Mongolia: Strengthening the Health Insurance System

Sovereign Project | 47007-001 Status: Active


Since its establishment in 1994, the social health insurance system in Mongolia has demonstrated good achievements, including high coverage of over 90.0% of the population. Health care delivery has also been sustained despite severe budget constraints in the early 1990s at the onset of the socioeconomic transition in Mongolia. However, those insured are increasingly dissatisfied with social health insurance because of poor service quality provided by hospitals and increasing out-of-pocket expenditures.

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Project Name Strengthening the Health Insurance System
Project Number 47007-001
Country Mongolia
Project Status Active
Project Type / Modality of Assistance Technical Assistance
Source of Funding / Amount
TA 8466-MON: Strengthening the Health Insurance System
Japan Fund for Poverty Reduction US$ 1.50 million
Strategic Agendas Inclusive economic growth
Drivers of Change Partnerships
Sector / Subsector

Health - Health insurance and subsidized health programs

Gender Equity and Mainstreaming
Project Rationale and Linkage to Country/Regional Strategy

Since its establishment in 1994, the social health insurance system in Mongolia has demonstrated good achievements, including high coverage of over 90.0% of the population. Health care delivery has also been sustained despite severe budget constraints in the early 1990s at the onset of the socioeconomic transition in Mongolia. However, those insured are increasingly dissatisfied with social health insurance because of poor service quality provided by hospitals and increasing out-of-pocket expenditures.

High out-of-pocket expenses have resulted from social health insurance reimbursement ceilings, exclusion of costly procedures and diagnostic services from reimbursement, limited reimbursement for medicines, enforcement of various forms of co-payments, existence of informal payments, and the need to seek better quality care abroad. As a result, out-of-pocket payments for health services stood at 41.0% of total health expenditures in 2010, while utilization of hospital services was lowest among the poor, raising concerns about the inclusiveness of growth. In 2009, 3.8% of total households (or 27,442 households) experienced catastrophic health expenditures, and 1.8% of total households became impoverished due to health payments.

The government subsidizes social health insurance for 58.0% of the population, but targeting is ineffective and does not take into account the ability to pay. Ineffective targeting results in 10.0% of the population remaining uninsured (mostly poor unemployed and herders). Although, the government subsidizes 58.0% of the population this accounts for only 9.0% of social health insurance revenues, as subsidies are set too low (currently about $5 per year per insured person) and are not indexed to the rising cost of care. Employees and employers in the formal sector, representing 28.0% of the insured population, generate 86.0% of health insurance revenues. The disparity between the proportion of formal sector workers who are insured (28.0%) and the contribution to social health insurance revenues (86.0%) has frustrated employers and made social health insurance unattractive to them. The remaining 5.0% of social health insurance revenues are contributions paid by self-employed and informal workers.

The present social health insurance system governance structure has led to tensions within government organizations (mainly the ministries of finance, health, and population development and social protection) and between the Health Insurance Organization and the Health Insurance Sub-Council. There are no clear lines of accountability for social health insurance performance. Moreover, the current legal framework further fragments responsibilities by making the Ministry of Health instead of the Health Insurance Organization responsible for functions such as designing the benefit package, setting payment tariffs, and selecting service providers. There is also potential for serious conflicts of interest where the main service provider (i.e., the Ministry of Health) also sets payment tariffs and selects providers to be reimbursed by social health insurance. The social health insurance system also lacks mechanisms and an effective information system through which insured people can report complaints and provide feedback on social health insurance deficiencies; these are essential for informed decision making and accountability.

The Health Insurance Organization has limited capacity, particularly in terms of service costing, actuarial projections, contract negotiations, and monitoring of quality of services. It is merely one of the departments of the Social Insurance General Office and is subject to legal restrictions when it comes to staff and operational resource allotment. These circumstances have prevented the Health Insurance Organization from developing into a strong purchaser of health services on behalf of the insured population. Furthermore, for the Health Insurance Organization to act as a purchaser of care on behalf of the insured requires an effective health information system to monitor quality of services and financial autonomy of public hospitals to enter into negotiations with the Health Insurance Organization. In addition, all public hospitals are allocated social health insurance funds systematically regardless of performance, preventing the Health Insurance Organization from effectively selecting hospitals to contract with.

