Mongolia: Protecting the Health Status of the Poor during the Financial Crisis

Sovereign Project | 43136-012

Summary

Ensuring the poor free access to essential health services is necessary to mitigate the impact of the financial crisis. The proposed medicard program will ensure free care for a range of services at FGPs, SHCs, and designated hospitals and pharmacies. The program will use existing institutional arrangements of the health insurance system to reimburse participating facilities. The medicard program will target the poor, to be identified through means testing. It is conceived as a temporary program to run as long as health insurance subsidies are poorly targeted to the poor and the health insurance benefit package does not cover essential health services or products. The medicard program seems justified until (i) universal health insurance coverage ensures the inclusion of poor households, (ii) co-payments for hospital care are under 10-20%, and (iii) co-payment is waived for poor households identified through proper means testing.

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Project Name Protecting the Health Status of the Poor during the Financial Crisis
Project Number 43136-012
Country Mongolia
Project Status Closed
Project Type / Modality of Assistance Grant
Source of Funding / Amount
Grant 9136-MON: Protecting the Health Status of the Poor during the Financial Crisis
Japan Fund for Poverty Reduction US$ 3.00 million
Strategic Agendas Inclusive economic growth
Drivers of Change Partnerships
Sector / Subsector For classification - For classification
Gender Equity and Mainstreaming Gender equity
Description

Ensuring the poor free access to essential health services is necessary to mitigate the impact of the financial crisis. The proposed medicard program will ensure free care for a range of services at FGPs, SHCs, and designated hospitals and pharmacies. The program will use existing institutional arrangements of the health insurance system to reimburse participating facilities. The medicard program will target the poor, to be identified through means testing. It is conceived as a temporary program to run as long as health insurance subsidies are poorly targeted to the poor and the health insurance benefit package does not cover essential health services or products. The medicard program seems justified until (i) universal health insurance coverage ensures the inclusion of poor households, (ii) co-payments for hospital care are under 10-20%, and (iii) co-payment is waived for poor households identified through proper means testing.

Micronutrients are distributed in 13 of 21 aimags in Mongolia. The proposed JFPR grant to Mongolia for Protecting the Health Status of the Poor during the Financial Crisis (the Project) will cover the remaining 8 aimags using a targeted strategy. At present, micronutrient sprinkles are distributed to all children under 24 months of age and to pregnant and lactating mothers. A targeted approach to distributing sprinkles will help improve the efficiency of the program and ensure its future sustainability. The targeting methodology (e.g., geographical or means test) will be identified during project implementation.

The overall objective of the Project is to protect the health of the poor in Mongolia during the financial crisis. The specific development objectives are to: (i) ensure targeted poor households' access to health services during the financial crisis through the implementation of the medicard program, (ii) contribute to the prevention of malnutrition in poor households through the targeted distribution of micronutrients, and (iii) document and analyze the experience and propose policy reforms to lower financial barriers that prevent the poor from accessing health services.

Project Rationale and Linkage to Country/Regional Strategy The assistance is in line with the development agenda for inclusive economic growth of ADB's Long-Term Strategic Framework 2008-2020 (Strategy 2020) and supports the Mongolia Country Partnership Strategy pillar of inclusive social development. The proposed Project is consistent with the health, nutrition, and social protection priority sectors of the Country Operations Business Plan 2008-2010. Health is a focus of ADB assistance to Mongolia, and ADB is the main funding agency in the sector. The Health Sector Master Plan stresses the need to provide essential health services to the people of Mongolia, with emphasis on vulnerable groups such as the poor and remote. The recently approved FNSWPP under MSWL is reintroducing targeting in the social welfare sector to directly benefit those who are most in need of government assistance. Approaches to malnutrition deserve a special focus in view of the intergenerational perpetuation of low education and productivity. Both the FNSWPP and the Health Sector Master Plan call for the full participation of communities and other stakeholders.
Impact The health of the poor in Mongolia is protected during the financial crisis
Project Outcome
Description of Outcome The poor are assured access to health services and basic nutritional services during the financial crisis (2009-2012)
Progress Toward Outcome

The Medicard program (the major output under the project) covered 100% of the target population including homeless (all aimags and districts of Mongolia) in 2012-2013. The MOH and MPDSP have endorsed action plan for the institutionalization of the Medicard program. The targeted pro-poor medical program is included in the amended Social Welfare law of January 2012, which was passed with assistance of the ADB supported Social Sectors Support Program. The passage of the draft health insurance law, which is expected to be discussed in 2014 Spring Session of the Parliament, will also reinforce the access to health services provided by Medicard program. Despite ministerial order of two ministries (MOH and MPDSP) to institutionalize the Medicard program upon completion of the project in December 2013, no budget was allocated from the state budget for this program in 2014.

