Country Programme on Subnational Health System Strengthening in Mongolia
To deliver health care interventions necessary to achieve and sustain health-related millennium development goals and universal health coverage stronger health systems are needed. A well-functioning health system responds in a balanced way to population’s needs and expectations by improving people’s health status.
Mongolia experiences several challenges and potential gaps in health-care provisions related to the geographical location, urban and rural settings, and across socio-economic groups of population. For instance, while the overall maternal mortality rate has decreased, there is a significant variation in maternal mortality across the country. More than 40% of maternal deaths occur among herder women in rural areas where access to medical services is poor.
A rapid urbanization coupled with a mining boom in the recent decade led to an increased burden onto health and social services. This, in turn, caused a shortage of human resources, funding and equipment weaken health care services’ accessibility, quality and equity.
The Government of Mongolia is committed to strengthen local governance and support decentralization. The current economic downturn urges the Government to delegate more power to local governments to enable an -efficient usage of limited resources for local priorities. The Government policy for 2012-2016 has focused on supporting decentralization through the new Budget Law and encouraging citizens’ involvement in decision making through local Development Fund.
To address existing challenges in the more decentralized legal and fiscal environment, since 2013 WHO has initiated subnational health system strengthening activities involving national and international partners. Due to its mandate to engage with partners where joint action is needed and provide expert technical support in health WHO is dedicated to improve collaboration and coordination among the development community and international partners. Together with the Ministry of Health WHO supported several meetings of health partners organized in 2013 at which national and international partners agreed to collaborate on sub-national level.
On May of 2016, the leaders of the G7 countries met in Ise-Shima to address major global challenges and it was introduced by G7 Ise-Shima Leaders’ Declaration. In terms of the health, especially, the G7 summit stress to implementing the health-related Sustainable Development Goals (SDGs) therein that ensure well-being at all stages and health security for all individuals, and foster inclusive economic growth for nations. UHC provides a comprehensive framework that underpins all of the health targets. To achieve UHC, health systems need to be strong, resilient, sustainable and responsive to the current and future needs of the populations they serve. The SHSS program concept is also aligned with this G7 declaration specifically about Universal Health Coverage (UHC) and Health System Strengthening (HSS). (See SHSS concept flowchart in appendix 1).
Major activities and outcomes since 2012
WHO has two pilot sites under its Health System Strengthening Project (HSS). The urban site is the largest district of Ulaanbaatar city, Songinokhairkhan, most heavily affected by rural-to-urban migration. The rural site is Umnugobi province (South Gobi) – the area most affected by mining and influx of population.
For supporting local health system, strategic documents on health system strengthening in Umnugobi province and Songinokhairkhan district for 2014-2017 were jointly developed with central and local governments with active involvement of non-governmental and private organizations and international development partners. The overall aim of the strategy is to build province/district model with good health system functioning including management, governance, referral system, financing, rational use of drugs, information system, and capacity of human resources to promote accessibility and quality of health care services and dissemination of results to other provinces and city districts (Figure 1).
In 2016 WHO is extending its’ activities within the framework of the sub-national health system strengthening initiatives including five Western provinces as Arkhangai, Uvurkhangai, Selenge, Khuvsgul, Darkhan-Uul, Tuv, Dornod, Dornogobi provinces and two more districts of Ulaanbaatar, namely Nalaikh, and Chingeltei. Initiatives are to be implemented in collaboration with international partners as UNICEF, UNFPA, UNAIDS, ADB-funded Health Sector Development Projects, KOICA, World Vision, Norwegian Lutheran Mission, and the Embassies of the Republic of Turkey, Kazakhstan and Czech Republic.
Figure 1. The Health systems framework
Health system strengthening in Songinokhairkhan district
The Songinokhairkhan District’s Health System Strengthening Strategy was signed on 28 January 2015 by Vice Minister of Health and Sports, General Director of the Health Department of Ulaanbaatar city, Governor of the District, Head of the District’s Health Centre and the WHO Representative in Mongolia. Activities are being effectively conducted by the Ministry of Health and Sports (MOHS) and city and district governmental organizations in collaboration with WHO, ADB, World Vision and other international and local civil society actors.
Health Information system in the district
Generating and using information in a strategic fashion is an essential element of a robust health system. However, lack of coordination mechanism on data collection and reporting systems; parallel and duplicative reporting; poor data exchange and interpretation; and insufficient provision of human resources and IT are major problems at district level.
