Mongolia: Fifth Health Sector Development Project

Sovereign 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
Jigjidsuren, Altantuya East Asia Department Request for information
  • Mongolia
  • Grant
  • Loan
  • 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
World Health Organization US$ 480,000.00
German Federal Ministry of Health US$ 186,000.00
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 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

As of end 2016, 85.2% (target 95%) of blood collected for transfusions screened with polymerase chain reaction (PCR), ELISA (E), or rapid test (T) methods.

As of end 2016, five hospitals out of total 19 hospitals is complying with national standards for hazardous solid medical waste treatment.

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)

Component 1.

The project supported the construction of the new National Transfusiology Center (NTC) which was completed in April 2016. NTC moved to the new building in October 2016 after the first batch of the medical equipment had been supplied and installed; procurement of laboratory equipment and furniture is still ongoing. Progress has been made in developing a quality management system to ensure NTC standard management and operation of blood procurement (collection, processing, testing, storage and distribution) and rational use (ordering, selection and compatibility testing, and the bedside transfusion practice). The management system is described in the Quality Manual, the document that consists of steering, supportive and operational processes that are being developed step by step with the support of the Canadian Society for International Health (CSIH) consultants. As of today, some of the documents are being translated into regulations endorsed by respective ministerial orders (operation of blood banks; recruitment, registration and retention of blood donors; data collection and reporting on blood procurement and use; monitoring and evaluation of blood banks' operation; blood safety monitoring indicators; and rational use of blood products); 63 standard operating procedures and equipment operating procedures, 110 forms for internal quality monitoring are approved by the director of the NTC. Quality standards for blood banks and guidelines on rational use of blood products are at the stage of finalization.

Training of key personnel is ongoing. The training covered the blood transfusion quality management, internal audit on quality transfusion, rational use of blood, quality manual and documentation, recruitment of voluntary donors, medical equipment inventory, and preventive maintenance.

The NTC is planning to apply for international accreditation in 2018. With the technical support of CSIH consultants, the NTC developed the Action Plan to obtain international accreditation under ISO 9001:2015 that specifies quality management system of the organization to assure its compliance with the standard statutory and regulatory requirements.

The project aims to establish a model maintenance unit in the NTC, which will serve as a basis of a new structure for medical equipment maintenance in the country. The project provided the model unit with 25 types of the equipment along with software (Computerized Maintenance Management System) for medical equipment inventory and maintenance work.

The project aims to improve blood safety through upgrading 26 blood banks (located in 21 aimag general hospitals, 3 soum health centers and 2 isolated district general hospitals in UB), providing equipment, training and organizing blood donor management systems. Renovation of the 26 blood banks is ongoing. Procurement of blood safety equipment for the 26 blood banks is completed; all equipment is installed in rural blood banks and operational. The project engaged individual consultants to conduct the knowledge attitude and practice (KAP) baseline survey on blood donation among general population and on blood safety and rational use among the health care workers in 2015. The survey results have been derived and will serve as a reference for developing training programs and materials, as well as public awareness campaigns planned under the project.

Component 2.

The project aims to expand the existing central medical waste management facility (CMWMF) that collects and treats medical waste from all health care facilities in UB, by construction of a new facility and introduction of new and advanced technologies, such as reusable plastic containers for sharps and plastic recycling. However, in fact, the Element company expanded the existing CMWMF by (i) increasing its autoclave capacity to 2,800 kg per day; (ii) enlarging the landfill site to 5 hectares; (iii) developing own landfilling capacity by purchasing heavy machinery and adding new employees; (iv) constructing a permanent disposal facility for hazardous waste with capacity to contain up to 2400 cubic meter of hazardous waste; and (v) constructing a manufacture for production of plastic containers for sharps. The project engaged researchers to conduct a baseline study to obtain accurate data on the quantity and quality of healthcare waste produced in UB. According to the survey, the total amount of medical waste produced in UB is about 2.06-2.47 tons including infectious, sharps, pathological, chemical and pharmacological types of waste. The Element LLC's current autoclaving capacity is sufficient to treat this amount of waste. It is obvious that there is no need to expand the current facility. However, the project can support the operator in establishing an incineration plant that will meet up-to-date international standards. This will complement the medical waste management capacity of the country and ensure full treatment and disposal security for all biohazardous waste generated in UB.