The project procurement of micronutrients (sprinkles) has been conducted in June 2011 and October 2012. In total 4.4 million sachets of micronutrients for children aged 6-23 months and 5.2 million micronutrient tablets for PLW were procured and distributed to 8 project aimags and 4 project districts. The consumption of micronutrients by children in 2011 was 83% which is higher than 18% in the baseline year of 2010.

The MOH has developed a mid-term strategy 2013-2016 for micronutrients supply and funding (plan). The Government will gradually take over the funding, procurement and distribution of micronutrients for children aged 6-23 months and PLW starting from 2013. This also applies to training of medical personal and information communication activities on usage of micronutrients.

Implementation Progress
Description of Project Outputs

Component A: The poor are assured access to health services during the financial crisis until December 2012

Component B: Malnutrition in poor households is prevented during the financial crisis until December 2012

Component C: Project management and policy development are ensured up to December 2012

Status of Implementation Progress (Outputs, Activities, and Issues)

Component 1.

The 1st phase of PMT completed in April 2011 with identification of and creation a database of 4,271households (HHs) in 1 district and 4 aimags.

Second phase of PMT identified 2334 poor HHs by the end of April 2012. The third phase completed in October 2012 with identification of another 5312 poor HHs as eligible for the Medicard program.

The 4th phase of PMT completed by November 2012. By the end of 2012 the Medicard program reached nationwide coverage and became accessible for 15262 poor HHs or 952822 people in 21 aimags and 9 districts of UB city.

Besides poor HHs identified through PMT, there are 2719 homeless people receive services from the Medicard program in 2010-2013.

The guidelines for implementing the Program Enhancing accessibility to health services for citizens eligible for social welfare benefits was approved by the Joint order No. 358/135 of the Minister of Health and the Minister of Social Welfare and Labor on 11 October 2010. The regulation was revised jointly by MOH and MPDSP in Nov 2012 (364/A60) in order to expand benefit package and improve access for eligible poor. According to revised regulation the Medicard project will cover cost of transportation from soum to aimag general hospital, full reimbursement of drugs prescribed by primary level medical doctors, and re-imbursement of co-payments paid by beneficiaries for laboratory tests, diagnostic procedures, medical consultations and hospitalization at the secondary level hospitals.

As of the end of December 2013, the Medicard program served a total 127,832 beneficiaries. Use of the Medicard benefits by the poor accelerated from last quarter of 2012 when the identification of the poor was completed and when Government revised the Medicard benefit package (November 2012).

Under this component on the request of MOH to support the Enerel Hospital, the only hospital that serves homeless in UB, the project provided with medical equipment for $434,000, and supported in post-graduate training for number of staff of the Enerel hospital.

Component 2.

The project first procurement of micronutrients (sprinkles) has been conducted in June 2011. In total 3.2 million sachets of micronutrients for children aged 6-23 months and 3.3 million micronutrient tablets for PLW were procured. The sprinkles for children were distributed to 8 project aimags and 4 project districts, while the tablets for women were distributed in 12 aimags and 6 districts (including 4 non-project aimags and 2 non-project districts, approved by ADB). The second procurement of micronutrients was organized in October 2012. In total 1.2 million of sachets of micronutrients for children and 1.9 million tablets for PLW were procured within allocated budget.

The coverage of sprinkles for children aged 6-23 month in distributed project aimags and districts is estimated at 45%, 69% and 80% in 2011, 2012 and 2013 respectively. The consumption of micronutrients by children reached 83% and 60.1% in 2012 and 2013 compared to 18% in the baseline year of 2010.

