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Mongolia: Fifth Health Sector Development Project

Sovereign (Public) Project | 45009-002 Status: Active

ADB is helping Mongolia improve the safety of patients and health workers in hospitals. The project will assist the Ministry of Health in setting up a national blood transfusion center and an improved central medical waste management facility in Ulaanbaatar. It will provide equipment for hospital sterilization and microbiology laboratories to prevent and control hospital-acquired infections.

Project Details

Project Officer
Altantuya Jigjidsuren East Asia Department Request for information
  • Mongolia
  • Health
Project Name Fifth Health Sector Development Project
Project Number 45009-002
Country Mongolia
Project Status Active
Project Type / Modality of Assistance Grant
Source of Funding / Amount
Grant: Fifth Health Sector Development Project
German Federal Ministry of Health US$ 186,000.00
World Health Organization US$ 480,000.00
Loan 2963-MON: Fifth Health Sector Development Project
concessional ordinary capital resources lending / Asian Development Fund US$ 30.00 million
Strategic Agendas Inclusive economic growth
Drivers of Change Gender Equity and Mainstreaming
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

Establishment of new NCTM completed. NCTM received the new medical and IT equipment, and furniture. The NCTM is currently undergoing an assessment towards ISO9001:2015 international accreditation.

26 blood banks located in 21 aimag general hospitals, 3 soum health centers and 2 isolated district hospitals in UB were renovated and equipped. As of 26 March 2019, renovation/construction of 7 medical waste facilities (MWF) out of 8 have been completed; 5 MWF have been fully equipped and operational. The renovation of 10 central sterilization departments (CSSDs) out of 19 have been completed; 6 CSSDs and 9 microbiology laboratories are fully operational.

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 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)

Component 1: Blood Safety

Output 1. The new National Center on Transfusion Medicine (NCTM) is established and internationally accredited. The project is close to completing the establishment of the NCTM. The procurement of the last batch of laboratory equipment for the NCTM was completed (package G7new, $1.56 million). Delivery and installation of the equipment will be completed in November 2018. The NCTM introduced several new and advanced blood processing technologies that prevent the blood transfusion-associated complications and significantly contribute to improved quality and safety of blood products. The establishment of the model equipment maintenance unit at the NCTM was completed.

The project made significant progress in updating the major regulatory documents related to the (i) operation of blood banks in aimags; (ii) recruitment, registration and retention of blood donors; (iii) data collection and reporting on blood procurement and use; (iv) monitoring and evaluation of the blood bank operations; (v) blood safety monitoring indicators; and (vi) rational use of blood products.

The NCTM is planning to apply for ISO9001:2015 international accreditation. Preparatory works are ongoing per the plan of actions under the close guidance of the international consultant. As a prerequisite, the NCTM was certified by a national accreditation on MNS-ISO9001:2016 in October 2017. Lloyds Register Shanghai was contracted as the international accreditation firm for NCT on 25 December 2018. The first firm conducted its first mission during 28-31 January 2019 and submitted its assessment report on 3 March 2019.

Output 2. Aimag general hospitals and soum health centers transfuse safe blood. The project successfully achieved its aim to improve blood safety through upgrading 26 blood banks, which are located in 21 aimag general hospitals, three soum health centers and two isolated district hospitals in Ulaanbaatar (UB), providing equipment, training and organizing blood donor management systems. As of today, renovation of all blood banks has been completed and all 26 blood banks have been equipped with the new equipment and have become fully operational. Training of the key personnel in the aimag and district general hospitals is ongoing as planned. As of today, a total of 1,694 staff from rural blood banks participated in 45 trainings under this component. The project reached its target to provide training on blood safety and rational use to 100% of medical staff working in such high-risk units as maternity, trauma, surgery and intensive care units nationwide. As of 31 December 2018, 840 staff have been trained.

Component 2: Medical Waste Management

Output 3. The Central Medical Waste Management Facility (CMWMF) is expanded and meets international standards. On the government request, this output was cancelled. In April 2018, ADB approved this change in the project scope and revised and signed with MOF the project loan agreement.

Output 4. The national medical waste management system is strengthened, and the project hospitals meet the requirements of national standards. The project aims to (i) establish an interim storage facility for medical waste in eight project hospitals (five aimag general hospital and three regional diagnostic and treatment centers); and (ii) provide waste management equipment to 24 project hospitals. As of 26 March 2019, five out of eight interim storage facilities have been fully commissioned and operational. The construction of three facilities has been completed and waiting for the user acceptance. The construction progress at one interim storage facility in Selenge aimag is 80% complete with a protection embankment to be built in April 2019.

The procurement of medical waste management equipment for 24 project hospitals was completed (package G5, $0.82million). The equipment was delivered to all 24 hospitals and installation is planned to be completed in December 2018.

The project achieved its objective to advance the country's legal and regulatory system for medical waste management (MWM). The consultants' recommendations for improvement and reinforcement of the legal documents were considered in development of a number of regulatory documents, which were endorsed by the respective government agencies

The training of the key personnel on MWM was completed. 31 December 2018, a total of 795 staff, including the General Authority for Specialized Inspection inspectors, participated in 27 trainings under this component. The project successfully institutionalized the MWM training at the National Center for Communicable Diseases (NCCD), which was selected as an institution for the MWM training.

