Transaction Advisory Support Terms of Reference for

Project Preparation and Procurement

Republic of Uzbekistan
Multi-disciplinary Hospital PPP Projects in Andijan and Bukhara

Background
The Government of Uzbekistan (GOU) is investing in the country’s infrastructure across
multiple sectors including health. As part of this, GOU is considering building new or refurbishing
existing hospital facilities in priority regions. It is envisaged that relevant specialty services will
be consolidated into a single location, the multi-disciplinary hospital. GOU has also resolved to
develop the multi-disciplinary hospitals in Andijan (Project- A) and Bukhara (Project-B) under
Public Private Partnership (PPP) modality (together the “Projects”) where prospective private
sector players are expected to deliver new/improved infrastructure, equipment and clinical
services. At least one of the two projects may also have medical education components.
In this context, the Office of Markets Development and Public Private Partnership (OMDP) at
Asian Development Bank (ADB) is providing Transaction Advisory Services (TAS) to the
Ministry of Health (MOH) and PPP Development Department (PPPDD) under the Ministry of
Economy and Finance (MOEF), collectively the Clients, in defining, structuring and procuring
the PPP projects as well as attracting qualified private sector investors. GOU is also receiving
Technical Assistance from the Asia Pacific Project Preparation Facility (AP3F) for these
activities. We anticipate the Projects to be implemented in two phases: Phase-1: project due
diligence, structuring, preparation of PPP concept and Project Evaluation Document (PED) as
required by Uzbekistan PPP law; and Phase-2: tender process leading to commercial and
financial closure.
ADB has engaged consultants covering different areas of expertise such as environmental
safeguards, social safeguards, legal and health to support OMDP in defining, procuring and
successfully delivering the Projects.1 This Terms of Reference (TOR) relates to the recruitment
of a qualified International Technical Advisor (the TA) to cover technical and commercial aspects
and support implementation of the Projects. The TA would be expected to work seamlessly with
other advisors in delivering the Projects.
An interim consultant has been engaged by ADB to undertake the assessments related to (i)
demand-supply gap in the two cities, (ii) site suitability, (iii) market sounding feedback from
prospective developers, hospital operators and/or investors, (iv) medical specialty mix for
consolidation, (iv) whole life cost projections, (v) high level shadow bid model, and (vi) draft
PED under Phase-1. In order to progress the Projects, the new TA will review and familiarize
themselves with existing project reports and analysis. The TA will not be expected to re-do the
above work already carried out.

Project Overview
The Andijan region is located on the eastern edge of the Fergana Valley bordering the Kyrgyz
Republic. The region is the most densely populated part of Uzbekistan with a population of
2.98 million and population density of 773 persons per square kilometer.2 The largest city in
the region is Andijan which is the fourth largest city in Uzbekistan (population: 318,419).3 The
healthcare system of Andijan has 35 hospitals employing more than 8,000 doctors, more than
25,000 nurses and more than 5,000 other personnel with 10,330 beds.

1
Including a national healthcare consultant appointed and placed at MOH to support the ADB TAS team and other
advisors in the provision of capacity building activities to the public sector partners, undertaking demand-supply
assessment, development of a pipeline of healthcare projects and project definition.
2 Investment Promotion Agency under the MIFT. 2022. Website
3 World Population Review. 2022. Website.

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 The Bukhara region is located in the south-west of Uzbekistan next to Turkmenistan and other
regions of Uzbekistan. The region has a population of 1.87 million and population density of
45.7 persons per square kilometer.4 The largest city in the region is Bukhara City (population:
247,644) which is the fifth largest city in Uzbekistan.5 Bukhara City is a tourist attraction with
the historic city centre included in the UNESCO World Heritage List and MOH is eyeing medical
tourism opportunities with respect to Project-B. The healthcare system of Bukhara has 30
hospitals with 6,166 beds, employing more than 6,000 doctors, more than 19,000 nurses and
more than 4,000 other personnel.
In both Oblasts, the government has decided to consolidate the tertiary care services under
one or two multi-disciplinary hospital by upgrading the existing multi-disciplinary hospital and
adding additional 250-300 beds for providing super specialty tertiary care treatment which is
currently being provided in other single specialty hospitals. The government wants these
hospitals to be developed under an integrated PPP model including provision of clinical and
non-clinical services by the private partner. At least one of the projects may entail provision of
medical education by the private partner.

