Leaving No One Behind in Planning Local Health Care Strategies

Mrs Davaasambuu Norov, 60, an all smiles woman and informal head of three younger families lives in the meadows of one of the most picturesque provinces of Mongolia, Arkhangai. She and her three children collectively own a couple hundred heads of livestock barely enough to feed families of her three children and support 7 grandchildren most of whom are in primary school. Due to living in fresh air and doing physical work required in the countryside Mrs Davaasambuu has never been much ill, as she says. Despite one problem she developed recently: hypertension.

“From time to time I was having a high blood pressure up until it accelerated to 200 systolic units last spring. So I had to travel to the centre to see a doctor. Unfortunately there were no beds in the hospital and had no other option than to pay 20.000 MNT (9 USD) for a day-stay in a private hospital,” said Mrs Davaasambuu unwittingly angry at the health sector. In total she spent 200.000 MNT (90 USD) for staying at an inpatient ward in a private hospital. Half of this amount was spent on medications she had to buy herself, spending hard-earned cash that the family received in exchange of gathering pine-nuts in the forest and selling livestock. She will soon run out of the medications that control her blood pressure, and will need more cash, which the Mongolian countryside lacks, especially in the current economic downturn.

“This is an example of how not to leave anyone behind and how not to expose people to financial hardship when they need health care. Hence WHO is advocating for introduction of universal health coverage so anyone in need of health care can get quality health services without experiencing financial hardship”, says Theadora Koller, a WHO expert on health equity, gender, and human rights. “In any country one can find sub-populations of people who are left behind being unable to get the health care they are entitled to due to issues with accessibility, affordability and acceptability of health services,” adds Koller.

Identifying such sub-populations during Mongolia’s Ministry of Health (MoH) supported and WHO-facilitated “Leaving no one behind” workshops was the most unexpected and revealing exercise for more than 100 health authorities and staff from 21 aimags and nine UB city districts’ Departments of Health. Internal migrants, people with disabilities, herders, especially the ones living in remote areas, border troops, artisanal miners, urban homeless, sexual minorities and many more sub-populations were identified by the health sector professionals as the ones who are left behind.

The concept

The “leaving no one behind” concept promoted by WHO for introducing universal health coverage and enabling countries to make progress in implementation of the Sustainable Development Goals endorsed by the UN member states in September 2015, received a full-fledged commitment from the Mongolian Government. In February 2016 Mongolia has endorsed Mongolia’s Sustainable Development Vision 2030 to aid the country in reaching the SDGs.

“Without introducing the “leaving no one behind” concept into the national and local policies reaching SDGs and Mongolia’s SDV-2030 will be impossible. I’d like to thank WHO for introducing this concept in such a timely manner,” said Mrs Beate Trankmann, the UN Resident Coordinator in Mongolia, who attended the opening sessions of two of the three workshops.

The workshops

Three “Leaving no one behind” workshops, each three days long, took place in September and November 2016 and were co-organized by Mongolia’s MoH, the Ulaanbaatar City Health Department and Arkhangai aimag’s Department of Health. Specialists from all three levels of WHO as the Headquarters, the Western Pacific Regional Office and the Country Office have led these trainings geared to help the local governments and departments of health to reflect the “leaving no one behind” concept in their four year health strategies or sub-programmes most of which are to be adopted by mid-2017.

At the opening ceremony of the first “Leaving no one behind” workshop held in Tsenkher soum of Arkhangai province last September the Minister of Health, Dr Tsogtsetseg Ayush, noted that the trainings were very timely as practical guidance to the MoH in drafting the long-term State Policy on Health and the local governments in developing their four year mid-term sub-programmes on the SPH implementation.

The workshops consisted of lectures and practical exercises during which the participants identified social determinants of health and looked at changes and modifications that need to be made in the local health systems, structures and functioning, financial and human resources as well as information systems to aid the goal of leaving no one behind in the health services delivery. For example, the MoH and WHO initiated integrated early screenings using mobile health technologies was identified as a perfect way of reaching out with preventive care and early diagnostics to people like Mrs Davaasambuu who live in a remote countryside far from health service delivery points or urban migrants who have no financial opportunities to pay for health checks.

“The practical sessions helped us to draw our actual local health sector plans leading us to formulate additional policies and actions to reach out to those who are left behind,” said Dr Ch. Bayarjargal, the former Director of Umnugobi aimag’s Department of Health. For example, in all three workshops the Mongolian men were identified to be much more prone to speedy driving and acquiring of chronic health conditions due to reckless attitude to their own health. Hence special health promotion programmes targeting male populations were identified as high-needs.

Re-thinking health care delivery

Behaviours of various people and groups in a community were played out by the participants to better understand the reasons for tackling traditional believes, social expectations and gender norms that may prevent people from receiving timely and proper health care. Understanding the social determinants of health and gender norms have directed the health care professionals in identifying the left out sub-populations and finding culturally sensitive approaches and adequate and smart policies to make the health care approachable, affordable and acceptable by these groups. The solutions were thought out from both, supply and demand sides. Thus rethinking of health care financing and human resources policies were encouraged as possible areas of reform to make sure that no one is left behind receiving health care services when and where needed.

“You, the heads and the managers of local health departments, are very powerful people,” said Dr Soe Nyunt U, WHO Representative in Mongolia. “Do not underestimate your power and do not wait for directions from the “above”. You can solve a wealth of issues on the ground in your native provinces and districts by bringing people quality and affordable health services.”

Mainstreaming the concept

A handbook on incorporating the “leaving no one behind” principle in formulating sub-national health sector plans written together by specialists of all three levels of WHO, is to be published soon. "It will be an invaluable tool for the Mongolians and for the international community which is vastly interested in Mongolia’s sub-national health system strengthening,” said Dr Soe Nyunt U. The sub-national health system strengthening is a flagship programme of WHO Mongolia that is being implemented since 2013.

It’s notable that in January 2017, the State Policy on Health 2017-2026 (SPH) was adopted by the Mongolian Parliament creating a framework for mainstreaming the “leaving no one behind” principle in health care provision. Following this the WHO county office has started a series of follow-up regional workshops supporting the inclusion of a strong focus on “leaving no one behind” in the 2016-2020 sub-programmes on implementation of the SPH.

It is now to be expected that due to embedding the “leaving no one behind” concept in the health sector policies and plans people like Mrs Davaasambuu will not need to trade receiving needed health care for feeding her grandchildren.

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