Component 3: Infection Prevention and Control

Output 5. Microbiology laboratory capacity of project hospitals meets national requirements. To ensure effective IPC, the project aims to upgrade microbiology laboratories in 19 hospitals, including eight aimag general hospitals, seven UB district hospitals and four tertiary level hospitals. Renovation of microbiology laboratories in the 19 project hospitals is ongoing with the estimated progress of 50% for completion scheduled in December 2018 (packages CW3, CW4, CW5, CW6, CW7; $4.38 million).

The procurement of equipment for 26 microbiology laboratories was completed and delivery of the equipment is ongoing (package G2; $3.56 million). Installation of the equipment will be synchronized with the renovation works and completed by the end of December 2018.

A good progress has been achieved in improving the microbiology testing guidelines (Attachment 4). In Q1/2019, 30 staff of tertiary hospitals were trained on new standard operating procedures (SOPs) after the upgrade of microbiology laboratories has been completed and the laboratories in project hospitals have been fully operational.

Output 6. Basic infrastructure and equipment for ensuring infection prevention control (IPC) in project hospitals are available. The project aimed to improve infrastructure and equipment of the central sterilization service departments (CSSDs) in the 18 project hospitals. The renovation works started in August 2018 (packages CW3, CW4, CW5, CW6, CW7; $4.38 million). As of 26 March 2019, the construction of 10 CSSDs are complete; six CSSDs are fully operational with the construction and equipment installation completed. The construction at four sites are ongoing while the sites construction at five sites have just been completed and waiting for the user acceptance. Procurement of equipment for 24 CSSDs was completed and equipment delivery is ongoing (package G1; $5.52 million). Installation of the equipment will be synchronized with the renovation works and completed by the end of December 2018.

Output 7. An effective surveillance system for hospital acquired infections is operational. The development of an active surveillance system for hospital acquired infections (HAIs) is one of the project's objectives. In 2015-2016, the project piloted active surveillance of the four most common hospital-acquired infections in selected three hospitals. Based on pilot findings and recommendations for an expansion, the project developed draft guidelines, which were comparable to international guidelines, on detection of common HAIs through active surveillance for the nationwide use. The approval of guidelines by MOH is pending. The project will support implementation of the new guidelines through trainings in the upgraded microbiology laboratories and procurement of reagents and fundamental supplies for training and startup of active surveillance in the project hospitals. In Q1/2019, 90 staff of 9 tertiary and secondary hospitals were trained in the use of surveillance system for hospital acquired infections.

Output 8. Awareness, knowledge and capacity of health authorities, health care workers and administrative staff on IPC have substantially improved. The project engaged an individual consultant to conduct a knowledge, attitude and practice (KAP) survey to assess competencies of healthcare workers in areas of IPC and HAI. The baseline survey, which was conducted in 2015, will serve as a baseline to measure progress of the project output. The end-line survey will be conducted in 1Q 2019. The information, education and communication (IEC) and behavior change communication (BCC) campaigns that started in February 2018 (para. 9 of the AM) covers IPC and MWM. The Mongolian language content was developed with assistance of NCCD and PIU including 14 posters and four videos on IPC for healthcare workers. The IEC and BCC materials on IPC will be disseminated to hospitals in Q4 2018.

The project has completed its objective to improve and update the IPC regulations and guidelines (Attachment 4). The IPC core training curriculum and training modules for under- and postgraduate training programs were reviewed and upgraded based on the WHO recommendations. The new modules were incorporated into training curricula of the Mongolian National University of Medical Science. The CSIH consultants carried-out various IPC trainings on active HAI surveillance, the role of a bacteriological laboratory in active HAI surveillance and internal audit. As of today, 929 doctors, epidemiologists, bacteriologists, laboratory technicians, nurses, administrative personnel, inspectors of the Government Authority for Sanitary Inspection (GASI) have attended 18 types of the trainings on IPC.

Output 9. IPC is ensured by strengthening the quality management system in hospitals and developing capacity of GASI. This output has been completed. The checklists to monitor healthcare staff practices related to hand hygiene, handling and disposing of sharps and other medical wastes were approved by relevant agencies and used for hospital internal quality monitoring. In total, 35 inspectors from 21 aimag and city inspection departments attended trainings on IPC and use of checklists in external auditing.

Geographical Location Nation-wide, Arhangay Aymag, Bayan-Olgiy Aymag, Bayanhongor Aymag, Bulgan, Bulgan Aymag, Central, Darhan, Dzavhan Aymag, East Aimak, East Gobi Aymag, Erdenet, Govi-Altay Aymag, Govi-Sumber, Hentiy Aymag, Hovd Aymag, Hovsgol Aymag, Khovd, Middle Govi, Omnogovi, Ovorhangay, Selenge Aymag, Suhbaatar Aymag, Ulaanbaatar Hot, Ulan Bator, Uvs Aymag
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 ADBs Safeguard Policy Statement (2009) and the Mongolia regulatory framework and was posted on the ADB website on 21 August 2012. The initial environmental examination addresses environment impacts, and risks related to (i) the Ulaanbaatar central medical waste management facility; (ii) the new National Center for Transfusion Medicine; (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 have been addressed through the implementation of the Environmental Management Plan (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 has been updated during the project implementation. The implementation of EMP has been regularly monitored and corrective actions were taken as required. The status of EMP were disclosed to the public.