Scope of Work
The TA will work under the coordination, supervision and direction of OMDP, who will act as
the main counterparty with the MOH, regional government and PPPDD. Due to the solution-
oriented nature of the advisory work, the TA will be expected to always work proactively and
to bring the benefit of their experience to identify/execute any additional tasks that would be
required to ensure success of the Projects. The TA would also be expected to ensure that all
expected tasks are carried out in accordance with good industry practice and in line with local
framework and international precedents. The TA will be expected to familiarize themselves
with the existing Projects documentation.
A. Phase-1: Project preparation and PED submission/approvals

I. Project Definition
Based on the identified medical specialty mix for consolidation and selected project sites, the TA
will develop the Project Definition.

4 Government of the Republic of Uzbekistan. 8 April 2022. Decree of the President of the Republic of Uzbekistan No.
UP-101. Tashkent.
5 Investment Promotion Agency under the MIFT. 2022. Website

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 A. Site Assessment
1. Conduct a high-level technical assessment of site to define general technical
conditions of soil and the site, to (i) screen for any potential restrictions or conditions
that could impair building, (ii) recommendations on potential general foundation
recommendations and civil works required to adapt the land if necessary; (iii) other
parameters necessary to implement the Project. The survey will include visual
inspection and assessment, review of available technical documentation and data for
the land plots, and discussions with local authorities.
2. Description of topographic and seismic characteristics of each land plot, to extent
possible.
3. Conduct a geo technical assessment of the site and assess the feasibility from a geo
technical perspective.
4. Conduct high level assessment of utility connection available and transport
connectivity including road access, public transport, etc.
5. Conduct a site regulatory assessment, including assessment of the local FAR
regulations, to identify any issues and concerns with respect to implementation of the
project from a regulatory perspective.
6. Develop a site SWOT analysis and analyze the impact of the finding of the site
assessment on the project configuration, overall feasibility and cost.
7. Based on the analysis above, the TA will be required to prepare a description of the
site that would allow bidders to assess construction conditions and connectivity costs.
B. Project Configuration
Develop for each Project
1. Specialty and service mix
2. Bed Mix
3. Manpower plan
4. Equipment plan
5. Schedule of Accommodation (SOA)
6. Capacity of various common utilities required

II. High level architectural/design solution

Based on the identified project configuration, the TA will develop the high-level design, which
will include at least the following for the new Hospital:
a) Prepare a Master Plan of the project detailing out the site layout, preliminary
architectural layout, block diagrams with sizing and clinical adjacencies,.
b) Medical and support equipment plan based on international best practice and norms,
including medical equipment schedules with quantities, estimated costs and
specifications for major/heavy equipment.
c) IT infrastructure likely to be required based on best practice and local requirements.
d) High level engineering solution including allowances for major plant and equipment,
utility connections, etc.

III. Economic and Social Safeguard Assessment

a) For the selected land plot for each Project, coordinate and incorporate inputs from
Environmental and Social Safeguard Consultants assessing E&S risks, with focus
on those that might pose a limitation on future operations and/or need urgent
interventions/remediation, including as a minimum the following risks and issues:
(i) potential physical/economic displacement of formal and informal occupants,
including those with recognizable legal rights and/or customary claims to land and
those with no legally recognizable legal rights or claims.

