Sri Lanka : Health System Enhancement Project
The project will contribute to the government''s development objective to ensure a healthier nation by supporting the development of a more responsive and comprehensive primary health care (PHC) system in Sri Lanka. It will enhance planning and delivering of essential PHC to geographically and socioeconomically deprived populations of Central, North Central, Sabaragamuwa, and Uva provinces. The project will (i) inform and operationalize government PHC reform initiatives, (ii) improve underserved communities'' access to primary health services, and (iii) address selected gaps in core public health capacities in line with the International Health Regulations (IHR).
Project Details
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Project Officer
Jayasundara, Herathbanda
South Asia Department
Request for information -
Country/Economy
Sri Lanka -
Sector
- Health
Project Name | Health System Enhancement Project | ||||||||||||||||||||
Project Number | 51107-002 | ||||||||||||||||||||
Country / Economy | Sri Lanka |
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Project Status | Active | ||||||||||||||||||||
Project Type / Modality of Assistance | Grant Loan |
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Source of Funding / Amount |
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Strategic Agendas | Environmentally sustainable growth Inclusive economic growth Regional integration |
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Drivers of Change | Gender Equity and Mainstreaming Governance and capacity development Knowledge solutions Partnerships |
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Sector / Subsector | Health / Disease control of communicable disease - Health sector development and reform |
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Gender | Effective gender mainstreaming | ||||||||||||||||||||
Description | The project will contribute to the government''s development objective to ensure a healthier nation by supporting the development of a more responsive and comprehensive primary health care (PHC) system in Sri Lanka. It will enhance planning and delivering of essential PHC to geographically and socioeconomically deprived populations of Central, North Central, Sabaragamuwa, and Uva provinces. The project will (i) inform and operationalize government PHC reform initiatives, (ii) improve underserved communities'' access to primary health services, and (iii) address selected gaps in core public health capacities in line with the International Health Regulations (IHR). | ||||||||||||||||||||
Project Rationale and Linkage to Country/Regional Strategy | Sri Lanka has made impressive gains in ensuring access and quality to health services for all. Life expectancy at birth increased to 75 years in 2015 from 70 in 1990. Maternal mortality reduced from 75 to 30 per 100,000 live births and infant mortality from 17.9 to 8.0 per 1,000 live births during the same period. Sri Lanka has achieved these efficiently with low overall health spending at 3.0% of gross domestic product (GDP). Most vaccine preventable diseases are at near elimination stage with immunization coverage at about 99%. Sri Lanka has been polio-free since 1994, and malaria- and filariasis-free since 2016. While Sri Lanka has benefited greatly from improvements in health outcomes during the Millennium Development Goals period (1990 to 2015), it is facing new health challenges related to population aging, changing disease pattern, economic and social changes, and changing lifestyles. These dynamics have resulted in a dramatic increase in noncommunicable diseases (NCDs), which are causing a surge in demand for health services and an increase in health care costs while reemerging and emerging communicable diseases remain a threat. Disparities in health outcomes, health-seeking behavior, life expectancy, and disease burden remain in lagging geographic areas especially in rural and estate sector populations, e.g., malnutrition in mothers and children is a persistent health issue and more acutely seen in the estate sector. The country is now more exposed to communicable diseases because of increased labor mobility and connectivity. Sustaining control of vaccine preventable diseases, malaria elimination efforts, and containment of global diseases will require continuous investments in the prevention and control of communicable diseases and disease surveillance in Sri Lanka. Primary health care delivery system. The public PHC system in Sri Lanka has been instrumental in providing universal comprehensive care at no cost to the population at the point of service delivery. One of the most characteristic features of the system is preventive health care services focusing on communicable diseases control and maternal and child care. The system covers 341 geographic areas, each with a population of about 80,000. Each area is managed by a medical officer of health and served by 5-10 field health centers with midwives, public health inspectors, and preventive health care staff. In parallel, there is an extensive network of