Mongolia is a landlocked country with vast territory and severe climate. With a population of slightly over three million, it is the least densely populated country in the world. Almost half of the population lives in its capital, Ulaanbaatar city, and approximately 30-40 percent are herders who live in rural and remote areas.
The primary health care system
There is a two-tier health system with primary care and specialized care, including referral care. The system was inherited from the former centralized Semashko system and has undergone modifications over time. Since 1991, piecemeal attempts have been made to strengthen the management of health system and health service delivery. Family group practices were introduced at the primary health care (PHC) level, regional diagnostic and treatment centres (RDTCs) were established at the regional level, and secondary level general hospitals were split into inpatient and outpatient sections in Ulaanbaatar.
The Health Act (2011) reorganized health care organizations in terms of function and structure in different levels of the system. For instance, Family group practices and soum hospitals were restructured into family/soum health centers with more focus on public health intervention rather than former curative services. Family health centers are private health facilities and deliver government funded public health services through contracts with the State. However, there was no sufficient fund and capacity due to lack of budget and excessive workload of family group practitioners, especially in Ulaanbaatar city. Also, delivery of health services is challenged by the country’s extremely low population density in a large territory.
PHC is defined as a package of essential services designed to address priority health problems at the community level, organized by the administrative units in Mongolia. There are differences between the provision of PHC services in urban and rural areas in terms of the setting, nature of providers, functions and funding mechanisms.
Budget and funding
PHC in Mongolia is funded by the government budget, and thereby, enables citizens to access free essential PHC services at family and soum health centers. However, due to a number of factors including remoteness, economic difficulties, internal migration, unemployment and lack of health seeking behavior, there still remain people who are not receiving the health services they need.
The Government of Mongolia introduced the mechanism of per capita payment in order to contract PHC providers. Rate of per capita was too low and different in respective categories in terms of age group and residential areas and needed to be increased. According to government resolutions dated 2012, 2015, 2017, and 2018 the rate was increased step by step.
The state budget is allocated through per capita, case basis and line item. This makes primary healthcare accessible to all citizens and reinforces the commitment of the Government of Mongolia to provide financial protection and deliver integrated people-centered services to each and every citizens.
In Mongolia, the Ministry of Health with support from the World Health Organization introduced a new strategic purchasing initiative in PHC through Social health insurance (SHI) reform in 2018. Due to this reform, a benefit package for PHC was extended to cover services such as day care, home care, rehabilitation care and some diagnostic tests. These services will be funded by case based payment and aims to link the current payment system with long term goals and leverage to provide public health preventive care services. It is currently in implementation and 5.2 billion MNT was allocated for PHC in 2018. In 2019, the budget was increased at 15.6 billion MNT.
Improving and extending the services of family health centres
Dr. G.Chantsalmaa, FGP of the Nemuulen FHC in the 23rd sub-district, UB city, shares her experience. “Increased fund really helps our family health centre to extend PHC and strengthen public health preventive services. We have improved own capacity on diagnostics as we bought rapid tests, lab devices for diagnosis and increased day care, rehabilitative care and home services for people as stipulated in legislation, regulations and guidance of the government and Ministry of Health indeed. Also, I would like to mention about additional financing from “Health Promotion Fund” of the government which provides us to extend health education and public health campaign for the community. As we are contractors, all these actions support us to raise even income or salary of our staff and influence positively in quality of services step by step”.
Dr. G.Chantsalmaa, FGP of the Nemuulen FHC, March 2019
Introducing the Health Insurance Government Agency
The Health Insurance General Office (HIGO) is the main agency for the SHI transfers money to the PHC facilities on a fee for services basis which is calculated based on the number of enrolled patients, visits or services used by the patient. The patient record for day care with extended medical treatment sheets approved by the order of Minister for Health, Service check list (SCL) approved by the resolution of the National Health Insurance Council numbered 08 dated May 4 2018 and e-health checklist registration system are the main tools to provide evidence to evaluate performance of the primary health services.
| № | Service package | Payment from HIGA (per person) (MNT) |
|---|---|---|
| 1 | Rehabilitative care | 20 000 |
| 2 | Day care | 30 000 |
| 3 | Home care | 25 000 |
| 4 | Diagnostics and lab | 20 000 |
(The above rate shall be increased in 2019 and working group established and started action by the order of the Director of HIGA)
Before 2018, there was no SHI financing to PHC which was only subsidized by the state budget. However, informal sector people according to social health insurance premium payment classification are self-employed and include herdsmen, unemployed and people who pay their premiums on their own. Therefore, it is important to cover them by health insurance to provide the benefits especially at the PHC level.On the other hand, due to the Law on Health Insurance, only accredited PHC centers are able to be contracted and financed by SHI fund.
In addition, HIGO has funded discounted drug for the insured since 2015. According to research of WHO (2017), the major reason of catastrophic payment for people was the drug purchasing because of its high prices and cost. By 2018, HIGO funded almost 47,494.6 million MNT for drug discount and nearly half of the population of Mongolia have benefited from this reform. During the last five years, the budget was increased by almost 4 times and number of people who benefited from the fund increased two-fold. At this stage, health insurance coverage is almost universal and reached 89% as of 2018.
