2012年-世界发展银行全球_Health_Equity_and_Financial_Protection_Report___Mongolia_36页_1mb

Summary of the Health Equity and Financial Protection Report - Mongolia

Core Content

This report provides an in-depth analysis of health equity and financial protection in Mongolia, focusing on disparities in health outcomes, health care utilization, government spending distribution, and health financing progressivity. The analysis is based on data from the 2005 Multiple Indicator Cluster Survey (MICS) and the 2007-08 Household Socio-Economic Survey (HSES), using the ADePT software for health-related modules.

Main Findings

1. Health Inequality by Income

• Ill health is more concentrated among the poor in Mongolia.
  • Child health indicators such as stunting, underweight, and diarrhea show significant concentration among the poorest quintiles.
  • Acute respiratory infection (ARI) does not show significant inequality.
• Adult health outcomes are not well captured due to limited data availability.
• Health behaviors are also unevenly distributed, with some indicators showing pro-rich trends.

2. Health Care Utilization Inequality

• Health care utilization is mostly pro-rich, with some exceptions.
  • Maternal and child health (MCH) interventions like immunization and ARI treatment are disproportionately used by the better-off.
  • Adult preventive care (e.g., HIV testing and counseling) is also slightly pro-rich.
  • Outpatient care at soum hospitals and FGPs is free for the poor, while private sector services are concentrated among the wealthy.
  • Inpatient care at soum hospitals and FGPs is pro-poor, but aimag and central hospitals show moderate pro-rich trends.

3. Benefit Incidence of Government Spending

• Government health spending is slightly pro-rich.
  • Outpatient care at aimag and central hospitals is clearly pro-rich.
  • Inpatient care at soum hospitals and FGPs is pro-poor.
  • Outpatient care at soum hospitals and FGPs is pro-poor under the constant unit cost assumption, not significant under the constant unit subsidy assumption, and pro-rich under the proportional cost method.
• Overall, the distribution of government health spending is slightly pro-rich, with the strongest evidence under the proportional cost method.

4. Financial Protection and Impact on Households

• Out-of-pocket payments have a moderate impact on household financial well-being.
  • About 10% of households spend more than 10% of total household consumption on out-of-pocket health payments.
  • Using a non-food consumption measure, 16% of households spend more than 10%, and 3% spend more than 40%.
  • Catastrophic out-of-pocket payments are highly concentrated among the wealthy.
  • Health spending increases poverty incidence and the poverty gap:
    • 12% increase using the $2.00/day poverty line
    • 7% increase using the national poverty line (750,000 tugrik)

5. Progressivity of Health Financing

• The health financing system is mildly and significantly progressive.
  • Direct taxation and out-of-pocket payments are very progressive.
  • VAT is mildly regressive.
  • Excise taxes are progressive.
  • Import duties show no significant effect on progressivity.
• SHI (Social Health Insurance) is predominantly funded by employee and employer contributions, with out-of-pocket payments for drugs being a major component.

Key Information

Health Financing Mix (2009)

• Total health expenditure as % of GDP: 4.7%
• Government health expenditure as % of GDP: 3.45% (2007), 3.05% (2008)
• Government health expenditure as % of total health expenditure: 85.2%
• Out-of-pocket expenditure as % of total health expenditure: 11.5%

Health Care Delivery System

• Public sector provides health services at four levels:
  • Primary care: Bag feldsher posts, soum hospitals, FGPs
  • Secondary care: Rural and urban general hospitals
  • Tertiary care: Central level hospitals and regional specialist centers
• Private sector includes 159 hospitals and 698 clinics, mostly in Ulaanbaatar.
• Private pharmacies are widespread (approx. 1,000), and self-prescribed drugs are the most costly item in household expenditure.

Payment Mechanisms

• Public sector has strict user fee collection and staffing rules, with payments going to the central treasury.
• Risk-adjusted capitation model and DRG system (115 groups) are used to allocate funding to providers.
• SHI fund reimburses private pharmacies for essential drugs when prescribed by FGPs or soum health centers.

Conclusion

The report highlights that health equity and financial protection remain major concerns in Mongolia. While government spending is slightly pro-rich, the health financing system is mildly progressive, with direct taxes and out-of-pocket payments playing a significant role. Out-of-pocket payments contribute to household financial burden and poverty, especially for the wealthier segments. The poor are less likely to access health services, particularly preventive and curative care, which exacerbates health inequalities. The public health system provides some pro-poor access, especially in primary care, but private sector dominance and inequitable funding mechanisms continue to pose challenges to equity and financial protection.