curative services in three tiers of care (955 PHC hospitals and dispensaries, and 149 secondary and tertiary health care hospitals). The government health sector provides as much as 90% of inpatient care, nearly 100% of preventive care, and 50% of outpatient care. At present, the health system planning, policy, and stewardship functions are centrally managed while management of primary and most secondary health care services is decentralized to provincial governments. Constraints. Since 1990, changing health challenges and population aging led to secondary and tertiary health care services being prioritized for investments at the expense of investments for primary curative and preventive care services. Deterioration of PHC facilities led to bypassing of primary curative care services for secondary and tertiary care for most health problems faced by the population. For example, secondary and tertiary health care today manage as much as 93% of childbirths, 75% of NCD patients, and 50% of outpatient services. On the preventive side, the medical officers of health continue to provide antenatal care, nutrition, and immunization services. However, the quality of services decreased because of lower investments (about 4.5% of public health spending), inadequate staffing, and other resource constraints. Expanded outreach and interventions for populations living in vulnerable and lagging areas are also hampered. Preventive health care services are limited to mothers and children and village environments. There is a need to expand the target group to include the total population (children, youth, adult men and women, and elderly) and expand coverage of NCDs. Government initiatives. The Government of Sri Lanka is reprioritizing PHC in line with its national health policy and strategic master plan. Sector reforms aim to establish a more responsive, patient-centered, and person-focused health care system. The system will enable health seekers to access a comprehensive package of essential health services including financial risk protection. The government's most recent policy on rational health care delivery for universal health coverage provides the guiding framework to reform the existing PHC system. The government is committed to develop a more comprehensive, accessible, and higher-quality PHC package to strengthen PHC services, reduce bypassing, and reach vulnerable groups. It is also committed to implement e-health to strengthen evidence-based health services. This includes scaling up the introduction of a patient e-health card, connecting health services for referral and better patient care, and improving information on diseases and health-seeking behavior using a geographical information system (GIS). The system will be linked to disease surveillance for national health security. To comply with International Health Regulations standards, the government aims to strengthen the health assessment of migrants and quarantine services at ports of entry (POEs). In support of efforts to strengthen PHC and the digital health information system, policy developments are in preparation for the essential services package, health human resources, family medicine, facility norms, and testing innovative approaches to strengthen PHC. Capacity building will also be implemented in management, e-health, quarantine and health security, procurement, accounting, gender, nutrition, and health care waste management. Value added by ADB assistance. Asian Development Bank (ADB) assistance brings value by (i) supporting equity-focused health care delivery reform especially in lagging and rural areas such as the plantation and estate sectors; (ii) adopting evidence-based planning based on GIS mapping and vulnerability index to identify and target underserved districts and populations; (iii) enhancing infrastructure design to address climate change and disaster risk resilience; (iv) scaling up e-health card and its integration with the government's web-based health information system to improve continuity of care and disease surveillance; (iv) supporting GIS units in central and district planning departments to improve disease surveillance and monitor health-seeking behavior; (v) institutionalizing distance learning for training PHC staff; and (vi) helping districts develop and implement innovative solutions to integrate and improve PHC services. Link to national development strategy and ADB sector priority. The project aligns with the government''s priorities identified in the Public Investment Programme, 2017-2020 and Vision 2025, and with the United Nation's Sustainable Development Goal 3 on universal health coverage. The project is in line with ADB''s country partnership strategy, 2018-2022 for Sri Lanka and paves the way for a long-term programmatic approach consistent with ADB''s health operations plan. ADB experience and lessons learned. The project is ADB''s reentry to the health sector in Sri Lanka after a gap of about 20 years. The prior project and other recently completed and ongoing ADB-financed projects in the social sectors have been implemented successfully. These past experiences