49173-003: Improving Access to Health Services for Disadvantaged Groups Investment Program | Asian Development Bank

Mongolia: Improving Access to Health Services for Disadvantaged Groups Investment Program

Sovereign (Public) Project | 49173-003 Status: Proposed

The investment program will reinforce past and ongoing sector reforms by expanding and improving access to quality primary and secondary health services in disadvantaged areas of Ulaanbaatar ger [traditional tent] areas, in Khovd and Uvs aimags (provinces), and selected soums (aimag subdistricts). It will also improve the health financing systems and reduce out-of-pocket health care expenses nationwide.

Project Details

Project Officer
Elfving, Rikard N. East Asia Department Request for information
Country
  • Mongolia
Sector
  • Health
 
Project Name Improving Access to Health Services for Disadvantaged Groups Investment Program
Project Number 49173-003
Country Mongolia
Project Status Proposed
Project Type / Modality of Assistance Loan
Source of Funding / Amount
MFF Facility Concept: Improving Access to Health Services for Disadvantaged Groups Investment Program
concessional ordinary capital resources lending / Asian Development Fund US$ 10.00 million
Ordinary capital resources US$ 148.34 million
Strategic Agendas Environmentally sustainable growth
Inclusive economic growth
Drivers of Change Gender Equity and Mainstreaming
Governance and capacity development
Partnerships
Sector / Subsector

Health / Health care finance - Health insurance and subsidized health programs - Health sector development and reform - Health system development

Gender Equity and Mainstreaming Gender equity
Description The investment program will reinforce past and ongoing sector reforms by expanding and improving access to quality primary and secondary health services in disadvantaged areas of Ulaanbaatar ger [traditional tent] areas, in Khovd and Uvs aimags (provinces), and selected soums (aimag subdistricts). It will also improve the health financing systems and reduce out-of-pocket health care expenses nationwide.
Project Rationale and Linkage to Country/Regional Strategy

Despite successful health reforms over the past 20 years, Mongolians continue to experience inadequate and inequitable access to quality health services, especially among disadvantaged groups, mainly due to high out-of-pocket expenditures, which represents 42% out of the total health expenditure. The health sector''s total expenditure is 3.4% of gross domestic product, below the World Health Organization's target of 5%. Major risk factors associated with noncommunicable diseases (tobacco and alcohol consumption, obesity, and lack of physical exercise the major cause of mortality in Mongolia) are above targets. Although Mongolia had achieved its Millennium Development Goal (MDG) targets for infant and under-5 years old mortality, and maternal mortality, disparities still exist which are directly linked to poverty, age of the mother, educational level, and location. Child malnutrition is 1.7 times higher in rural areas, and proportion of underweight children in poor households is 3.9 times higher. Significant regional variations are recorded in maternal mortality due to pregnancy complications (1.8 2.1 times higher in rural areas than the national average), and stillbirths (1.1 6.1 times).

Shortage and deficient quality of primary health care. Rapid influx of migrants to Ulaanbaatar is overwhelming available health infrastructure and the government's capacity to provide health services. The situation is worsened due to deficient laboratory services, minimal outreach activities, poor maintenance, weak human resources capacity, and unregulated private sector. There are 35 family health clinics (FHCs) lacking in Ulaanbaatar alone. A recent survey covering ger areas of Ulaanbaatar shows that FHCs substantially underperform in terms of service readiness. Primary health care (PHC) in rural areas is facing similar challenges as to urban areas, especially scarce financing and improper maintenance. Integrated models of care, where services are coordinated across the primary and secondary health care levels, have not been introduced. The emergency care service in Ulaanbaatar is underperforming causing increased waiting times, incorrect treatments due to missing equipment, and a compromised ambulance fleet with safety concerns.

Need for improving secondary health services in Khovd and Ulaanbaatar. The district hospitals in Khovd and Ulaanbaatar are inadequate to meet service delivery with national standards. Most district hospitals were not designed as hospitals, therefore, provide a narrow range of services (e.g., absence of surgical capacity and maternity services). They are often poorly maintained, with outdated equipment and under capacitated staff. Few private hospitals are operational and not affordable for most of the population. Integrated public and private hospital planning is absent. Residents of Khovd aimag, Ulaanbaatar ger areas, and other nearby aimags suffer from high-priced and deteriorating primary and secondary health care services. These locations are not covered under any ongoing or planned national program for PHC.