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 (ii) potential land related claims and grievances related to its previous uses and/or
linked to prior government managed resettlement, historical disputes, forced
evictions.
(iii) historical soil, underground water contamination, including by legacy
contaminants such as lead /other heavy metals, asbestos, PCBs, pesticides.
(iv) access to public utilities, including sewerage system.
(v) access to reliable and sufficient drinking water source without compromising
local water needs. If drilling of a water well will be needed, land use restrictions due
to the need of establishing a sanitary zone in accordance with Uz Sanitary Norms
and rules No 0244-07 (dated 12.29.2007) should be respected.
(vi) avoidance of overlap or impacts to legally protected areas and internationally
recognized sites of high biodiversity value.
(vii) any other environmental and social issues which may impose any restrictions
or risks for the project
b) Coordination between the Environmental Safeguards Consultant, The TA and the
AP3F Thematic Specialist (Environmental and Climate Change) to (A) gather
available historical and recent climate data for the projects’ areas (Bukhara and
Andijan Oblasts), particularly variables relevant to the shortlisted/identified project
areas and designs, precipitation patterns including flooding history, temperature
increase/ trends, mudflows etc; (B) to calculate sensitivity of the proposed
healthcare facilities’ components to climate change impacts; and strengthen climate
resilience of the projects’ design to ensure that all healthcare facilities’ structural
assets are designed to cope with the anticipated impacts of climate change on the
two Regions (e.g. greater incidence of extreme events such as flash floods/mudflows
and heatwaves).
c) Coordination between the Environmental Safeguards Consultant, The TA and the
AP3F Thematic Specialist (Environmental and Climate Change) to assess the effect
of consolidation on livelihood of staff of existing hospitals, assuming that the
hospitals which would be consolidated under the Projects will be decommissioned.
d) Coordination with the Environmental Safeguards Consultant and the AP3F Thematic
Specialist (Environmental and Climate Change) to identify, assess, evaluate and
recommend appropriate climate mitigation (GHG reducing) interventions / options to
be considered by operators of the Projects;
e) Collaboration between the TA, the Environmental Safeguards Consultant and the
AP3F Thematic Specialist (Environmental and Climate Change) to arrive at cost
estimates for the identified and recommended climate adaptation/resilience and
mitigation measures (GHG reducing) interventions / options to be included in the
project design and project feasibility studies.
IV. Financial Model
Based on the available high-level financial model, the TA will develop a detailed Financial Model
for each of the Projects along the following lines:
a) The model should allow for the input of an array of assumptions and outputs typical
for social sector / health PPP projects including construction period, operating
period, actual fixed O&M expenses, pretax project IRR, project IRR, NPV, WACC,
equity IRR, DSCR and LLCR.

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 b) The models should ensure appropriate accounting and tax compliance relevant to
Uzbekistan projects of this nature and present financial statements (balance sheet,
income statement, cash flow statement) and have a scenario manager and
affordability calculation worksheet;
c) The model should allow for the testing of a number of feasibility metrics including
affordability for the public sector and VFM for GOU under the proposed PPP
structure;
d) The model should be easy to understand, reflect the applicable recommended
transaction structures, be capable of accommodating reasonable changes in
structure going forward, and adhere to industry best practices and modeling
standards;
e) A Model User Guide (the “User Guide”) should be prepared to provide step-by- step
instruction about using the models, changing assumptions and inputs etc. to derive
expected outcomes. For the avoidance of doubt, the User Guide would not
anticipate any coding changes to the models but only changes to input assumptions
and other parameters.
f) Quality control of the model including model audit, if required by either ADB or the
Government, should be ensured.
g) The models should be provided to ADB in an unlocked form, i.e. formulas visible
and editable in cells, and, as a minimum, the models should include the following for
the entire PPP contract periods:

 Input tabs: Worksheets comprising time based and non-time-based input

assumptions with scenario manager options;
 Capex and Maintenance Costs: Worksheet incorporating unit rates for CAPEX
and Maintenance Costs. The TA should also provide details of the replacement
capex over the period of the contract;
 O&M Cost: Worksheets providing calculations for O&M cost of the hospital
including salary of clinical and non clinical staff, maintenance cost, consumables
and drugs, etc.
 Revenue: Worksheet providing details of specialty wise volumes for IPD and
OPD, volume of various diagnostic tests, tariff and revenue from other sources
 Fiscal Impact: Estimation of the fiscal impact on the government
 Step-ups and indexation: Step-ups, where relevant, and indexation mechanism
for various cost and revenue items;
 Accounting and tax: Accounting and tax depreciation and treatment;
 Financing drawdown, repayment and others:
o Currencies: dual currency financing, in US Dollar (“USD”) and local currency;
o Drawdown: Flexibility to permit different drawdown options (e.g. pro-rated
and sequential) for various funding tranches, including but not limited to, senior
debt and shareholder contributions;
o Repayment: Defined repayment types (e.g. sculpted, straight line, equal
amounts etc.) for individual funding tranches; and
o Others: Reflecting important covenants such as DSCR, DSRA, LLCR, etc.;