With support of WHO Western Pacific Regional Office (WPRO) and the University of Oslo, Norway, the WHO Country Office Mongolia has organized an introductory workshop and practical sessions on setting-up a District Health Information System 2 (DHIS 2) in Songinokhairkhan district. In addition, IT staff of Songinokhairkhan district’s Health Centre together with representatives from the MOHS, Centre for Health Development (CHD), National Centre for Communicable Diseases (NCCD) and the Umnugobi province’s Health Department attended a training at the DHIS 2 Academy Vietnam Following this training, training of trainers was organized in Songinokhairkhan district under facilitation of DHIS 2 Academy Vietnam The DHIS 2 is to be piloted in the district step by step in the course of the next 2 years.
Model district hospital
In Mongolia, at a district level primary and secondary health care and services are provided through Family Health Centres and Districts’ General Hospitals. However, only four general services including internal medicine, neurology, elderly and pediatric care, are offered at secondary in-patient care level in the Songinokhairkhan district. These do not meet operational standards of Districts’ General Hospitals. The rest of medical services including obstetrics, gynaecology, surgery, traumatology, traditional medicine, ophthalmology, otolaryngology, dentistry, communicable diseases, cancer, TB, HIV/AIDS, adolescents’ health, mental health, narcology, rehabilitation and immunization are provided through outpatient clinics of the Districts’ General Hospitals. Therefore, with support of ADB, a project to build a model District Hospital with capacity to deliver at least 7 types of essential medical services has been implemented since 2011. WHO and the ADB’s Health Sector Development Project-4 are jointly providing technical and financial support for developing strategy and operational plans of the Songinokhairkhan District’s new hospital.
Community engagement in health promotion activities
In 2015 WHO and UN Habitat initiated the “Community Engagement for Improvement of Health of People” project in Songinokhairkhan district. The project was implemented by UN-Habitat in close collaboration with Songinokhairkhan district’s health authorities and with WHO’s technical and financial support. The project conducted integrated health promotion activities among people via establishing community development councils through community mobilization and engagement. As a result, 1600 residents were involved in trainings on health promotion and communication, 90 volunteers were prepared and 5 Community Development Councils (CDC) were established in the district. One CDC was re-organized to become a non-governmental organization.
Program-specific activities in the district
Within NCD prevention and control program, Zumba Fitness Training for Trainers was organized for 50 people including employees of the District’s Governor’s Office, district’s health care facilities, NGOs and school and kindergarten teachers. With WHO support, health workers of Songinokhairkhan District’s Health Center participated in the International conference on "Implementation of Article 14 of the Framework Convention on Tobacco Control” held in Beijing in November 2014. Following the conference, the District’s Health Center is now implementing public advocacy activities related to tobacco cessation such as conducting consultation services for individuals and communities through online networks, quit-lines and Healthy Lifestyle Cabinets.
Under Communicable Diseases Programme, ‘Reach Every District’ strategy implementation was scaled up to 4 sub-districts (khoroos) to deliver targeted health care service packages to mothers, children, elderly and unregistered citizens. TB control and prevention capacity building trainings and early detection of TB among risk populations were supported in the district.
The WHO conducted a training on development and implementation of water safety plan (WSP) in ger districts (yurt-dwelling communities) mobilizing the AusAID financial support. The training was conducted for 30 officials including officers from District Governor’s Office and health centres, heads and social workers of khoroos (sub-districts) and heads of family health centers. Under supervision of national trainers on WSP, participants developed water safety plans for their respective khoroos. Following implementation of the WSPs, technical advice is being rendered and monitoring provided by inspectorate agencies.
Health system strengthening in Umnugobi province
The “Mid-Term Strategy of Health System Strengthening in Umnugobi province for 2015-2017” was signed by the Minister of Health and Sports, Governor of Umnugobi, Head of Department of Health and WHO Representative in Mongolia on 3 March 2015.
The strategy aims at meeting essential health needs and resolving priority health problems of Umnugobi residents through fostering horizontal linkages and supporting collaborative efforts of state and non-state actors and international organizations.
Health information system in the province
Health information system is one of the building blocks of province’s health system. Inadequate infrastructure and lack of power supply in soums (sub-provinces) have negative impacts on data quality and safety. Consequently, this may also result in negative effects on responsive actions. Telemedicine is essential to receive and transmit information timely. At present, Regional Diagnostic and Treatment Centre (RDTC) is connected to national health centers. However connectivity to soums remains quite limited. A training of trainers in DHIS 2 was organized in Umnugobi province. As a result of these initiatives, province’s Health Department has agreed to pilot DHIS 2 programme in 2016 under the Health System Strengthening Strategy with support from the\ MOHS, CHD, WHO and DHIS 2 Academy of Vietnam.
Health care quality management
Quality and patient safety are essential attributes of good health services. Although local health organizations have substantially improved their health care quality management some health indicators haven’t yet reached the required level of quality of health care services. Namely, there is not a sustainable decrease in infant mortality and early screening of non-communicable diseases is low. Injuries and sexually transmitted diseases tend to grow.