The MOH has established the micronutrient coordination committee chaired by Vice-Minister. The Committee met twice in 2013, organized a multi stakeholder round table meeting and developed a draft ministerial order on (i) general guiding principles on procurement and usage of micronutrients, (ii) guidelines on administration of micronutrients to children and PLW, (iii) information collection and reporting, and (iv) information, education and communication strategy on micronutrient usage among the population. The project has supported the MOH and MOH has approved a Plan to supply micronutrients, including the cost for 2013-2016 and funding sources. According to the plan, in 2013 MOH funded MNT83 million which shared 26% of total required for 2013. With support of the project MOH has adopted in May 2013 the Mid-term strategy on micronutrients, including regulation on procurement, distribution, reporting.

The project conducted trainings for 867 FHCs' medical doctors and nurses on Integrated Management of Childhood Illness (IMCI) in project 8 aimags and 7 districts. There were 850 copies of manual for participants on IMCI and 100 copies of manual for trainers were re-published and distributed during the training. 5000 copies of poster, 18000 copies of brochure and 28000 leaflets usage on micronutrients for pregnant and lactating women and children were published and distributed to FHCs.

Project procured 100 pieces of weight scale and 245 pieces of height scale for children and distributed to project FHCs and SHCs.

Geographical Location Component A (Medicard) will be implemented nationwide. Component B (Micronutrient) will cover 7 districts of Ulaanbaatar and eight aimags including Bulgan, Govisumber, Darhan-Uul, Dornogovi, Orhon, Ovorhangay, Hovsgol, and Hentiy.
Safeguard Categories
Environment C
Involuntary Resettlement C
Indigenous Peoples C
Summary of Environmental and Social Aspects
Environmental Aspects No impact
Involuntary Resettlement No impact
Indigenous Peoples No adverse impact. Where appropriate, IEC outreach to communities will use appropriate languages in ethnic minority areas.
Stakeholder Communication, Participation, and Consultation
During Project Design

The Project was designed through a participatory process involving key stakeholders, who invariably expressed their agreement with the proposed project objectives, components, and implementation approach. The Project will continue to involve key stakeholders in: (i) introducing targeting for the medicard and nutritional supplement programs; (ii) generating, delivering, and testing approaches; and (iii) assessing current practices, as well as the needs and priorities of disadvantaged communities and families. Many activities stimulated by the Project will require the active participation of communities and beneficiaries, including the distribution of nutritional supplements, qualitative satisfaction surveys, and focus group discussions of medicard beneficiaries. Stakeholders will take part in project monitoring and evaluation, as well as in advising on policy. Local governments will be closely involved throughout the Project, mainly through their support to local FGPs, SHCs, and social welfare systems and their involvement in monitoring and evaluation. Where relevant, ethnic minorities will be targeted and involved in consultations, and they will not be adversely affected by the Project.

MOH, the Executing Agency of the Project, will benefit from the introduction of targeting methodologies that can be integrated into a wider range of programs that particularly seek to direct access to health services to the poor. MSWL and MOH will benefit from coordinating means testing across sectors, thereby improving efficiency and the outreach of government assistance and building local capacity. Aimag and soum authorities will receive technical assistance in assessing ways to target assistance and address health access and nutrition issues in disadvantaged communities and families. MOH will benefit by being able to provide micronutrient assistance nationwide and by exploring targeting as a way of improving efficiency and promoting the sustainability of their programs.

During Project Implementation

Under the Component A, administrative and financial flow of the Medicard program was finalized in close collaboration with the SIGO and other stakeholders. Guideline for implementing the Medicard program was approved by the MoH and MSWL as joint order No 358/135 and submitted to the participating health care facilities and ADB.

Launching of the Medicard program was organized at the MOH conference hall with wide participation of key stakeholders and mass media. For the preparation of the opening ceremony, the PIU prepared speeches by a Minister of Health and Vice Minister of Social Welfare and Labour for the Opening Ceremony of the Medicard Program among the homeless people and developed TV program scenario on the Medicard program as request of J.Tsolmon, Vice Minister of Health.

Comprehensive M&E strategy for the project was developed compiling all tools and instruments of the process and outcome evaluation of the project. Later it will be discussed widely with active participation of key stakeholders at M&E workshop.

The PIU and national consultants involved in training on Poor household database use organized by the MOSWL and reached in agreement to have a list of poor households of the lowest 10 percent of poor households. A contract was established between the MOH and MOSWL on database of poor households on 14 March 2011.

