project is included in the country operations business plan (2012-2014) and is consistent with the current country partnership strategy (2012-2016), which emphasizes social development through efficient delivery of health services.

Impact Improved quality of health services in Mongolia
Project Outcome
Description of Outcome Improved patient and health worker safety in project-supported hospitals in Mongolia
Progress Toward Outcome
Implementation Progress
Description of Project Outputs

Component 1: Safe Blood Transfusion

1. The new national transfusiology center is established in Ulaanbaatar and internationally accredited.

2. Aimag (province) general hospitals and soum (administrative subdivision of the aimag) health centers transfuse safe blood.

Component 2: Medical Waste Management

3. The central medical waste management facility is expanded and meets international standards.

4. The national medical waste management system is strengthened and the project hospitals meet the requirements of national standards.

Component 3: Hospital Hygiene and Infection Prevention and Control

5. Microbiology laboratory capacity of project-supported hospitals meets national requirements.

6. Basic infrastructure and equipment for ensuring IPC in the project-supported hospitals are available.

7. An effective surveillance system for hospital-acquired infections is operational.

8. Awareness, knowledge, and capacity of health authorities, health care workers, and administrative staff on IPC have substantially improved.

9. IPC is ensured by strengthening the quality management system in hospitals and developing the capacity of the General Agency for State Inspection (GASI).

Additional Output. Project Management.

Status of Implementation Progress (Outputs, Activities, and Issues)

Output 1: The construction of the new National Transfusiology Center (NTC) is about 83% completed and is meant to be finish in 2015

Output 2: Civil works, equipment procurement and training all ongoing in the aimags

Output 3: assessment of civil works ongoing

Output 4: ongoing

Output 5: Civil works, equipment procurement and training all ongoing in project sites

Output 6: needs assessment and equipment procurement ongoing

Output 7: Active surveillance system is being discussed in the working group with assistance from project consultants

Output 8: Studies on knowledge, attitude and behavior ongoing

Output 9: Ongoing

Geographical Location
Safeguard Categories
Environment B
Involuntary Resettlement C
Indigenous Peoples C
Summary of Environmental and Social Aspects
Environmental Aspects

The project is classified as category B. An initial environmental examination including an environmental management plan (EMP) was prepared in compliance with ADB's Safeguard Policy Statement (2009) and the Mongolia regulatory framework, and was posted on the ADB website on 21 August 2012. The initial environmental examination assesses and addresses environment impacts and risks related to (i) the Ulaanbaatar central medical waste management facility; (ii) the new National Transfusiology Center; (iii) smaller blood safety, infection prevention and control, medical waste facility installations in project aimags; and (iv) project associated facilities. The main adverse impacts and risks during the construction and operation phase include limited standard construction impacts, and risks related to unsafe collection, storage, treatment, and disposal of medical and chemical liquid waste generated by health facilities. These impacts and risks will be addressed through the implementation of the EMP that includes adequate mitigation and monitoring arrangements, responsibilities for EMP implementation and supervision, environmental training and capacity building, and budgets for implementation of EMP.

The EMP will be updated based on final design and will be submitted to ADB for review and approval prior to awarding the civil works contract. Contractors during construction, and facility operators as well as MOH during operation will implement these measures. The effectiveness of these measures will be regularly evaluated in the framework of the environmental monitoring program, and corrective actions defined as required. The Government of Mongolia, through MOH, is committed to manage identified environmental risks and agreed on a comprehensive set of loan covenants. Relevant environment information was disclosed to potentially affected people, and the results and findings of the consultation process were used to modify the initial environmental examination and the project design. Consultation and participation will continue throughout project implementation and any environmental complaints or disputes will be handled in accordance with the grievance redress mechanism established for the project. The project will have significant environment, health, and safety benefits. Mongolia's medical waste management system, including liquid hazardous waste, will be significantly strengthened by improving medical waste management systems within health care facilities, by upgrading the central medical waste management facility in Ulaanbaatar to meet internationally accepted standards.

The quarterly environmental monitoring report (January to July 2015) has been submitted. No environmental issues have been identified as of July 2015.