and the project preparation process indicate strong commitment by the government at the national and regional levels. The leadership provided by the Ministry of Health, Nutrition and Indigenous Medicine (MOHNIM) and the four provincial administrations during the project preparation stage is expected to continue into project implementation. Development coordination. MOHNIM convened the donor coordination committee to ensure collaboration with and among development partners. The World Health Organization (WHO) has a leading role in policy development and sector coordination. The project will collaborate with WHO in terms of technical assistance to support selected areas related to the essential services package, health system strengthening, human resource development, and health security. The project also intends to work with the United Nations Children's Fund (UNICEF) and the World Food Programme on nutrition, as well as the International Organization for Migration on migrant issues. ADB''s support will be coordinated with the World Bank program support to strengthen PHC, and regular discussions are held to prevent duplication of efforts and to synergize on the results and outcomes. |
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Impact | A healthier nation is ensured with a more comprehensive PHC system |
Project Outcome | |
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Description of Outcome | Efficiency, equity, and responsiveness of the PHC system improved |
Progress Toward Outcome | By end of reporting period, the cluster system reform process has been implemented in all nine districts. The evaluation will be carried out by comparing the findings of the end-line survey against the baseline, as well as analyzing the outcomes of the pilot cluster and HSEP supported non-cluster areas in contrast to the control area. Outpatient utilization was estimated as the percentage of people in the catchment population who utilized the PHC for outpatient services according to the baseline household survey. The proportion of females in the catchment populations utilized PHC was higher than that of males. The highest utilization rates were observed in the elderly, followed by children under 5 years of age. The patients' knowledge and satisfaction were calculated using the data from PHC user survey. The details of calculation are available in the Baseline report. At the baseline, overall, 52.8% of the PHC users were satisfied (scored 70% or more in the multi-item satisfaction scale). Satisfaction level was somewhat lower in the 45-64 year age category (50.6%) than those aged below 18 years and above 65 years. Overall, 53.5% of the PHC users were aware (scored 70% or more in a multi-item hospital awareness scale) of the services provided at the PHC. The awareness was higher in females than males. |
Implementation Progress | |
Description of Project Outputs | Primary and secondary health care enhanced in Central, North Central, Sabaragamuwa, and Uva provinces. Health information system, disease surveillance capacity, and COVID-19 response strengthened Policy development, capacity building, and project management supported |
Status of Implementation Progress (Outputs, Activities, and Issues) | Output 1 Out of 135 PMCUs and DH, 35 completed (25.18%) (Secondary data from the PMU by the end of reporting period), a Gender Consultant has initiated developing the criteria for considering a facility as providing gender responsive health care. M&E team will analyze baseline and annual survey data once the definition has been finalized and agreed upon under the gender responsive and inclusive essential service package for outpatient and clinic services provided by PHC facilities supported in target provinces. All MOH within cluster areas provide gender responsive nutrition services to infants and children under 5 years of age and school children further MOH provides specific nutrition services to pregnant and postpartum females. Recruitment of consultancy firm for behavior change and community mobilization for increasing primary health care utilization has been withheld as budget allocation has been transferred to the emergency procurement of medical supplies. Output 2 Establishment of electronic patient information sharing system for stage one in progress. (Qualitative study). Two out of 9 clusters (Thambuthegama and Dambulla) have been identified as pilot areas and the initial work is in progress. (Discussion with Director, information, Ministry of Health). Developed software has been piloted. Only few of the health facilities were sending notifications via email and not by an electronic system under the target of developing a system to send notifiable disease surveillance information via electronically to medical officers Core capabilities to carry out quarantine services with a score of at least 4 joint external evaluation reports to increase eight ports of entry in Sri Lanka not available after 2017, the latest score was available in the baseline score JEE report 2017 and was 3.0 The target has been completed to establish capacity to screen and diagnose COVID19 