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, and by upgrading the central medical waste management facility in Ulaanbaatar to meet internationally accepted standards.

Involuntary Resettlement No involuntary resettlement effects are foreseen and is classified as a category C project. The National Center for Transfusion Medicine was established on existing government land and did not affect residents or residential buildings. The blood banks are located within aimag/district hospitals.
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 gender 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 Borrower 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) is recruited to support the executing agency in project implementation and capacity development for all project components. 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. 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.
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 $2,000,000 or more and works contracts estimated to cost $5,000,000 or more. Goods contracts with values less than $2,000,000 and works contracts with values less than $5,000,000 will follow national competitive bidding. Works and goods contracts with values less than $100,000 will be procured using ADB's shopping procedure.
Responsible ADB Officer Altantuya Jigjidsuren
Responsible ADB Department East Asia Department
Responsible ADB Division Mongolia Resident Mission
Executing Agencies
Ministry of Health (formerly 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 27 Mar 2019

Loan 2963-MON

Approval Signing Date Effectivity Date Closing
Original Revised Actual
10 Dec 2012 07 Feb 2013 14 Jun 2013 31 Dec 2018 28 Feb 2021 -
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 22.52 0.00 83%
Counterpart 7.71 Cumulative Disbursements
Cofinancing 0.67 10 Dec 2012 22.05 0.00 81%
Status of Covenants
Category Sector Safeguards Social Financial Economic Others
Rating Satisfactory Satisfactory Satisfactory - Satisfactory Satisfactory

Project Data Sheets (PDS) contain summary information on the project or program. Because the PDS is a work in progress, some information may not be included in its initial version but will be added as it becomes available. Information about proposed projects is tentative and indicative.

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Title Document Type Document Date
Fifth Health Sector Development Project: Procurement Plan Procurement Plans Jun 2019
Fifth Health Sector Development Project: Follow-up Review Report Project Procurement-Related Reviews Jan 2019
Fifth Health Sector Development Project: Audited Project Financial Statements (January-December 2017) Audited Project Financial Statements Oct 2018
Эрүүл мэндийн салбарын хөгжил хөтөлбөр-5 төсөл : Төслийн Мэдээллийн Тайлан Translated PDS Sep 2018
Fifth Health Sector Development Project: Audited Project Financial Statements (January-December 2016) Audited Project Financial Statements Oct 2017
Fifth Health Sector Development Project: Project Procurement-Related Review Report Project Procurement-Related Reviews Aug 2017
Fifth Health Sector Development Project: Updated Gender Action Plan Gender Action Plans Apr 2017
Fifth Health Sector Development Project: Audited Project Financial Statements (January-December 2015) Audited Project Financial Statements Jun 2016
Fifth Health Sector Development Project: Audited Project Financial Statements (January-December 2014) Audited Project Financial Statements Jun 2015
Amendment to the Loan Agreement for Loan 2963-MON: Fifth Health Sector Development Project Loan Agreement (Special Operations) Apr 2015
Loan Agreement (Special Operations) for Fifth Health Sector Development Project Loan Agreement (Special Operations) Feb 2013
Fifth Health Sector Development Project Project/Program Administration Manual Nov 2012
Fifth Health Sector Development Project: Gender Action Plan (As of Board Approval) Gender Action Plans Nov 2012
Fifth Health Sector Development Project Reports and Recommendations of the President Nov 2012
Fifth Health Sector Development Project Initial Poverty and Social Analysis Oct 2011

Safeguard Documents See also: Safeguards

Safeguard documents provided at the time of project/facility approval may also be found in the list of linked documents provided with the Report and Recommendation of the President.

Evaluation Documents See also: Independent Evaluation

None currently available.

Related Publications

None currently available.

The Access to Information Policy (AIP) establishes the disclosure requirements for documents and information ADB produces or requires to be produced in its operations to facilitate stakeholder participation in ADB's decision-making. For more information, refer to the Safeguard Policy Statement, Operations Manual F1, and Operations Manual L3.

Requests for information may also be directed to the InfoUnit.


Tender Title Type Status Posting Date Deadline
LOAN 45009-002 (MON): Fifth Health Sector Development Project Invitation for Bids Active 11 Jul 2019 23 Aug 2019
Loan 2963-MON: Fifth Health Sector Development Project [G2] Invitation for Bids Closed 13 Dec 2017 25 Jan 2018
Loan 2963-MON: Fifth Health Sector Development Project [G1] Invitation for Bids Closed 12 Dec 2017 23 Jan 2018

Contracts Awarded

Contract Title Approval Number Contract Date Contractor Contractor Address Executing Agency Contract Description Total Contract Amount (US$) Contract Amount Financed by ADB (US$)

Procurement Plan