The project aims to (i) establish an interim storage facility for medical waste in 6 aimag general hospitals and in Darkhan and Erdenet cities; (ii) provide waste management equipment to 21 hospitals; and (iii) improve medical waste management systems and capacity building for personnel countrywide. As of today, the MOH awarded a civil works contract to establish an interim waste storage facility in 2 out of total 8 general hospitals. Supply and installation of medical waste management equipment in the project hospitals has not yet started due to delays of the renovation works in the hospitals.

The project made progress in improving the country's legal and administrative system for medical waste management (MWM). Based on a review of the currently existing MWM related policy documents, the CSIH consultants provided recommendations for improvement and reinforcement of the legal documents. These recommendations include: (i) a new guideline on calculation of recurrent hospital costs associated with MWM and setting tariffs for medical waste disposal, (ii) new inspection checklists to be used by inspectors under the external quality assurance system, (iii) recommendations on classifications of medical wastes, and (iv) recommendations on revision of the medical waste treatment guidelines, including guidelines for treatment of chemical, liquid and pathological wastes.

Component 3.

To ensure effective infection prevention and control, (IPC) the project aims to upgrade microbiology laboratories in 21 hospitals. The upgrade includes renovation works, supply of equipment, review and update of the existing policy and guidelines on infection control, and capacity building. Renovation works are planned to start in 2017 subject to availability of the government counterpart funding. Renovation of microbiology laboratories and the equipment upgrade are based on requirements of the national and international standards. Procurement of the equipment is postponed until the completion of renovation works in the hospitals.

Progress has been achieved in improving the microbiology testing guidelines and staff capacity building. The project consultants assessed compliance of microbiology laboratories in project hospitals with bio-safety standards for using standard checklists based on national and international requirements, and developed standard operations procedures (SOPs) for routine microbiology and antimicrobial susceptibility testing (procedures for sample collection, identification, susceptibility testing, interpretation, reporting and quality control). Staff training on new SOPs is planned in 2016-2017.

The project aims to improve infrastructure and equipment of the central sterilization service departments (CSSD) in 21 project hospitals. Subject to availability of the counterpart funding, renovation of the hospitals and microbiology laboratories is planned to start in 2017.

The project consultants reviewed the current ministerial orders on IPC and observed implementation of these orders at the work places in the hospitals. Based on the observation findings, the project (i) revised the IPC technical guidelines; (ii) developed checklists to monitor healthcare staff practice related to hand hygiene, handling and disposing sharps and other medical wastes; and (iii) developed job descriptions for hospital epidemiologists and infection control practitioners.

Development of an active surveillance system for hospital acquired infections (HAIs) is one of the project's objectives. In 2015-2016, the project commenced piloting of active surveillance of the most common hospital acquired infections in the selected 3 hospitals. A preliminary analysis of data already shows that HAIs are severely underreported in Mongolia. The final decision on introducing the IPC surveillance system (including the scope of the surveillance) should be made by MOH based on full understanding of its cost implications as well as its benefits.

The project engaged an individual consultant to conduct a KAP survey to assess competencies of healthcare workers in areas of IPC and HAI. The survey results are finalized and submitted to the MOH. The survey results will serve as a baseline to measure progress of the project inputs. The project carried-out various IPC trainings on (i) active HAI surveillance, (ii) HAI as an issue in care, (iii) the role of a bacteriological laboratory in active HIA surveillance, and (iv) internal IPC audit. As of today, the training sessions were attended by 233 doctors, epidemiologists, bacteriologists, laboratory technicians, nurses, administrative personnel, inspectors of GASI and education departments.

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.

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 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 Staff

Responsible ADB Officer Jigjidsuren, Altantuya
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 24 Mar 2017

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 7.96 0.00 29%
Counterpart 7.71 Cumulative Disbursements
Cofinancing 0.67 10 Dec 2012 6.99 0.00 26%
Status of Covenants
Category Sector Safeguards Social Financial Economic Others
Rating - - - - Satisfactory -

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Evaluation Documents See also: Independent Evaluation

None currently available.

Related Publications

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