On 15 June 2012, PIU organized a day-long meeting jointly with officials of the Public health policy implementation coordination department of MoH, Public health institute, ADB, UNICEF, JFPR 9131-MON to discuss supply and distribution of multiple micronutrient supplementations, and projected needs for 2012.

The meeting on "Medicard program implementation, progress and lessons learned" was held on 22 June 2012 with participation of MoH, MSWL, SIGO, CSIO, and pharmacies. The participants were shared with the project achievements, challenges and discussed further institutionalization of the Medicard program.

A business luncheon was held with MoH officials on 27 June 2012 to discuss development of the regulation, stated in article 21.3 of Social welfare law; institutionalization of the medicard program; and budgeting for the program's cost in second half of 2013.

Business Opportunities
Consulting Services

The Project will recruit two national consultants for 16 person months each by individual recruitment: (i) a health economist with expertise in health financing and policy and (ii) a nutritionist with expertise in implementing public nutrition programs in Mongolia. The two experts will help the PIU implement the technical aspects of the Project and assist the international consultants during their field assignments. The Project will recruit a national monitoring-andevaluation specialist for component A with a lump sum contract.

The Project will recruit two international consultants for 4 person months each through individual recruitment: (i) a public health expert with expertise in health services organization, health financing, and policy; and (ii) a nutritionist with expertise in implementing public nutrition programs. The two experts will have three field assignments in Mongolia at project inception, mid-term, and completion. The main roles of the two experts will be to assist the PIU in (i) designing the implementation mechanisms of the two components; (ii) preparing and validating the monitoring and evaluation system; (iii) drafting the policy for submission to the Government; and (iv) evaluating the Project, including the preparation of the knowledge product. The two international experts will each prepare three reports; inception, midterm, and final.

The consultants will be recruited by the PIU of the THSDP with technical input from the project coordinator and in accordance with ADB's Guidelines on the Use of Consultants (2007, as amended from time to time).

Procurement Procurement under the Project will be conducted in accordance with ADB's Procurement Guidelines (2007, as amended from time to time). Goods and services estimated to cost less than $50,000 will be procured using ADB's shopping procedure. Goods with a higher estimated value but less than $500,000 will be procured using national competitive bidding. The PIU of the THSDP will be responsible for procurement, with technical inputs from the project coordinator. To procure items below $10,000, the PIU of the THSDP may purchase the items directly from the supplier. In such cases, ADB should be satisfied that the price is reasonable. International competitive bidding is not envisaged under this Project. National competitive bidding procurement and procedures will be in accordance with the Mongolian Procurement Law, subject to modifications agreed with ADB. Procurement related to the Project's management will be conducted by the PIU of THSDP in accordance with ADB's Procurement Guidelines.
Responsible ADB Officer Altantuya Jigjidsuren
Responsible ADB Department East Asia Department
Responsible ADB Division Mongolia Resident Mission
Executing Agencies
Ministry of Health_and SportsDr. J. TsolmonMinisty of Health, Government Building-8, Olympic Street-2, Sukhbaatar District, Ulaanbaatar 14210, Mongolia
Timetable
Concept Clearance 11 Mar 2009
Fact Finding 16 Mar 2009 to 21 Mar 2009
MRM -
Approval 30 Jul 2009
Last Review Mission -
PDS Creation Date 16 Nov 2009
Last PDS Update 27 Mar 2014

Grant 9136-MON

Milestones
Approval Signing Date Effectivity Date Closing
Original Revised Actual
30 Jul 2009 16 Sep 2009 16 Sep 2009 16 Mar 2011 31 Dec 2013 30 Apr 2014
Financing Plan Grant Utilization
Total (Amount in US$ million) Date ADB Others Net Percentage
Project Cost 3.08 Cumulative Contract Awards
ADB 0.00 30 Jul 2009 0.00 2.44 81%
Counterpart 0.08 Cumulative Disbursements
Cofinancing 3.00 30 Jul 2009 0.00 2.44 81%
Status of Covenants
Category Sector Safeguards Social Financial Economic Others
Rating - - - - - Satisfactory

Safeguard Documents

See also: Safeguards

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Evaluation Documents

See also: Independent Evaluation

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