Involuntary Resettlement No involuntary resettlement effects are foreseen and is classified as a category C project. The National Transfusiology Center will be established on existing government land and will not affect local residents or residential buildings. A resettlement plan and framework are therefore not required. Should there be any change in scope or other changes with unanticipated resettlement impacts during project implementation, land acquisition and resettlement activities will be implemented in accordance with ADB's Safeguard Policy Statement (2009).
Indigenous Peoples The project is classified as category C for indigenous peoples. The assessment determined that there will not be any negative impact on indigenous peoples. The project will carry out an assessment of and implement effective ways to design and deliver information, education, communication activities to the public to ensure social inclusiveness and effective communication.
Stakeholder Communication, Participation, and Consultation
During Project Design Three workshops were held with related governmental departments, beneficiaries, environment protection bureau, local governments, etc., to inform the project design. The poverty and social analysis involved focus group and key informant interviews with health care workers, patients, and the general public. Development of the environmental impact assessments and environmental management plan (EMP) involved two rounds of public consultations. The tender action plan (GAP) has been prepared and discussed with the Ministry of Health. The GAP and EMP set out detailed ongoing public participation plans.
During Project Implementation Public disclosure of all project documents was made at the project management office and on the ADB website, including the project information document, design and monitoring framework, consolidated environmental impact assessment, report and recommendation of the President, public sector legal agreement, project administration memorandum, and environmental monitoring reports. The GAP and EMP indicate how consultation will continue throughout implementation.
Business Opportunities
Consulting Services

The Recipient is responsible for selecting, engaging, and supervising consultants engaged under the loan funded by ADB. All consultants will be recruited according to ADB's Guidelines on the Use of Consultants (2010, as amended from time to time). A consultant firm to provide a total of 129 person-months of consulting services (37 international, 92 national) will be recruited to support the executing agency in project implementation and capacity development for all project components. The consulting firm will be engaged using quality- and cost-based selection (QCBS) with the standard ratio of 80:20. Three consulting firms will be engaged under lump sum contracts using consultants' qualification selection (CQS) for facilitating international accreditation of the National Transfusiology Center, architectural support for project facilities and environmental assessment of the central medical waste management facility. The firms are required to submit full technical proposals under QCBS and biodata technical proposals under CQS. In total, 33 person-months of national consultants will be recruited for all three components following individual consultant selection procedure for providing safeguards, social, technical, legal, and monitoring support to the project. The terms of reference for all consulting services are outlined in Section D.

The World Health Organization will cofinance consulting services ($420,000), training ($20,000) and equipment ($40,000) for the following activities:

(i) Component 1: capacity building and equipment for quality improvement of blood transfusion services.

(ii) Component 2: training to scale-up initiatives of mercury-free health care facilities.

(iii) Component 3: develop technical guidelines for infection prevention and control and training of infection prevention and control practitioners.

Procurement All procurement of goods and works will be undertaken in accordance with ADB's Procurement Guidelines (2010, as amended from time to time). International competitive bidding will be applied to goods contracts estimated to cost $500,000 or more and works contracts estimated to cost $1,000,000 or more. Goods contracts with values less than $500,000 and works contracts with values less than $1,000,000 will follow national competitive bidding. Works and goods contracts with values less than $50,000 will be procured using ADB's shopping procedure.
Responsible ADB Officer Claude Bodart
Responsible ADB Department East Asia Department
Responsible ADB Division Mongolia Resident Mission
Executing Agencies
Ministry of Health_and Sports
1st Floor, Government Building VIII
Olympic Street 2, Ulaanbaatar
Concept Clearance 07 Oct 2011
Fact Finding 03 Jul 2012 to 06 Jul 2012
MRM 07 Sep 2012
Approval 10 Dec 2012
Last Review Mission -
Last PDS Update 10 Sep 2015

Loan 2963-MON

Approval Signing Date Effectivity Date Closing
Original Revised Actual
10 Dec 2012 07 Feb 2013 14 Jun 2013 31 Dec 2018 - -
Financing Plan Loan Utilization
Total (Amount in US$ million) Date ADB Others Net Percentage
Project Cost 38.38 Cumulative Contract Awards
ADB 30.00 10 Dec 2012 9.27 0.00 34%
Counterpart 7.71 Cumulative Disbursements
Cofinancing 0.67 10 Dec 2012 0.94 0.00 4%
Status of Covenants
Category Sector Safeguards Social Financial Economic Others
Rating - - - - Satisfactory -

Evaluation Documents

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