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 Name||Fifth Health Sector Development Project|
|Project Type / Modality of Assistance||Grant
|Source of Funding / Amount||
|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|
|Description of Outcome||Improved patient and health worker safety in project-supported hospitals in Mongolia|
|Progress Toward Outcome||The project assisted in establishment of the new National Center for Transfusion Medicine and 26 blood banks nationwide. The project has accomplished its aim to strengthen the blood safety by ensuring production of safe and quality blood products, capacity building of staff concerned, organizing blood donor management systems and increasing public awareness. Construction of 8 medical waste facilities (MWF) out of planned 8 have been completed. The renovation of 19 central sterilization departments (CSSDs) out of planned 19 have been completed. The renovation of 19 microbiology laboratories in out of the planned 19 have been completed.|
|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
Output 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
Output 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 successfully achieved its goal to establish the new NCTM, which will meet international standards. The NCTM has obtained a national MNS-ISO9001:2016 accreditation in October 2017. In 2018-2019, the NCTM has undergone an international ISO9001:2015 accreditation by the independent accreditation body - Lloyds Register Shanghai and received a 3-year Certificate of Approval per ISO 9001:2015 and GB/T 19001-2016 (No(s): ISO 9001-00020397) on 22 May 2019. 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 project assisted the EA 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.
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 today, 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 achieved its aim to establish an interim storage facility for medical waste in eight project hospitals (five aimag general hospital and three regional diagnostic and treatment centers), and provide waste management equipment to 21 project hospitals. As of today, construction of all eight interim storage facilities have been completed. Procurement of 17 types of medical waste management equipment was completed (package G5, $0.85million); the equipment was delivered and installed in all 21 hospitals. 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. Training of the key personnel on MWM was completed. As of today, 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 fully completed upgrading microbiology laboratories in 19 hospitals, including eight aimag general hospitals, seven UB district hospitals and four tertiary level hospitals (packages CW3, CW4, CW5, CW6, CW7; $4.38 million). The project procured 25 types of equipment for microbiology laboratories; all equipment is installed in all 19 hospitals (package G2; $3.56 million). As of today, the microbiology laboratories in all 19 hospitals are functional.
Good progress has been achieved in improving the microbiology testing guidelines. The project consultants supported in development of 40 standard operating procedures (SOPs) to be used in microbiology laboratories. Staff training on new SOPs covered 140 staff including laboratory specialists and technicians of 20 hospitals. New SOPs are being implemented in 13 project hospitals following on-the-job training and equipment installation.
Output 6. Basic infrastructure and equipment for ensuring infection prevention control (IPC) in project hospitals are available. The project also completed its aim to improve infrastructure and equipment of the central sterilization service departments (CSSDs) in the 19 project hospitals (footnote 3). As of today, renovations of CSSDs in all 19 project sites have been completed (packages CW3, CW4, CW5, CW6, CW7; $4.38 million). Procurement of equipment has been completed and equipment delivered and installed (package G1; $5.52 million). All 19 CSSDs are functioning. On the government request, the project is upgrading CSSDs in eight additional hospitals, including three tertiary level hospitals and five aimag general hospitals. The upgrade will include facility renovation and supply of equipment. Civil works at most sites have been completed and equipped being installed.
Output 7. An effective surveillance system for hospital acquired infections is operational. The project completed its objective to develop and operationalize an active surveillance system for hospital-acquired infections (HAIs). In 2015-2016, the project piloted active surveillance of the four most common hospital-acquired infections in selected three hospitals. Based on the pilot findings and recommendations for an expansion, the consultants assisted MOH in developing guidelines comparable to international guidelines on detection of common HAIs through active surveillance for the nationwide use. New guidelines were approved by MOH in February 2019. The project assisted in operationalizing 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.
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, serve as a baseline to measure progress of the project output. The end-line survey data were collected in Q1 2019. The report is under finalization and acceptance by MOH. The information, education and communication (IEC) and behavior change communication (BCC) campaigns that started in February 2018 cover IPC and MWM. With assistance of NCCD and PIU, the Mongolian language content, including 14 posters and four videos on IPC for healthcare workers, was developed. The IEC and BCC materials on IPC were disseminated to hospitals in 2018. The project has completed its objective to improve and update the IPC regulations and guidelines. The IPC core training curriculum and training modules for under- and postgraduate training programs were reviewed and upgraded per the WHO recommendations. The new modules were incorporated into the 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, a total of 1,532 doctors, epidemiologists, bacteriologists, laboratory technicians, nurses, administrative personnel, inspectors of the Government Authority for Sanitary Inspection (GASI) have attended 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.