diseases by December 2020. Construction Work conducted for the following hospitals have been completed under the upgrading of primary, secondary and tertiary level hospitals capacity to treat and manage patients including COVID 19 patients: ICU BH Madirigiriya ICU BH Thambuttegama PCR Colombo East Base Hospital ETU GH Kalutara ICU TH Kurunegala PCR TH Karapitiya COVID-19 ward TH Batticaloa, Hambantota Port Contract awarded and construction ongoing Galle. SBD has been prepared with price escalation clause for Trincomalee and Colombo. Refurbishment of isolation rooms at NIID in the rebidding process Establishment of Iodine Therapy at GH Rathnapura construction ongoing Establishment of Iodine Therapy at GH Anuradhapura construction ongoing NIID Laboratory Complex - Rebidding process. Secondary data from Suwa Seriya to be obtained under the upgrading of Suwa Seriya ambulance system in all districts Output 3 The already available Maternal and Child Health policy, Maternal and Newborn strategy and National strategic Plan for Adolescent and Youth Health are gender responsive under the operational polices and guidelines with gender dimensions to complete delivering a comprehensive package of PHC (incorporating the essential service package, management and functioning of cluster hospitals and geographic information system for based planning and monitoring in health sector. Discussion with FHB is in progress. Gender dimensions are included in the national MCH policy and the relevant strategies for 11 units of FHB to have integrated gender dimension in all their policies and strategic plans. M&E firm has developed a database to auto-calculate the indicator of "at least 30% of medical officers and other staff of PMCUs and divisional hospitals in target provinces with increased knowledge in PHC based on the secondary data. By the end of 2021, a total of 270 health staff from the project districts have undergone online training programmes on gender conducted by the Gender Consultant. The participants included 141 Medical officers, 101 nursing officers and 14 other staff. Action related to policy development has not been initiated yet under the target of PHC staff from PMUs, divisional hospitals, and medical officers of health areas with increased knowledge in gender sensitivity and gender related policies heir policies and strategic plans. |
Geographical Location | Central Province, North Central Province, Province of Sabaragamuwa, Province of Uva |
Safeguard Categories | |
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Environment | B |
Involuntary Resettlement | C |
Indigenous Peoples | C |
Summary of Environmental and Social Aspects | |
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Environmental Aspects | The project is classified as Category B for environment in accordance with ADB's Safeguards Policy Statement (2009). Adverse environmental consequences of the project will be largely restricted to component 1 under which support will be provided to existing PHC facilities to upgrade 30% (135) of its primary medical care infrastructure facilities and small-scale repairs to field health centers. The nature of construction envisaged will be small-scale, simple and straightforward, mostly restricted to expansion of the outpatient departments for primary medical care facilities and repairs and refurbishment to field health centers. |
Involuntary Resettlement | The project is classified as C for IR based on the screening and assessment of qualitative sample survey of 29 of 135 sites. Selected PMCUs and DHs in the nine districts will be supported via infrastructure upgrades and provision of equipment. Land acquisition and resettlement is not triggered as all civil works are aligned to reconstruction on existing centers which are owed by the Government of Sri Lanka. |
Indigenous Peoples | The project is classified as C for IP based on ADB's guidelines. The due diligence confirms classification of C categorization for IP impacts. Screening and assessment outlined in the due diligence report show no impacts on the Indigenous Vedda population (the only IP group in the country) in both the Uva and North Central provinces (project areas with habitats). |
Stakeholder Communication, Participation, and Consultation | |
During Project Design | The Ministry of Health, Nutrition and Indigenous Medicine (MOHNIM) is the primary stakeholder together with the provincial directorates of health services in the provinces of Uva, Central, Sabaragamuwa, and North Central. Based on the ADB public communication policy and ADB safeguard policy statement, the project assisted the executing agency to prepare a stakeholder communication strategy. |
During Project Implementation | Stakeholder feedbacks are encouraged in stakeholder meetings, hospital civil society meetings and during review activities. Patient satisfaction surveys routinely carried out in health care institutions will be utilized to obtain feedbacks from project beneficiaries. Stakeholders will have communication access through ADB website and project website which will serve as the main information sharing channel. Direct communication with PMU and PIU is also possible for public and other stake holders. |