To address the deficiencies above, Parliament is revising the Citizens' Health Insurance Law. The revision of the law is undergoing a broad consultation process, including with civil society organizations. It is envisaged that the revised law will introduce broad reforms to improve governance and financial sustainability; improve targeting of government subsidies, including for the poor; increase access to an essential benefit package; and strengthen the autonomy and operational capacity of the Health Insurance Organization. The revised Citizens' Health Insurance Law will give more weight to reforms that the Health Insurance Organization and the Health Insurance Sub-Council have started to implement with TA provided by German development cooperation through GIZ and ADB.

Impact Increased financial accessibility of health services, especially for the poor

Project Outcome

Description of Outcome Improved performance of the social health insurance system
Progress Toward Outcome
Implementation Progress
Description of Project Outputs

1. Increased capacity for social health insurance financing

2. Improved performance through management systems and capacity development of the Health Insurance Organization

3. Strengthened governance of the social health insurance system

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

Output 1: Project consultants provide capacity building and coaching in determining cost of services to set realistic reimbursement rates. Pilot cost study conducted in 2015 in 17 public and private hospitals. Study covered selected 10 diseases reimbursed from the SHI Fund. Costing methodology is developed, staff is trained. Study will continue in 2016. Study report is available. In relation to enforcement of the revised HI Law of 2015, the consultants supported HI organization to do costing study of cancer treatment which is included in an expanded insurance benefit package.

Output 2: Quality monitoring tools along with a set of quality indicators and disease checklists were developed and piloted in 12 hospitals.

Consultants are working on development of the Midterm strategy of the HIO and its business plan.

Output 3: TA consultants are supporting the establishment of new National Health Insurance Council and its technical committees. Work on financial governance is taking into account amendments under the revised Health Insurance Law, which have implications on financial sustainability (e.g., substantial expansion of the benefit package). Tools to monitor clients' satisfaction and Grievance Redress Mechanisms were developed and submitted to the National Council.

Social marketing strategy is developed.

Geographical Location Nationwide

Summary of Environmental and Social Aspects

Environmental Aspects
Involuntary Resettlement
Indigenous Peoples
Stakeholder Communication, Participation, and Consultation
During Project Design TA processing was carried out in close consultation with government officials and the donor community, including nongovernment organizations.
During Project Implementation The TA will closely communicate with with insured members, including through regular satisfaction surveys to monitor progress to achieve outcome targets. The governance component of the project will involve key partners to ensure social partners participation in policy development and decision-making on health insurance. A complaints and redress mechanism will be developed for the insured members by 2015.

Business Opportunities

Consulting Services The TA will be implemented over 36 months from 30 November 2013 to 31 October 2016. ADB will recruit a consulting firm using quality-based selection with a simplified technical proposal to provide 29 person-months of international and 56 person-months of national consultants, including experts in social health insurance policy and management, governance, and capacity building. A national health insurance specialist and a national administrative and finance coordinator will be recruited individually to facilitate day-to-day organizational and technical matters, liaise with the executing agency and other stakeholders, and monitor the outputs of the consulting firm. All consultancy services will be recruited in accordance with ADB's Guidelines on the Use of Consultants (2013, as amended from time to time).
Procurement The national health insurance specialist will be responsible for procuring the TA equipment under the supervision of the executing agency in accordance with ADB's Procurement Guidelines (2013, as amended from time to time). The executing agency will retain the equipment upon TA completion.

Responsible Staff

Responsible ADB Officer Altantuya Jigjidsuren
Responsible ADB Department East Asia Department
Responsible ADB Division Mongolia Resident Mission
Executing Agencies
Ministry of Population Development and Social Protection
Government Building-2
United Nations Street-5
Ulaanbaatar, Mongolia


Concept Clearance 14 Feb 2013
Fact Finding 14 Jan 2013 to 18 Jan 2013
Approval 25 Sep 2013
Last Review Mission -
Last PDS Update 31 Mar 2016

TA 8466-MON

Approval Signing Date Effectivity Date Closing
Original Revised Actual
25 Sep 2013 13 Dec 2013 13 Dec 2013 31 Oct 2016 30 Apr 2017 -
Financing Plan/TA Utilization Cumulative Disbursements
ADB Cofinancing Counterpart Total Date Amount
Gov Beneficiaries Project Sponsor Others
0.00 1,500,000.00 200,000.00 0.00 0.00 0.00 1,700,000.00 25 Sep 2013 772,449.17
Title Document Type Document Date
Strengthening the Health Insurance System Technical Assistance Reports Sep 2013

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