Output 10. The project implementation unit (PIU) under the MOH is managing the day-to-day
implementation of project activities including procurement, disbursement, monitoring, progress reporting, and management of consulting services.
|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|
|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.|
|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 $100,000 will be procured using ADB's shopping procedure.|
|Responsible ADB Officer||Jigjidsuren, Altantuya|
|Responsible ADB Department||East Asia Department|
|Responsible ADB Division||Mongolia Resident Mission|
|Concept Clearance||07 Oct 2011|
|Fact Finding||03 Jul 2012 to 06 Jul 2012|
|MRM||07 Sep 2012|
|Approval||10 Dec 2012|
|Last Review Mission||-|
|Last PDS Update||30 Sep 2020|
|Approval||Signing Date||Effectivity Date||Closing|
|10 Dec 2012||07 Feb 2013||14 Jun 2013||31 Dec 2018||28 Feb 2021||-|
|Financing Plan||Loan Utilization|
|Total (Amount in US$ million)||Date||ADB||Others||Net Percentage|
|Project Cost||113.80||Cumulative Contract Awards|
|ADB||90.00||10 Dec 2012||26.78||0.00||98%|
|Cofinancing||0.67||10 Dec 2012||26.81||0.00||99%|
|Status of Covenants|
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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
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ADB Provides $1.4 Million to Strengthen Mongolia's COVID-19 PreparednessULAANBAATAR, MONGOLIA (17 March 2020) — The Asian Development Bank (ADB) has reallocated $1.4 million from a health project in Mongolia to procure essential medical equipment for early detection, emergency care, and management of severe respiratory diseases in wake of the novel coronavirus (COVID-19) pandemic. ADB also approved a $225,000 small-scale technical assistance to strengthen Mongolia’s national capacity for infection prevention and control.
Safe Blood Transfusions for Mongolia's PatientsThe Asian Development Bank is helping Mongolia improve the safety of patients and health workers in hospitals, focusing on the safety of blood products, also known as hemovigilance.
|Tender Title||Type||Status||Posting Date||Deadline|
|LOAN 45009-002 (MON): Fifth Health Sector Development Project||Invitation for Bids||Closed||11 Jul 2019||23 Aug 2019|
|Loan 2963-MON: Fifth Health Sector Development Project [G2]||Invitation for Bids||Closed||13 Dec 2017||25 Jan 2018|
|Loan 2963-MON: Fifth Health Sector Development Project [G1]||Invitation for Bids||Closed||12 Dec 2017||23 Jan 2018|
|Contract Title||Approval Number||Contract Date||Contractor||Contractor Address||Executing Agency||Contract Description||Total Contract Amount (US$)||Contract Amount Financed by ADB (US$)|
|SUPPLY AND INSTALLATION OF STERILIZATION AND STORAGE EQUIPMENT TO CENTRAL STERILIZATION SERVICE DEPARTMENTS (CSSDS) OF 7 PROJECT HOSPITALS||Loan 2963||16 Dec 2019||JV OF SINOPHARM INTERNATIONAL CORPORATION||FORTUNE TOWER 1, NO.4 HUI XIN DONGJIE, CHAO YANG DISTRICT,BEIJING, CHINA,PEOPLE'SREP.OF||Ministry of Health||SUPPLY OF GOODS||1,122,781.26||1,122,781.26|
|THE SUPPLY, DELIVERY AND INSTALLATION OF CULTURING AND ID/AST INSTRUMENT TO MEDICAL EQUIPMENT FOR MI CROBIOLOGY LABORATORIES OF 20 PROJECT HOSPITALS||Loan 2963||07 Nov 2018||JV OF LIFETRONIK LLC||GYALS R&D CENTER, DANDARBAATAR ST.32,UL AANBAATAR,TEL:75754422/1177 MONGOLIA||Ministry of Health||SUPPLY OF GOODS||1,651,196.00||1,651,196.00|
|SUUPLY AND INSTALLATION OF STERILIZATION AND STORA GE EQUIPMENT TO CENTRALIZED STERILIZATION SERVICE DEPARTMENTS (CSSDS) OF 20 PROJECT HOSPITALS||Loan 2963||05 Oct 2018||SHANDONG WEIGAO GROUP MEDICAL POLYMER CO.,LTD||18 XINGSHAN ROAD HIGH-TECH INDUSTRIAL D EV'T ZONE,264210,WEICHAI CITY,SHANDONG P CHINA,PEOPLE'SREP.||Ministry of Health||SUPPLY OF GOODS||3,085,672.00||3,085,672.00|
|GENERAL LABORATORY EQUIPMENT AND FURNITURE SUPPLY TO MICROBIOLOGY LABORATORIES OF 20 PROJECT HOSPITA LS.||Loan 2963||27 Sep 2018||JV OF MEDIMPEX INTERNATIONAL LLC||UNION BUILDING, 13TH FLOOR,UNESCO ST 62 SUKHBAATAR DISTRICT,ULAANBAATAR MONGOLIA||Ministry of Health||SUPPLY OF GOODS||1,518,109.00||1,518,109.00|
|SUPPLY AND INSTALLATION OF DECONTAMINATION, ASSEMB LING AND PACKAGING EQUIPMENT TO CENTRAL STERILIZAT ION SERVICE DEPARTMENTS OF 20 PROJECT HOSPITALS||Loan 2963||18 Sep 2018||JV OF MEDMONGOL LLC &MMM (MUNCHENER MEDIZIN||SUKHBAATAR DISTRICT,1STKHOROO,EMBASSY ST 14-1, ATLANT BUILDING,SUITE 102,ULAANBAA MONGOLIA||Ministry of Health||SUPPLY OF GOODS||2,250,747.00||2,250,747.00|
|Title||Document Type||Document Date|
|Fifth Health Sector Development Project: Procurement Plan||Procurement Plans||Nov 2020|