ADB Approves Loan for the First Healthcare Project in Turkmenistan

Project documents identify significant operational and governance challenges that are not shared publicly by the government. The Ministry of Health and Medical Industry (MOHMI) in Turkmenistan as the main implementing partner of the project has, as of November 2025, has not shared any information about the loan or the project itself on its website. The project document also notes that civil society organizations will not participate in the project design since “there are no civil society organizations involved in human resources for health currently”. Progres Foundation develops and shares project related concerns in this article.

In September 2025, Asian Development Bank (ADB) approved the project “Improving Nursing Quality and Capacity in Turkmenistan”. The project will be implemented from November 2025 to November 2030 and it will be financed by a $75 million loan from ADB, $23.02 million by the government of Turkmenistan and a $2 million grant from JFPR (Japan Fund for Prosperous and Resilient Asia and the Pacific). Although ADB has worked in close partnership with Turkmenistan for the past 25 years providing more than $600 million in loans, grants and technical assistance, “Improving Nursing Quality and Capacity” is their first health sector project in Turkmenistan.

The project aims at modernizing the Ashgabat Nursing School that will accommodate 1000 students and build dormitories for 100 people; updating its nursing curriculum, improving the quality of teaching and strengthening the role of nurses in healthcare; and making the new nursing school an inspiration model to other nursing facilities in the country.

ADB has a public webpage dedicated to the project where it publishes project documentations and data. Progres Foundation has read the documents. In this article we would like to highlight data and insight from these project documents.

Analysis and monitoring of projects funded by the International Financial Institutions (IFIs) help the civil society and the public at large gain a deeper understanding of what is being undertaken for the improvement of quality of life in the country, ask for better transparency and government accountability, monitor compliance with national and international safeguards, and provide feedback to mitigate potential risks.

Country profile per ADB’s project documents

Turkmenistan has been identified as an upper-middle income country by the World Bank in 2012 and ranked 91st out of 191 economies in the Human Development Index in 2022. For over two decades, the country has also committed to eliminating discrimination against women and regularly reports to CEDAW on its progress. Nevertheless, the country’s medical system faces major weaknesses in key areas, such as non-communicable disease reduction, health literacy and disease prevention, and specialized tertiary hospital services.

Child and maternal mortality rates remain among the highest in Europe and Central Asia and about 10% of the population lives in poverty. The number of nurses per 1000 population is very low (3.9) compared to the regional average (8 per 1000). Even the ratio of nurses to doctors standing at 1.8:1 is much lower than the average of the Organization for Economic Co-operation and Development (OECD), which is 2.6:1.11. Nationwide, there were 2366 nursing school graduates in 1990, but until 2023, that number fell to about 600. The overall number of available nurses and midwives also followed the same trend, decreasing from 34,420 to about 25,600 over the same time period.

Although 73% of healthcare workers are women, they make up only 57% of management positions in the healthcare sector. Nurses and midwives are seen as “extensions of women’s roles as caregivers”, their job duties mainly involve assisting doctors rather than caregiving and they are among the most underpaid healthcare workers. There is also a strong gender imbalance in nursing, with women holding over 90% of all positions.

There are currently only 6 nursing schools in Turkmenistan and the number of graduates (approx. 600 students annually) are not enough to meet the population demand. The nursing schools still rely on outdated curriculum that was built around providing treatment rather than public health and disease prevention and requires 4.5 years of education to get a diploma while other countries produce competent nurses in only 3 years.

A shortage of quality lecturers and access to skills training as well as effective systems to ensure quality education also creates major competency issues among health care workers. Moreover, nurses are excluded from roles as educators, curriculum developers, or representatives in medical or educational governance.

Public consultations

The Initial Poverty and Social Analysis document of the project outlines the Transaction Technical Assistance (TRTA) phase during which several studies will be conducted including students and working nurses. The studies will identify qualifications, demand factors, social and financial challenges of students in Ahal province to join and finish a medical college as well as working conditions of nurses in terms of gender equality and how female nurses can advance in their professional careers. There is no additional information on the dates, design or results of these assessments.

During the TRTA, consultations will also be held with beneficiaries and stakeholders that include representatives of medical college teachers and students as well as the general public in order to determine acceptability, range, quality and affordability of health services. The poor and other potentially excluded vulnerable groups (e.g. handicapped) are also to take part in consultations regarding access to education. The consultations aim to fulfill the following purposes:

• To share information about the project and get feedback;
• To reveal and address relevant issues at early stages;
• To suggest appropriate mitigation measures.

