亚开行-支持蒙古的初级卫生保健：经验，教训和未来方向（英文）-2021.1-28页_214kb

Summary of "Supporting Primary Health Care in Mongolia: Experiences, Lessons Learned, and Future Directions"

Core Content

This document provides an overview of the development and reform of primary health care (PHC) in Mongolia, with a focus on the role and impact of the Asian Development Bank (ADB) in supporting these reforms. It outlines the historical context, the initial government efforts, ADB's contributions, the results achieved, remaining challenges, lessons learned, and future directions for PHC in Mongolia.

Main Points

1. Historical Context of PHC in Mongolia

• Pre-1990s System: Mongolia's health care system was heavily influenced by the Soviet Union, based on the Semashko model, characterized by strong central planning, state financing, and delivery of health care.
• PHC Characteristics: PHC was dominated by curative services (outpatient and inpatient) rather than preventive care. Despite high coverage in terms of health facilities and staff, the system was inefficient and lacked responsiveness to patient needs.
• Health Indicators: While input indicators were strong, output indicators such as life expectancy and infant mortality were relatively poor compared to other countries at a similar level of development.

2. Initial Government Efforts to Reform PHC

• Economic and Political Changes: The collapse of the Soviet Union led to economic crisis and the need for socioeconomic reforms, including the health sector.
• Reforms Introduced: The government initiated reforms in the early 1990s, including the introduction of a national health insurance scheme, nontax financing, and improved financial protection for the people.
• Family Medicine Pilot: In 1993, the Ministry of Health (MOH) introduced family medicine-based PHC in Ulaanbaatar, assigning one doctor and one nurse to serve a defined population.
• Challenges Faced: Lack of training, financial incentives, and appropriate equipment hindered the effectiveness of PHC. FGPs were often located in secondary hospitals, leading to low utilization.

3. ADB Support to PHC in Mongolia

• Health Sector Development Programs (HSDP, SHSDP, THSDP): ADB supported multiple programs over the years, aimed at restructuring the health system and promoting PHC.
• Key Initiatives:
  • HSDP (1997–2003): Established family group practices (FGPs) in urban areas, introduced capitation-based financing, and focused on improving service delivery and gatekeeping.
  • SHSDP (2003–2010): Focused on rural health services and institutional capacity development. Introduced ICT and improved maternal health services.
  • THSDP (2007–2014): Continued PHC restructuring, introduced new standards and service packages, and aimed to improve access for the poor and vulnerable.

4. Results Achieved

• Urban PHC: FGPs were established in Ulaanbaatar, covering 60% of the population by 2002.
• Rural PHC: Soum hospitals were upgraded, and new service packages and referral systems were introduced.
• Improved Access: Initiatives like Medicard improved access to essential health services for vulnerable groups.
• Health Indicators: While some improvements were made, key health indicators such as maternal mortality continued to worsen in rural areas.

5. Remaining Challenges

• Autonomy of FGPs: Despite being private entities, FGPs were treated as budgetary institutions, limiting their autonomy.
• Resource Allocation: Soum hospitals lacked resources and equipment, leading to continued deterioration.
• Training and Capacity Building: Insufficient refresher training and on-the-job learning for PHC staff reduced the effectiveness of reforms.
• Public Awareness: The information campaign was not sustained, leaving pre-existing biases in favor of hospital care unchanged.
• Referral System: Poor coordination and unclear referral mechanisms led to duplication of services and continued reliance on referral-level hospitals for PHC.

6. Lessons Learned

• System Restructuring: ADB's support was crucial in restructuring the health system toward PHC and preventive care.
• Private Sector Involvement: Private entities or partnerships played a key role in delivering PHC services, but their integration into the system was hindered by policy and financial constraints.
• Financing Models: Capitation-based models were introduced but faced challenges in implementation and sustainability.
• Training and Education: Continuous training and capacity building for PHC staff are essential for long-term success.
• Public Awareness and Communication: Sustained public information campaigns are necessary to shift attitudes toward PHC and reduce reliance on hospitals.

7. Future Directions

• Continued Support for Rural PHC: ADB is requested to continue supporting rural PHC, especially in areas with limited access to services.
• Integration of Services: Strengthening the referral system and ensuring better coordination between PHC and higher-level services.
• Policy Stability: The need for consistent policy frameworks and long-term planning to avoid frequent changes that disrupt progress.
• Technology and Infrastructure: Further investment in ICT and infrastructure to improve service delivery and data collection.
• Community Engagement: Encouraging local participation and community-based health solutions to enhance accessibility and responsiveness.

Key Information

• PHC Reforms: Mongolia shifted from hospital-based curative services to a more preventive and community-focused model.
• ADB Role: ADB provided technical assistance and supported multiple health sector development programs, including HSDP, SHSDP, and THSDP.
• Health Indicators: Despite high coverage, Mongolia's health outcomes were not as favorable as expected, highlighting the need for better system efficiency and effectiveness.
• Financial and Institutional Challenges: The system faced issues with financing, resource allocation, and institutional capacity, particularly in rural areas.
• Sustainability Concerns: The success of PHC reforms was limited by inconsistent policies, lack of training, and insufficient public awareness.

Conclusion

The reform of primary health care in Mongolia has made significant strides, particularly in urban areas, but challenges remain in rural regions. ADB's support has been instrumental in driving these reforms, but the system still requires more sustainable policies, better resource allocation, and continued investment in training and infrastructure. The lessons learned from these efforts can be valuable for future health programs in Mongolia and other countries facing similar challenges.