Inefficient health financing system. Mongolia's input-based health financing model is outdated, inefficient, and not sustainable to meet the medium- and long-term needs of the sector. It is not in line with evidence-based good practices on health financing. The current state funding model reflects negatively on hospital service quality. Moving away from input-based financing (budget lines) towards more efficient output-based financing (purchasing of services) is constrained by the health insurance organization (HIO) capacity to properly plan, cost, and negotiate to purchase services.

Road map. The State Policy on Health, 2017- 2026 and Mongolia's Sustainable Development Vision 2030 govern the sector road map. The key sector targets by 2026 are to (i) utilize at least 5% of gross domestic product and 12% of government spending on health with an increasing proportion going to PHC; (ii) limit out-of-pocket expenditures to 25% of total health spending; (iii) maintain universal health coverage; (iv) further reduce infant, child, and maternal mortality from 2015 levels; (v) reduce alcohol and tobacco consumption; (vi) increase the number of facilities that have adequate equipment maintenance from 10% to 80%; (vii) establish an integrated digital health system; (viii) shift to an output-based financing system of hospitals; (ix) integrate public and private health services planning and delivery through public private partnership (PPP) and nongovernmental organizations; (x) strengthen the technical capacity of relevant institutions; (xi) promote good governance; (xii) improve the legal and regulatory framework to provide health care in an equitable and inclusive manner; and (xiii) introduce evidence-based modern diagnostics and treatment techniques. Appendix 2, Table A2.1 details the alignment of the sector road map and the proposed investment program.

Policy framework. The State Policy on Health, 2017- 2026, is the overarching policy framework for the sector. It aims to increase average life expectancy of Mongolians by improving quality and inclusiveness of health care services through universal health coverage. The Health Law regulates the range and quality of services in the health sector and defines financing strategies, including users' financial contributions. The Health Insurance Law defines the scope of compulsory insurance and regulates the roles between the key actors). It also determines the size of health insurance benefits, in which disadvantaged groups can enroll free-of-charge. There is a relatively well-developed and regulated framework for PPPs, however, with few results and traction in the health sector. The Budget Law regulates public health services at the local government level, the Public Procurement Law guides all procurement in the sector, and the Development Policy and Planning Law supports multistakeholder participation for health concerns in policy making. This broad policy framework provides a solid foundation for the health sector, however, it will require adjustments as new challenges arise (e.g., aging population) and policy priority changes (e.g., private sector involvement in health insurance).

Strategic context. Since 1997, the Asian Development Bank (ADB) has successfully supported policy reforms linked to global health commitments such as universal health coverage, MDG's and sustainable development goals. Mongolia almost reached universal health coverage in 2017 and realized significant increase in financing for PHC (24% of government spending in 2017), which was nonexistent prior to ADB engagement. All previous health investments supported by ADB were rated successful and ongoing projects are on track and expected to be completed by 2020. Today, assistance is provided to establish a model district hospital in Ulaanbaatar with comprehensive set of services; increase the hygiene, blood safety, and medical waste management capacity of hospitals; and improve the governance and autonomy of hospitals for better efficiency. ADB''s long-term presence in the sector, with its broad experience in reforming the sector, makes it an ideal and trusted partner. The proposed investment program is in line with ADB's Strategy 2030; country operational business plan for Mongolia, 2019 -2021; country partnership strategy for Mongolia, 2017- 2020; and Operational Plan for Health, 2015 -2020.

Impact Health status of Mongolians improved
Outcome Access to affordable quality primary and secondary health services in Khovd and Uvs aimags, Ulaanbaatar ger areas, and selected soums improved
Outputs

Urban and rural primary health care strengthened

District and aimag hospital services improved

Health financing system strengthened

Capacity in procurement and financial management of relevant government entities for health strengthened

Geographical Location Ulan Bator
Summary of Environmental and Social Aspects
Environmental Aspects
Involuntary Resettlement
Indigenous Peoples
Stakeholder Communication, Participation, and Consultation
During Project Design
During Project Implementation
Responsible ADB Officer Elfving, Rikard N.
Responsible ADB Department East Asia Department
Responsible ADB Division Urban and Social Sectors Division, EARD
Executing Agencies
Ministry of Health (formerly Ministry of Health and Sports)
1st Floor, Government Building VIII
Olympic Street 2, Ulaanbaatar
Mongolia
Timetable
Concept Clearance 05 Sep 2018
Fact Finding 04 Jun 2018 to 14 Jun 2018
MRM 23 Nov 2018
Approval -
Last Review Mission -
Last PDS Update 26 Sep 2018

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