Business Opportunities | |
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Consulting Services | A design and supervision consultant for all civil works to be carried out under the project will be engaged using the quality- and cost-based selection (QCBS) method with a standard quality cost ratio of 90:10. All consulting services will be engaged in accordance with the ADB Procurement Policy (2017, as amended from time to time) and Procurement Regulations for ADB Borrowers (2017, as amended from time to time). |
Procurement | All procurement of goods, works, nonconsulting and consulting services for the proposed Project will be carried out in accordance with the ADB Procurement Policy and Procurement Regulations for ADB Borrowers (2017, as amended from time to time). Procurement items include civil works, medical equipment, computers, and vehicles. |
Responsible ADB Officer | Jayasundara, Herathbanda |
Responsible ADB Department | South Asia Department |
Responsible ADB Division | Sri Lanka Resident Mission |
Executing Agencies |
Ministry of Health |
Timetable | |
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Concept Clearance | 05 Oct 2017 |
Fact Finding | 23 Apr 2018 to 04 May 2018 |
MRM | 07 Aug 2018 |
Approval | 23 Oct 2018 |
Last Review Mission | - |
Last PDS Update | 08 Dec 2022 |
Grant 0618-SRI
Milestones | |||||
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Approval | Signing Date | Effectivity Date | Closing | ||
Original | Revised | Actual | |||
23 Oct 2018 | 26 Oct 2018 | 05 Feb 2019 | 31 May 2024 | - | - |
Financing Plan | Grant Utilization | ||||
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Total (Amount in US$ million) | Date | ADB | Others | Net Percentage | |
Project Cost | 22.50 | Cumulative Contract Awards | |||
ADB | 12.50 | 25 Apr 2023 | 5.45 | 0.00 | 44% |
Counterpart | 10.00 | Cumulative Disbursements | |||
Cofinancing | 0.00 | 25 Apr 2023 | 7.30 | 0.00 | 58% |
Status of Covenants | ||||||
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Category | Sector | Safeguards | Social | Financial | Economic | Others |
Rating | - | Satisfactory | Satisfactory | Satisfactory | - | Satisfactory |
Grant 9222-SRI
Milestones | |||||
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Approval | Signing Date | Effectivity Date | Closing | ||
Original | Revised | Actual | |||
30 Sep 2021 | 07 Oct 2021 | 17 Nov 2021 | 31 May 2026 | - | - |
Financing Plan | Grant Utilization | ||||
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Total (Amount in US$ million) | Date | ADB | Others | Net Percentage | |
Project Cost | 3.00 | Cumulative Contract Awards | |||
ADB | 0.00 | 25 Apr 2023 | 0.00 | 0.00 | 0% |
Counterpart | 0.00 | Cumulative Disbursements | |||
Cofinancing | 3.00 | 25 Apr 2023 | 0.00 | 0.00 | 0% |
Status of Covenants | ||||||
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Category | Sector | Safeguards | Social | Financial | Economic | Others |
Rating | - | Satisfactory | Satisfactory | Satisfactory | - | Satisfactory |
Loan 3727-SRI
Milestones | |||||
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Approval | Signing Date | Effectivity Date | Closing | ||
Original | Revised | Actual | |||
23 Oct 2018 | 26 Oct 2018 | 05 Feb 2019 | 31 May 2024 | - | - |
Financing Plan | Loan Utilization | ||||
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Total (Amount in US$ million) | Date | ADB | Others | Net Percentage | |
Project Cost | 37.50 | Cumulative Contract Awards | |||
ADB | 37.50 | 25 Apr 2023 | 20.52 | 0.00 | 55% |
Counterpart | 0.00 | Cumulative Disbursements | |||
Cofinancing | 0.00 | 25 Apr 2023 | 23.96 | 0.00 | 64% |
Status of Covenants | ||||||
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Category | Sector | Safeguards | Social | Financial | Economic | Others |
Rating | - | Satisfactory | Satisfactory | Satisfactory | - | Satisfactory |
Loan 4121-SRI
Milestones | |||||
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Approval | Signing Date | Effectivity Date | Closing | ||
Original | Revised | Actual | |||
30 Sep 2021 | 07 Oct 2021 | 17 Nov 2021 | 31 May 2026 | - | - |
Financing Plan | Loan Utilization | ||||
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Total (Amount in US$ million) | Date | ADB | Others | Net Percentage | |
Project Cost | 120.00 | Cumulative Contract Awards | |||
ADB | 110.00 | 25 Apr 2023 | 33.67 | 0.00 | 31% |
Counterpart | 10.00 | Cumulative Disbursements | |||
Cofinancing | 0.00 | 25 Apr 2023 | 17.04 | 0.00 | 15% |
Status of Covenants | ||||||
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Category | Sector | Safeguards | Social | Financial | Economic | Others |
Rating | - | Satisfactory | Satisfactory | Satisfactory | - | Satisfactory |
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ADB Provides $50 Million to Enhance Sri Lanka's Health System
ADB's Board of Directors has approved a grant and loan package totaling $50 million to support the development of a more responsive and efficient primary health care system in four underserved Sri Lankan provinces.