With the WCO’s technical and financial support the MOHS organized a training on health care quality management for 60 health managers, doctors and nurses. Major topics of the training were methods and tools of quality management, quality control and ethics and communication of health workers.
Emergency medical services
A specific of an emergency health care in the Mongolian countryside is a need to cover long distances by cars to deliver medical services. The farthest soum in this province is located in 320 km. from the province centre. This requires from 10-12 hours of driving on unpaved roads to reach the place. This reality has undesirable consequences for timely delivery of care and services. Hence emergency and surgical care delivery capacity should be improved regularly.
WHO provided technical and financial support to the WHO Collaborating Centre for Emergency and Essential Surgical Care at the National University of Medical Science (NUMS) to organize trainings on emergency and surgical care in Umnugobi province. Specialized doctors and teachers of this Centre trained 60 doctors and nurses through conducting skills-based trainings on site including practical sessions on emergency and surgical care and surgical operations at soum level. They also conducted training on “Basic Life Trauma Support” for 20 drivers employed by health care facilities.
Programme-specific activities in the province
Trainings and advocacy on tobacco cessation are regularly conducted through the “Healthy Life” service set up at the province’s Health Department with WHO’s technical and financial support. The service is connected to all 15 soums of Umnugobi and offers trainings and consultations in person and by phone through an established quick-line and internet.
Within the Environmental Health Program, a “Mining and Health Forum” was held in Umnugobi province in July 2014 in collaboration with three related ministries, the local government, the Global Fund to Fight AIDS and TB and private mining companies. WHO, the Canadian International Resources and Development Institute and the Canadian Coalition for Global Health Research organized a 12-days training on Health Impact Assessment in Umnugobi province involving national and international stakeholders. An important training on Water Safety Plan development was conducted among 30 people including officials from governor’s office, health workers of the province’s Health Department and seven soum health centres. WHO financed one staff from the province’s Health Department to participate in the “Household Drinking Water Safe Storage and Treatment” training in Laos in October 2014.
Currently, “Reach Every Soum” Strategy is implemented in all 15 soums of the province with WHO’s technical support and financing from the USA Centre for Disease Control. The RED Strategy has been implemented by a multi-sectoral team consisting of representatives from health, education and social protection sectors, the province’s Civil Registration Office and Police Department. Managerial and technical teams for implementing the RED Strategy were established on provincial and soum levels.
Mobile health service project in Western provinces and at national level
Province’s Health Department is responsible for the delivery of health services through provision of primary, secondary and rehabilitative health services. Mobile health service is attached to both primary and secondary health services. However, people living in remote rural areas still have limited access to health care services. Since 2010 the Government of Mongolia and its development partners undertook a number of efforts to improve mobile health services in rural areas.
To ensure universal access to quality services and address disparities WHO, ‘People in Need’ and ‘Caritas’ Czech NGOs developed and co-funded the “Improving Mobile Health Services in Mongolia” project in consultation with the MOHS and local health organizations. The project started in 2015 and focused on Western provinces of Gobi-Altai, Bayan-Ulgii, and Khovd. It is implemented by the ‘People In Need’ and ‘Caritas’ Czech NGOs with the WHO’s technical and financial support and funds donated by the Ministry of Foreign Affairs of the Czech Republic. With the main objective of strengthening the sub-national health system, the project aimed at providing methodological support and scaling up and institutionalising mobile health service practices in Western provinces to provide better access to health care and improve diagnostics for remote rural population of Mongolia.
Within the project framework, an advocacy seminar along with on-site field trip on mobile health service for decision-makers was organized in 2015 at Zavkhan province. Members of Parliament, State Secretary of MOHS, Heads of Health Departments of 9 provinces from Western, Central and Southern regions and representatives from some development partners such as WHO, World Vision, Norwegian Lutheran Mission, ‘People In Need’ and ‘Caritas’ Czech NGOs were among 35 participants of the activity. The following the advocacy seminar, MOHS in collaboration with the project unit and WHO has updated the previous Ministerial Order, for mobile health service which was approved in 1999 as replacing by new Ministerial Order # A/147, “Provision of healthcare service in means of mobile health service” on 29 April 2016. Moreover, “Provision of healthcare service in means of mobile health service” handout materials for health workers have been developed and trainings were conducted among health workers with integration to mHealth training.
Emergency medical service project in Uvurkhangai and Arkhangai provinces
Socio-economic and health indicators of the Arkhangai and Uvurkhangai provinces demonstrated a strong need to improve the health system comprehensively. With current health system capacity it is challenging to deliver safe and quality health services in responsive, financially fair and equitable manner, using available resources effectively.
