Evaluation Paper on Health and Social Protection Sector in Mongolia

Evaluation Document | 1 October 2008
This report provides an independent assessment of Asian Development Bank (ADB) assistance to the health and social protection sectors in Mongolia and to identify lessons and areas to further improve the effectiveness of its future interventions.

Mongolia's transition to a market-oriented economy in the 1990s adversely affected the Government's ability to finance and deliver health services and provide social security services to cushion the social impacts of the transition. Following the transition, the Government initiated steps to change the social welfare system from provision of universal access to more targeted assistance.

The Government's development strategies for health identified improved access to and quality of health care, particularly maternal and child health services and primary health care (PHC), as immediate targets. The Government considers improving the quality of the health care system, ensuring access to and quality of PHC, and reforming health care financing to be key instruments to reduce poverty, accelerate economic growth, and reduce disparities in the development process, particularly between rural and urban areas. ADB has been a major partner in the Government's efforts to reform the health sector since the early 1990s.

The Government's main goals for the social protection sector are to reduce unemployment and poverty, improve living standards (particularly for the poor), ensure social guarantees, and improve the quality of and access to care services.

Summary of Findings for the Health Sector

Although implementation of ADB projects, TAs, and grants has generally proceeded satisfactorily, the achievement of sector results has been affected by political instability, inconsistent policy approaches, and political resistance to sector reforms.

ADB's health sector strategies have been based on the Government's stated priorities, ADB's country strategies, sector studies, and policy dialogue with the Government and other development partners. However, there has only been "modest" progress in replacing a health system dominated by high-cost, urban-based hospitals with a system that relies more on PHC and preventive services. Key sector goals such as the rationalization of hospitals and personnel have also faced stiff political opposition, and have not yet been achieved. Consequently, the study finds ADB's strategic performance in the health sector to be "partly successful".

ADB's sector assistance has been consistent with its sector strategies, responsive to the critical needs in the sector, and in line with the Government's priorities. ADB interventions have supported efforts to attain health-related Millennium Development Goals. ADB introduced significant and necessary changes in the health system, notably family group practices to provide PHC in urban areas. However, family group practices continue to face significant challenges of inadequate funding, ambiguous legal status, and unsatisfactory quality of services. State policies on civil registration have also prevented many migrant poor from accessing essential health services. Moreover, implementation of reforms in the health sector including rationalization of hospitals and health personnel, and improving allocation of resources between hospital (curative) and PHC (preventive) services, remains a largely unfinished process. For these reasons, ADB's sector assistance in health is assessed "partly successful". Combining the strategy and program assessments, overall performance in the health sector is rated "partly successful."

Summary of Findings for the Social Protection Sector

ADB's sector strategies have been consistent with the Government's poverty reduction strategy. However, contribution to development results is assessed as "modest" because a key objective of sector assistance - to focus public resources more on the poorest to allow for increased levels of assistance per beneficiary - has not been attained after the Government adopted a social welfare package in 2006 that increased benefits to all newborns, schoolchildren, newlyweds, pregnant mothers, and mothers with five or more children. ADB's performance is also assessed as "modest" due to lack of selectivity and focus, insufficient diagnostic work on the Government's capacity to actually implement a social welfare system involving narrow targeting, and failure to convince Parliament of the necessity to focus assistance on the poorest. As a result, ADB's strategic performance for the subsector is found to be "partly successful."

ADB's assistance has led to improvements in the delivery of social security services. However, the effectiveness of ADB interventions has been limited. Despite measures to assist the unemployed, only a small proportion has received assistance in the form of vocational and skills training, and new business development. The proportion of employees enrolled in pension and unemployment insurance schemes to the total number of employees has been declining in recent years. Effective targeting of social assistance has not been undertaken - many nonpoor still receive welfare benefits. For these reasons, ADB's sector program in social protection is assessed as "partly successful." Based on the bottom-up and top-down assessments of ADB's strategy and assistance, the overall rating is "partly successful."

Lessons Identified

ADB's experience in implementing interventions in health and social protection provides important lessons for future and ongoing ADB operations. It highlights the critical importance of securing political support and social consensus before undertaking programs involving sector policy reform. The mixed experience in health and social protection policy reform implies that substantial upfront effort needs to be made in policy analysis, consultation, outreach, and consensus building before policy reforms are framed and loan agreements are reached.

Key Issues

Issues for possible ADB involvement in the future include reforming health sector financing, addressing human resource issues in the health sector, and providing health care and social security for undocumented citizens. In health care financing, ADB assistance should be closely linked to the Government's commitment to implement the Health Sector Master Plan policy to rationalize health expenditure by addressing the inefficient allocation of resources between curative and preventive services. ADB should assist the Government to fast-track civil registration of the unregistered poor to enable them to access education and health services, and other targeted state benefits. ADB should continue to engage in policy dialogue with the Government to determine how it can more effectively provide assistance in efforts to merge the functions of the Ministry of Health and Ministry of Social Welfare and Labor.


  • Executive Summary
  • Introduction
  • Mongolia's Health Sector
  • Social Protection in Mongolia
  • Lessons, and Future Challenges and Opportunities
  • Appendixes