Mongolia Health Sector

Achievements and Challenges:

Where Next?

February 2009

2

Health Outcomes

Sector:

• Financing

• Allocation

• Efficiency and Equity

• Health Insurance

Reforms of 2006

Remaining Challenges?

The Current Crisis/Where Next for Health?

Outline

3

Outcomes Good Relative to

Level of Economic Development

Vietnam

Turkey

South Africa

Russian Federation

Mongolia

Malaysia

KazakhstanIndia

Georgia

ColombiaChina

Cambodia

Brazil

Bangladesh

Azerbaijan

Armenia

0

20

40

60

80

100

120

140

160

180

0 5,000 10,000 15,000 20,000

GDP p.c. (constant international US$)

In

fan

t m

ortality

VietnamTurkey

South Africa

Russian Federation

Mongolia

Malaysia

KazakhstanIndia

Georgia

ColombiaChina

Cambodia

Brazil

Bangladesh

Azerbaijan

Armenia

0

50

100

150

200

250

300

0 5,000 10,000 15,000 20,000

GDP p.c. (constant international US$)

Un

der-fiv

e m

ortali

ty r

ate

4

Success in Delivery System

MongoliaUzbekistan

VietnamKyrgyz Republic

Kazakhstan

Cambodia

Azerbaijan

20

40

60

80

100

0 5,000 10,000 15,000 20,000

GDP pc (PPP)

% o

f c

hil

dren

ag

es 1

2-2

3 m

on

th

s

imm

un

ized

for m

easle

s (

20

04

)

Azerbaijan

CambodiaKazakhstan

Kyrgyz

RepublicVietnam

UzbekistanMongolia

20

40

60

80

100

0.00 5,000.00 10,000.00 15,000.00 20,000.00

GDP pc (PPP)

% o

f c

hil

dren

ag

es 1

2-2

3 m

on

th

s

imm

un

ized

for D

PT (

20

04

)

5

Maternal Mortality and Child Delivery

Azerbaijan

BangladeshBolivia

Brazil

Bulgaria ChileChina

Colombia

India

IndonesiaKazakhstan

MexicoMongolia

PhilippinesSouth Africa

Thailand

Vietnam

0

300

600

900

1200

0 5,000 10,000 15,000 20,000

GDP p.c. (international US$)

Matern

al

mortali

ty r

atio

MongoliaUzbekistan

Vietnam

Kyrgyz

Republic

Cambodia

Azerbaijan

0

20

40

60

80

100

0 5,000 10,000 15,000 20,000

GDP pc (PPP)

% o

f t

otal b

irth

s a

tten

ded

by

skille

d h

ealt

h s

taff (

20

00

-0

4)

6

But…Variations in Mortality

(by Income and Geography)

0

10

20

30

40

50

60

70

80

Ula

anbaata

r

Centr

al

Khangai

East

West

Capital ci

ty

Aim

ag

Soum

cente

r

Rura

l

Poore

st

Ric

hest

Mort

alit

y ra

te

IMR

U5M

Source: Data on infant mortality rates (IMR) and

under-five mortality rates (U5MR) from 2005 Middle

Income Countries.

7

Changing Disease Profile

(NCDs & need for primary/secondary prevention)

Source: WHO Gobal Database

Thailand

Sri Lanka South Africa

PhilippinesMalaysia

Indonesia

India

China

Chile

Brazil

Argentina

Mongolia

Uzbekistan

Vietnam

Kyrgyz Republic

Kazakhstan

0

10

20

30

40

50

60

70

80

0 5,000 10,000 15,000 20,000 25,000 30,000

GDP pc (PPP)

Pre

vale

nce

of sm

okin

g a

mong

adult m

ale

s (2

000-0

5)

8

Health Outcomes

Health Sector:

• Financing

• Allocation

• Efficiency and Equity

• Health Insurance

Reforms of 2006

Remaining Challenges?

The Current Crisis/Where Next for Health?

Outline

9

VietnamUzbekistan

Mongolia Sri LankaCambodia

Kazakhstan

IndiaIndonesia

China

0

20

40

60

80

100

120

140

160

180

200

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000

GDP p.c. (current international US$)

To

tal

healt

h e

xp

en

dit

ure p

.c. (

cu

rren

t U

S$

)

VietnamUzbekistan Russian Federation

Pakistan

Mongolia

Sri Lanka

Cambodia

Kyrgyz Republic

Kazakhstan

India

Indonesia

China

Brazil

Azerbaijan

0.0

2.0

4.0

6.0

8.0

10.0

12.0

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000

GDP p.c. (current international US$)

To

tal h

ealth

exp

. as %

o

f G

DP

Total Health Expenditure and GDP

Source: Data from World Development Indicators (2006) and WHO Statistical Information System (2006).

10

Composition of Public Funding

Health Insurance small and

payroll contributions come from

only 20% of members

Has it added more funding to the

health sector?

How will declining economy and

declining employment change

this?

How does it link to Health

Insurance protection?

0

20

40

60

80

2006

Insurance

Budget

Other

11

Decline of Health Insurance Coverage Continue?