The document also notes that civil society organizations will not participate in the project design by stating “there are no CSOs involved in human resources for health currently”.

The documents do not specify the time frame for the TRTA phase and only mention that the preliminary architectural design of the Ashgabat nursing school will be finalized by September 2025. The number and type of consultations that have as of September 2025 taken place include only a series of discussions with PIU (Project Implementation Unit consisting of 15 staff within MOHMI) and a two-day workshop in Ashgabat with stakeholders of different agencies with MOHMI, the Ministry of Agriculture and Environment Protection, the Ministry of Education, the Ministry of Finance and Economy, the Central Bank of Turkmenistan, Ashgabat city Hakimlik, the Nursing School of Ashgabat and technical staff. It remains unclear whether or when further consultations with the rest of the stakeholders and beneficiaries will be conducted.

Expected outcomes

The key objectives of the “Improving Nursing Quality and Capacity” project entails replacing the Ashgabat Nursing School with a new and modern building on a new campus with facilities for effective and quality teaching and learning, redesigning the curriculum that emphasizes direct-patient and preventative care, enabling nurses to become leaders and teachers through skills upgrading, and revising job descriptions of nurses to strengthen their positions.

The current Ashgabat Nursing School educates roughly 800 students and the new building and facilities will be able to host 1000 students at a time and 100 people in its dormitories with a special edible garden and mother-and-baby room. It will also improve nursing education by upskilling faculty, integrating modern teaching methods and clinical training, expanding the nurse diploma program to 4,600 hours over at least 3 years with at least 30% of hours spent in clinical practice, and promoting joint teaching by nurses to better connect theory and practice. The inclusion of nurses and midwives in the governance of the school is also expected to be increased as another outcome of the project.

Although the upgrades will be implemented directly in the Ashgabat Nursing School, the project has the potential to benefit the rest of the country by serving as a national pilot. Teachers from regional nursing schools will be involved in training activities and will transfer new teaching methods to their institutions. The revised curriculum, competency framework, ethics codes, and updated job descriptions developed and tested in Ashgabat are intended for future adaptation nationwide. The project will also support MOHMI in workforce planning by developing a national health workforce masterplan and strengthening its capacity to forecast nursing and midwifery needs using data.

Operational and governance challenges

ADB also identifies significant operational and governance challenges in Turkmenistan’s healthcare administration and rates the financial management risk as “substantial”. MOHMI’s limited international loan project experience, heavy reliance on manual spreadsheets, lack of financial reporting skills in English, insufficient separation of duties and limited transparency in contractor selection are flagged by ADB as causes for concern. Yet ADB assigned MOHMI the biggest share of project management responsibilities and plans to achieve compliance by retaining technical oversight and providing consultations.

Questions from Progres Foundation

The first healthcare project loan by ADB aims to support the modernization of nursing education and strengthen the quality and status of nurse professionals in Turkmenistan. Although the documents accessible online provide information about some aspects of the project, such as project timeline, project management and expenses, safeguards, gender equality and social dimensions, there are several outstanding questions related to transparency and accountability:

• How can CSO’s including independent CSO’s participate in the consultations?
• Will the project address the major structural issues in healthcare: suppression of information and statistics?
• Will the Bank produce and publicly share the report on needs assessment including needs of the teachers and students, nationwide statistics in nursing in the country?
• The support is provided in the form of the loan. What is ADB’s policy of issuing loans to countries that use dual exchange rate such as Turkmenistan? Is it ethical?
• Construction works as well as developing training modules for teachers and a new curriculum for students are due to start by mid-2026. How does ADB and MOHMI plan to ensure that all the necessary consultations with stakeholders and beneficiaries are held, evaluated and implemented into the parts of the project until its start date?
• What is the clear and objective process for selecting teachers (multiplicators) from other regional nursing schools to ensure equal representation across regions and effective implementations of new teaching methods over the long term?
• How will the new curriculum’s focus on preventative care be successfully integrated into the existing, predominantly curative approach in the health care sector?
• The document states that the Project Implementation Unit (PIU) will “keep a project grievance log book” that registers grievances and reflects the status of resolution. Will there be specific, accessible channels and guaranteed timeline for reporting issues, response and resolution?