Tenders
Contracts Awarded
Contract Title | Approval Number | Contract Date | Contractor | Address | Executing Agency | Total Contract Amount (US$) | Contract Amount Financed by ADB (US$) |
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Procurement of medical supplies and consumables for MSD (surgical) - Polydioxanone Ndl, PG Suture Ndls etc. (Lot 1 to Lot 5) | Loan 4121 | 24 Jan 2023 | M/s B Braun Lanka (Pvt) Ltd. | Level 11, HNB Tower, No. 476, T B Jaya Mawatha, Colombo 10 | Ministry of Health | 2,635,324.46 | 2,634,821.16 |
Procurement of Peritoneal dialysis solution 2liter bag with integrated asymmetric Y set (1.5 % concentration) and Peritoneal dialysis solution 2liter bag with integrated asymmetric Y set (2.5 % concentration) for SPC | Loan 4121 | 25 Nov 2022 | M/s Peritone Health SDN BHD | Lot 12, Industrial Zone, Phase 4Kulim Hi-Tech Park, 09000 Kulim Kedah, Malaysia | Ministry of Health | 5,700,000.00 | 5,700,000.00 |
Recruitment of consultancy firm for provision of support for community empowerment and capacity building for improving the nutrition status of mothers and children under five years under 9 districts covering the estate and rural sector | Loan 4121 | 19 Jul 2022 | M/s. The Foundation for Health Promotion | No. 21/1, Kahwatta Road, Attidiya | Ministry of Health | 209,510.35 | 209,510.35 |
COVID- PROCUREMENT OF RAPID ANTIGEN TEST KITS FOR COVID-19 - G33 | Loan 3727 | 16 Feb 2021 | GEORGE STEUART (PVT) LTD | NO. 7E POSTMASTERS PLACE, OFF TEMPLES ROAD, MOUNT LAVINIA SRI LANKA | Ministry of Health & Indigenous Medical Services | 1,469,663.56 | 1,465,604.54 |
PROCUREMENT OF VEHICLES- 38 DOUBLE CABS- G1 | Loan 3727 | 16 Feb 2021 | M/S UNITED MOTORS LANKA PRIVATE LIMITED | NO. 100, HYDE PARK CORNER, COLOMBO 2. SRI LANKA | Ministry of Health & Indigenous Medical Services | 1,810,544.67 | 1,805,544.19 |
MONITORING AND EVALUATION FIRM (BASELINE AND END L INE)- S-2 | Loan 3727 | 04 Sep 2020 | SRI LANKA BUSINESS DEVELOPMENT CENTRE | 288/8/P, ROYAL GARDENS, RAJAGIRIYA. SRI LANKA | Ministry of Health & Indigenous Medical Services | 510,955.38 | 510,429.53 |
COVID-REIMBURSEMENT OF THE EXPENDITURE INCURRED ON THE COVID-19 PANDEMIC RESPONSE ACTIVITIES IN THE MEDICAL SUPPLY DIVISION IN MOHIMS- BATCH 2 | Loan 3727 | 04 Sep 2020 | VARIOUS | VARIOUS SRI LANKA | Ministry of Health & Indigenous Medical Services | 1,889,812.70 | 1,889,812.70 |
COVID-REIMBURSEMENT OF THE EXPENDITURE INCURRED ON THE COVID-19 PANDEMIC RESPONSE ACTIVITIES IN THE MEDICAL SUPPLY DEVISION IN THE MOHIMS | Loan 3727 | 13 Jul 2020 | VARIOUS | VARIOUS SRI LANKA | Ministry of Health & Indigenous Medical Services | 1,125,887.52 | 1,125,887.52 |
DESIGN AND SUPERVISION CONSULTANCY FIRM FOR INFRASTRUCTURE DEVELOPMENT (S-01) | Loan 3727 | 06 Dec 2019 | RESOURCES DEVELOPMENT CONSULTANTS LTD | 55/2-1, GALLE ROAD, COLOMBO 3 SRI LANKA | Ministry of Health,Nutrition & Indigenous Medicine | 1,768,272.63 | 1,768,272.63 |
Procurement Plan
Title | Document Type | Document Date |
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Health System Enhancement Project: Procurement Plan | Procurement Plans | Feb 2023 |
Health System Enhancement Project - Additional Financing: Procurement Plan | Procurement Plans | Sep 2021 |