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  Sensitivity analysis: Capable of carrying out various “what-if” scenarios and
sensitivity analysis related to currency depreciation, funding assumptions, solar
assumptions, cost increases, timing delays, climate mitigation and adaption
measures/interventions.
 All assumptions used in the model shall be explained and justified.
V. Financial Feasibility

a) The TA will conduct the financial feasibility for each project separately.
b) The TA will be required to analyze all the financial elements of projects and conduct an
assessment of all of the costs and revenues related to the projects, including but not
limited to:
 Estimate all of the necessary capital expenditure required for each of the projects
including all construction, plant/equipment and IT infrastructure;
 Estimate all the operational costs required to operate each of the projects, by key
headings such as manpower, drugs and supplies, consumables, support services,
lifecycle maintenance, utility costs, etc.,
 Estimate of the revenue generated from the project over the PPP contract period
taking into consideration the ramp up of the utilization, patient mix, market tariff for
various services and procedures and tariff available under any extant government
insurance scheme
c) As an outcome of the Financial Feasibility the TA should provide an assessment of the
viability, affordability and sustainability of each project.
VI. Project Structure

a) Support ADB in analyzing various options for PPP by providing any technical inputs
required and assist in conducting the financial analysis of each option
b) Provide a high-level risk allocation matrix which clearly identifies the main risks related
to each Prioritized Subproject, the party responsible for such risk and possible
mitigation strategy to be considered in the project structure.
c) Support ADB in developing the project structure by providing any inputs as required
from the Project Definition and/or Financial Feasibility and Financial Model
d) Participate in the discussion and presentation of the project structure to the Client and
support in finalization of the project structure
e) Provide technical inputs to the legal consultant appointed by ADB in developing the
Term Sheet.
VII. Economic/Fiscal/and Social Assessment

The TA will be required undertake economic and social assessments based on the selected
clinical model and detailed Financial Model, including but not limited to:
a) Carry out Economic IRR (EIRR) analysis in a way that is consistent with local
requirements.
b) Undertake a comprehensive fiscal liabilities assessment to evaluate the financial
obligations associated with each Project.6
c) Social impact assessment (as a separate section in the PED).7

6
The analysis shall be in line with local fiscal liability assessment methodology identified in the Government Decree
Government #558 dated 23 October 2023.
7 Please see PED Social section content requirements identified in the Cabinet of Ministers Resolution #259 dated
26 April 2020.

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 VIII. PED approvals
The TA will be supporting the OMDP through the PED approvals by the Cabinet of Ministers.
The TA shall be available to provide clarifications and/or adjustments to the PED, including
Financial Model to incorporate comments (if any) from the PED approving authorities.

B. Phase-2: Tender process leading to commercial and financial closure

I. Procurement Support
The TA will be expected to play a key part in determining the appropriate procurement strategy
(including bid evaluation methodology), along with the legal advisers and the OMDP team.
Once that strategy is agreed, the TA will be expected to play a lead role in developing a full
set of technical procurement and contractual documentation. The list below is indicative only
and focuses on the areas where the TA is expected to lead. Clearly, it will also be expected to
contribute to other commercial/financial parts for the documentation as appropriate:
a) Financial sections of Prequalification documents;
b) Financial evaluation of such documents;
c) Assist with setting up and executing all market sounding activities, including a
Bidder’s Conference, should one be held;
d) Assist ADB in responding to clarification from bidders about technical and
commercial aspects of the Projects;
e) Technical specifications including output specifications for the construction
components of the project and any services within the scope of the PPP;
f) Performance based KPIs for clinical outcomes and quality of service;
g) Performance based non-clinical KPIs for quality facility management services,
including building/estate and grounds maintenance, cleaning/waste management,
security, laundry, general management and administration and others ;
h) Development and calibration of a Payment Mechanism that incentives performance
and allocates risks appropriately;
i) Contribute to all commercial discussions/documentation of a financial or technical
nature as appropriate;
j) Develop the technical and financial bidding requirements for inclusion in the
Invitation to Tender;
k) Assist OMDP with developing a robust evaluation methodology which is appropriate
for the selected PPP model and meet local procurement regulations and best
practice generally;
l) Draft a Terms of Reference for an Independent Certifier, who’s role will be to monitor
the construction process and certify when complete as well as monitor performance
throughout the operating phase;
m) Develop a Monitoring Plan for an Independent Certifier for the operating phase for
each hospital;
n) Develop measurable and objective KPIs by which the performance of the private
sector can be monitored and measured during the life of the contract as well as
advise on liquidated damages/penalties to be included in the contract;
o) Define reporting requirements for the private sector;
p) Develop a set of technical criteria for the handback of the Hospitals at the end of the
concession;