What it means for patients
Interview with Ms.G.Nergui, February 2019
Ms.G.Nergui, 60 year old pensioner, lives in Bayangol district of Ulaanbaatar city. So far her health status is not good as she has had diabetes and chronic condition of arterial hypertension since 1993. She is in need of strict health seeking behavior due to chronic condition and complications of the diabetes. Kidney disorder caused by diabetes is also another health issue which worries her. She often attends the District Health Center and Family Health Center, takes remedy for her diabetes. Doctor of the endocrinology cabinet of the District Health Center has provided medical check-up and monitoring to control her health status for the last 25 years.
In her opinion, access to PHC services is good but it also depends on citizens’ own initiative and capacity. For instance, people’s own attitude to seek healthy behavior and take responsibility for a healthy lifestyle is a highly influential factor for health care accessibility. The price of medicine is high and its affordability will vary depending on people’s level of income. Last year, health insurance discounted some medicine which improves my affordability and access to medicine. Also, Haemodialysis has been subsidized by the state budget since 2017 which is much helpful for patients like me who are in need of it on a regular basis.
She is satisfied with the quality of care received from the District and Family health centers. But, she has also mentioned that quality of health care depends on both health professionals and clients’ knowledge, skills, attitude and communication.
Overcoming geographical barriers
Moreover, in order to overcome geographical barriers of the health service delivery, mobile health (MHealth) technology has been introduced to Mongolia since 2016 to provide herders and rural populations from remote areas with essential PHC services at their local family areas. Currently, more than 60 of PHC facilities use this new innovative technology for their service delivery. PHC is available both in the centre of the province and in the most remote herders’ community areas.
Story on Mobile Health technology: Altai soum, Govi-Altai aimag is located 360 km away from aimag center. In September 2017, primary care providers at SHC organized mobile health examinations and screening for herder households residing 55 km away from the soum center. A herder man, aged 62, was diagnosed with liver cancer using mobile abdominal ultrasound apparatus. A man was immediately referred to a higher level of care at NCC for further investigation and management. The primary diagnosis was confirmed and he underwent a surgical procedure with success. Then, he was referred back to SHC for further clinical control.
Soum doctor is conducting health examination using mobile ultrasound apparatuses on herders, Tsagaannuur soum, Khvusgul province, January 2019
Mongolia’s progress in UHC
UHC is one of the priority area of for the Government of Mongolia. In 2016, the Parliament approved Mongolia’s Vision for Sustainable Development – 2030. The vision set out a series of health-related goals such as extending the life expectancy of Mongolians to 78 through promoting a healthy lifestyle; strengthening the country’s disease prevention system; improving surveillance and preparedness for communicable disease outbreaks; and reducing maternal and child malnutrition and mortality.
In 2017, the Government approved State policy on Health, which is the main long term policy of the health sector based on “Leaving no one behind” principle recommended by WHO. Mongolian Prime Minister Ukhnaa Khurelsukh highlighted universal health coverage in his speech to the Parliament for the opening of the 2018 spring session.
In his speech to the Parliament on 20th April 2018, Prime Minister Khurelsukh announced political will to make progress towards UHC that the Government of Mongolia will increase and extend the range of services covered by health insurance. More than 5billion MNT (approx. 2million USD) will be added to the health sector budget to finance some diagnosis, rehabilitative, home and day care services to be provided by PHC facilities. Actually, current political will to allocate more funds for PHC through Health insurance government agency towards long term SDG goals.
“We believe these initiatives will contribute to better health for Mongolians, as the country progresses towards UHC,” said Dr. Sergey Diorditsa, WHO Representative to Mongolia.
Dr. Sergey Diorditsa, WHO Representative to Mongolia, World Health Day event on Universal Health Coverage, Ulaanbaatar, Mongolia, April 2018.
He also spoke of the need to further strengthen capacity in order to provide quality health services. As a result of introducing advanced technologies and developing human resource capacity in recent years, a number of diseases that could not previously have been treated in Mongolia are now being addressed, and their burden is decreasing.
The Government is also working to improve people’s access to discounted essential medicines. Last year, more than 1.5million people in duplicated number benefited from medicines reimbursed by the health insurance fund with a value of 26.8 billion MNT (approx. 11million USD). To improve access to care in remote areas, the Government is implementing a mobile health scheme, with technical and financial support from WHO. Mobile health teams provide services including screening for communicable and noncommunicable diseases in communities and local clinics.
PHC plays an important role in delivering National Programmes. “Healthy liver programme” can serve as one typical example. Liver cancer and cirrhosis due to hepatitis B and C are one of the major leading causes of death in Mongolia. To address this, the Government has begun rolling out a “Healthy Liver” programme aimed at improving early detection. In 2017, more than 535,000 people, 57% of the 40-65 year old population, were screened. For its next stage in 2018, more than 1.2million people aged 15-39 and over 65 years are offered screening..
All in all, the Government of Mongolia is committed to making progress towards universal health coverage through strengthening PHC services, introducing innovative technology and increasing financial protection of the people who need quality health services.