SHI coverage by beneficiary category

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Flat-rate contribution

Payroll contribution

Government subsidy

Source: MOWSL

12

Resource AllocationComposition of MOH budget allocation, 2006

Secondary and

tertiary hospitals

51%

Primary providers

and pharmacies

28%

Public health

institutions and

agencies

9%

Administration

3%

Sport-related

expenditures

3%

Other

6%

Source: MOH. Secondary and tertiary hospitals include clinical hospitals, district hospitals, aimag and city

hospitals, and other referral hospitals. Primary providers and pharmacies include soum and inter-soum hospitals,

family group practices, and pharmacies (reimbursed by HIF). The largest component of ‘Other’ is the government

subsidized health insurance contribution for some households.

13

Variations across Geographic Areas (Aimag)

2006 MOH allocation to aimags p.c.

0 10,000 20,000 30,000 40,000 50,000 60,000

UlaanbaatarOrkhon

BayanUlgiiKhuvsgul

UvurkhangaiSelenge

KhovdArkhangai

Darkhan-UulBayankhong

DornodUmnugobi

TuvSukhbaatarDornogobi

BulganZavkhan

DundgobiKhentii

UvsGobiAltai

Gobi

Source: MOH and Regional GDP data from 2006 Statistical Yearbook.

14

Too Many Beds and Hospitals

Thailand

Sri Lanka

Philippines

Malaysia

Indonesia

Colombia

ChinaChileBrazil

Argentina

Azerbaijan

Cambodia

Kazakhstan

Kyrgyz RepublicUzbekistan

Mongolia

0

20

40

60

80

100

120

0 5,000 10,000 15,000 20,000 25,000 30,000

GDP pc (PPP)

Hosp

ital beds

per

10,0

00

Source: Data from 2006 World Health Report (WHO)

15

Too Many Physicians

Source: Data from 2006 World Health Report (WHO)

Thailand

South Africa

Russia

Philippines

Mexico

Malaysia

Indonesia

Colombia

ChinaBrazil

Argentina

Azerbaijan

Cambodia

Kazakhstan

Kyrgyz Republic

Uzbekistan

Mongolia

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

0 5,000 10,000 15,000 20,000

GDP pc (PPP)

Ph

ysic

ian

s p

er 1

,00

0 p

op

.

16

Health Outcomes

Health Sector:

• Financing

• Allocation

• Efficiency and Equity

• Health Insurance

Reforms of 2006

Remaining Challenges?

The Current Crisis/Where Next for Health?

Outline

17

2006 Health Reforms

1. Full budgetary financing for primary care (FGPs and soum hospitals)

2. Move to financing line items to package of services From budgetary financing for fixed costs and health insurance financing for variable costs for

secondary and tertiary hospitals, towards a model where the financing split is determined by type

(or „package‟) of service

Will need to pool funds to make this work

3. Capitation payment (payment per „covered‟ individual) for FGPs and introduction of capitation-based financing for

variable costs of soum hospitals

4. Hospitals case-based payment (“DRGs”) (fixed payment rate for different types of „cases‟) for most services provided by secondary and

tertiary hospitals

5. Hospital Autonomization provisions for state-owned health facilities to use financial surpluses for the improvement of

working environment and social protection of their health personnel.

18

Health Outcomes

Health Sector:

• Financing

• Allocation

• Efficiency and Equity

• Health Insurance

Reforms of 2006

Remaining Challenges?

The Current Crisis/Where Next for Health?

Outline

19

Outcomes

Maternal Mortality Rate by Province, 2006

80-120

>161

<39

20

Demand Side:

OOPs and Informal Payments: How High?

55%

74%

43%

2%

81%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Cambodia

(2000)

China

(2001)

Indonesia

(2001)

Thailand

(2000)

Vietnam

(1992)

Share of Informal Payments Among Users in Health Services (%)

21

Supply Side

Governance of SHI and the Pooling of Funds• Changes in the current fragmentation of funding and purchasing of services. This includes full pooling of public funds across

sources of revenues such as general budget and health insurance revenues, and development of a real single payer for services

Basic Benefits Package by the new single payer, the Health Insurance Fund (HI Fund)

• New package was developed in 2005 but not fully implemented

Refinement of new Provider Payment systems• new capitation model for FGPs and the case-mix payment per admission system for hospitals

Rationalization and Modernization of Hospital Sector• Collaboration and an eventual consensus across multiple actors in the hospital sector in the capital city. There are several sub-

sectors including the city (9 district hospitals), the MOH (MOH facilities), “parallel system” hospitals (e.g., Defense, Railroads and other large state-financed organizations),, and the private sector (an estimated 10% of all admissions)

• A hospital facility strategy to identify end-results of hospital optimization and selection of a model for implementing this process to achieve end-results. Different implementation models exist including the network model (Estonia), administrative fiat model (Kazakhstan, Moldova), and public-private partnerships (Armenia)

Civil Service Reforms across all sectors including Health• And/or improved autonomization of hospital facilities creating flexibility of inputs and improving accountability mechanisms

22

Impact of New Economic Crisis

Insurance Coverage Decline?

Increased Utilization Rates?

Increased OOPs?

Need for More Government

Revenues for Health sector?

Issues across geographic

areas?

What Else? What Have We

Missed?

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