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 q) Coordinate with the Social Safeguards Consultant and AP3F Gender Consultant on
the inclusion of specific gender-related provisions for the development, promotion
and implementation of policies (across design, construction, and O&M) aligned with
the legal and regulatory frameworks in Uzbekistan;
r) Any other support as required to deliver the Project.
II. Selection of winning bidder and Financial Close
a) The TA will assist OMDP with evaluating all bids received and any interactions
required with any of the bidders during any negotiation process;
b) Help OMDP to develop commercial and financial close protocols, including the
monitoring of any financial processes as required;
c) Ensure the technical and financial components of the final contract are fully up to
date and reflect the agreed commercial and technical positions; and
d) Any other support as required to deliver the Projects including working with the
ADB team to develop the lessons learnt documentation after Financial Close.

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 Deliverables
The TA is expected to provide the following deliverables for each of the different assignments:

Indicative
timeline from
Deliverable Payment
start of
mobilization milestone
Phase-1: Detailed Financial Model and PED approvals
~ 4 months from kick-off
1. Deliverable-1: Final PED report for approval 4 months 25% per project
by Cabinet ministers, which: or 50% for both
 Incorporate feedback and comments projects (after
received on draft PED from the ADB, MOH, approval of PED
PPPDA etc. and issue the revised PED and by the
the Summary Presentation for government)
Government’s review and approval.
 The revised final PED should include at
least:
 Project definition;
 Detailed financial model
 Detailed financial feasibility assessment
 Fiscal, economic and social assessment
models;
 High level architectural/design solutions;
 Project structure;
 Term sheet for technical and commercial
inputs to procurement document for
selection of bidders
 Working with ADB team, addresses any
comments received from the Government
and reflect in the report/presentation or
prepare clarifications.
 Issue the final PED and the Summary
Presentation.
Phase-2: Tender process
~ commercial close 10-12 months from end of Phase-1 approval by cabinet ministers)
1. Deliverable-2: According to 20% per project
 Inputs in the Request for Qualification tender upon
(RFQ), Request for Proposal (RFP), PPP schedule commercial
agreement and other documents (e.g. bid close
evaluation and scoring) as required.
 Negotiation support to achieve commercial
and financial closure;
2. Deliverable-3 According to 5% per project
Inputs towards execution of financial schedule upon financial
closure (meeting CPs to achieve first close
disbursement)
All reports shall be accompanied by supporting materials and Excel spreadsheets. Each report
will also be accompanied by a report in Word format summarizing findings and supporting
materials and spreadsheets. The TA will also present these findings to the Client and
Government or other consultants, either in person or through videoconference. All raw data
collected shall be provided in electronic format to ADB.
Language
All deliverables shall be submitted in both English and Russian languages.

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 Schedule and place of assignment
The TA’s assignment will be for a total of 36 months. The TA shall spend significant time on
site in Uzbekistan and have a conference call with ADB at least once every 2 weeks, but
possibly on a weekly basis, to provide an update.

Team Composition
The TA should assemble a team of key experts which clearly demonstrate expertise and
proven experience in (i) defining, evaluating, and structuring PPP transactions in the health
sector in emerging markets, (ii) experience with hospital PFI projects, (iii) advising public
authorities for similar complex procurements, preferably in the health sector.
Total
Educational
Position/Expertise minimum Experience
Qualifications
person-month
inputs
International Experts
Team Leader and 4 PPP experience that would enable The candidate
Health PPP Expert the expert to recommend will have at least
international best practices in terms a bachelor’s
of business models applicable to the degree from an
sector. Proven experience in acceptable
defining, evaluating, and structuring university
PPP transactions in the health sector
in emerging markets, health
financing mechanisms, structuring
sustainable and bankable revenue
models for PPP projects and/or
private sector health services,
advising public authorities for similar
complex procurements in the health
sector. Other requirements:
 At least 15 years of relevant
international professional health
sector and/or PPP experience in at
least 3 countries including in
Central Asia;
 Experiences in successfully
delivering (i.e. at least commercial
close achieved) health sector PPP
projects with clinical services is
mandatory;
 Experience in health PPPs in
Uzbekistan would be considered
highly advantageous;
 Demonstrates experience
across a number of different health
PPP models including clinical
services;
 Relevant Project Management
experience;
 Excellent English skills (written,
oral) mandatory; and
 Knowledge of Russian and/or
Uzbek language is an advantage