To deal with the existing challenges, the MOHS and WHO officially asked for support on implementation of a joint project “Health System Strengthening in Arkhangai and Uvurkhangai Provinces” from the Embassy of the Republic of Turkey by end of 2014. Objectives of the project were to develop leadership and management skills, scale-up capacity of the health care service delivery system with focus on emergency medical services, and improve participation of civil society, communities and families in prevention and control of common health problems and road traffic accidents.
Based on positive response from the Embassy of the Republic of Turkey, a proposal and work plan was jointly discussed by the Governments of Mongolia and Turkey and WHO. The parties agreed to train rural health workers on emergency medical services in Mongolia and Turkey as well as organize information, education and communication activities for public on prevention of road traffic accidents. An assessment of and training on emergency medical care was conducted in Uvurkhangai and Arkhangai provinces by the MOHS with support from WHO, WHO CC at NMUMS, Ministry of Health of Turkey and Turkish Cooperation and Coordination Agency. A training on emergency care and disaster management was organized in Izmir, Turkey for 15 health staff from MOHS, Province’s Health Department, Regional Diagnostics and Treatment Centre, and Provinces’ General Hospitals.
Introducing mobile health technology at the primary health care and community levels
WHO is supporting the government of Mongolia in introducing mobile health (mHealth) at the primary health care (PHC) and community levels. Within this initiative, total 17 sets of mHealth equipment including android blood pressure devices, portable electrocardiography (ECG) and ultrasound equipment were distributed to 12 soums and 3 districts in UB city for use of NCD screening at the PHC level. Following this distribution, three times trainings under topic of “Methodologies on provision of healthcare service in means of mobile health service and application of portable wireless medical equipment for screening of non-communicable diseases at the primary health care level” were conducted among PHC providers including doctors, nurses and feldshers at Western, Central regions and Ulaanbaatar city. In the training conducted at Central Region total of 36 people participated into the session including Mr S.Lambaa, Minister of Health and Sports and Dr Soe Nyunt-U, WHO Representative in Mongolia. Through this training it was highlighted that to introduce mHealth technology at PHC level nationwide for next 3 years to accelerate UHC with the principle with no one left behind.
In addition, “Mobile Health Technology at the Primary Healthcare and Community Level in Mongolia” has been implementing since January 2016, funded by Korea Foundation for International Healthcare (KOFIH). The main goal of the project is to improve health of the population especially by reaching out to disadvantaged population groups through introducing Mobile Health (mHealth) technology at the PHC and community level within health system strengthening concept. The project is implementing in Songinokhairkhan district, Ulaanbaatar and Umnugobi province where sub-national health system strategy has being implemented since 2014. This project will be implemented until January 2017, and is hopefully expected to be expanded to another region in the future.
Sub-national health system strengthening technical support and collaboration in other provinces
Health of Bayan-Ulgii residents shows poor performance of the health system in this province that is home to the largest ethnic minority of Mongolia, Kazakhs. For instance, in 2013 maternal mortality rate was 144.8 per 100,000 live births in the province - significantly higher than the national average of 42.6 per 100,000 live births. Currently, the World Vision and the Norwegian Lutheran Mission are implementing projects aiming to improve capacity of primary health care including maternal and child health care and services. To support collaboration among development partners towards sub-national health system strengthening the WCO developed a project proposal on health system strengthening in Bayan-Ulgii province and submitted it to the Embassy of the Republic of Kazakhstan in 2014. As a result, Republic of Kazakhstan has made the decision to train 20 health care workers from Bayan-Ulgii, Khovd and Uvs provinces in Kazakhstan based on discussions with the MOHS.
Despite the steady progress made over the past five years in developing national capacities for surveillance and response, challenges still remain. Thus, efforts directed at maintaining national health security, at subnational level in particular; enhancing human resource capacity, further improving quality of laboratory services and establishing well-functioning coordinating mechanisms need to be supported. For building a model province on public health preparedness and response, WCO submitted a project proposal to KOICA in 2014 on strengthening public health preparedness and response in Selenge province, bordering with Russia. KOICA decided to support the follow-up to the 2011-2012 project on “Climate Change and Vectorborne Disease Control”. The new project will help implementing exit strategies recommended by the previous project.
Way forward: expansion phase from 2016 and beyond
Programmatic integration and consolidation as well as expansion of partnerships are envisaged for the future. To ensure sustainability of the WHO supported subnational health system strengthening efforts WHO will continue:
- leveraging local ownership of the HSS projects through capacity and responsibility building;
- building up on present partnerships;
- engaging more international organizations and development partners into the subnational health system strengthening partnerships;
- consolidating efforts for sustainable results and achievements.
- Mid-Term Strategy of Health System Strengthening in Umnugobi Aimag 2015-2017
- Strategy of Health System Strengthening in Songinokhairkhan District 2014-2016