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 Total
Educational
Position/Expertise minimum Experience
Qualifications
person-month
inputs
Healthcare Planner 2  At least 5 years of international The candidate
experience, in at least 2 countries, will have at least
of health planning activities for a bachelor’s
large regional/tertiary hospitals in degree or
developing countries; equivalent (e.g.
 Central West Asia regional degree in
experience is an advantage; hospital
 Relevant experience in the management,
preparation of feasibility studies, planning, hospital
inputs to tendering process etc.; administration,
 Excellent English skills (written, etc. ) or a related
oral) mandatory; and field
 Knowledge of Russian and/or
Uzbek language is an advantage
Financial Modeler 6  At least 7 years of relevant The specialist
experience in the preparation of should have at
financial models for similar least an
projects; and advanced degree
 Excellent English skills (written, (e.g. masters n
oral) mandatory. relevant field,
CFA, chartered
accountancy,
MBA or similar)
finance or related
discipline
Healthcare Architect 1  At least 10 years of relevant The candidate
international experience in at least should at least
3 countries, of developing similar have a bachelor
hospitals at concept stage; degree in
 Proven ability to specify architecture or
requirements in output terms related field
suitable for a PPP procurement;
 Ability to evaluate designs
proposed by bidders;
 Excellent English skills (written,
oral) mandatory; and
 Knowledge of Russian and/or
Uzbek language is an advantage
Engineer/Equipment 2  At least 5 years of relevant The candidate
Specialist/ Cost international experience in will have a
Specialist developing engineering solutions Bachelors
for similar hospitals. degree or
 Experience in developing equivalent in
specifications and forecasting Engineering or
whole life costs on hospital projects relevant fields
including at concept design stage.
 Good command of the English
language mandatory; and
 Knowledge of Russian and/or
Uzbek language is an advantage

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 Total
Educational
Position/Expertise minimum Experience
Qualifications
person-month
inputs
Health economist 0.5  At least 10 years of experience The candidate
in conducting EIRR analysis of will have at least
healthcare projects; a masters degree
 Experience of conducting EIRR in health
analysis on at least 2 hospital economics or
projects; equivalent level
 Experience in health sector degree in related
projects is preferred. field

National Experts
Health Expert 2  Knowledge of the local The candidate
healthcare financing system, will have at least
healthcare services and hospital a master’s
operations. degree (or
 At least 7 years’ experience in equivalent) in
the health sector; and health science,
 Good command of the English chemistry,
language and fluency in Russian biology or a
and or Uzbek related field
Engineer and Cost 1  At least 7 years' relevant The candidate
Consultant experience in cost projections and will have a
benchmarking in Uzbekistan; and master’s degree
 Good command of Russian and (or equivalent) in
or Uzbek language mandatory, and civil engineering
and working level (oral, written) or equivalent
command of English.
Local Coordinator 6  At least 5 years of relevant The candidate
experience in project coordination will have a at
in Uzbekistan; The projects in least graduate
healthcare sector, PPP or degree in
experience working with IFI economics,
projects will be an advantage; and finance or
 Good command of Russian and equivalent
Uzbek mandatory and working level
(oral, written) command of English.
Evaluation scoring will only be done for the above Key Experts. However, in addition to the
above referenced “Key Experts” the TA may hire additional experts, either international or
national, as appropriate to deliver the scope of services. Any “Non-Key Experts” required to
achieve the TA deliverables will be identified by proposing firms and included in their technical
and financial proposals, personnel work plan, and schedule, in accordance with their proposed
approach and methodology. The proposing firm must determine and indicate the number of
person-months required for each Key or non-Key Expert.

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