THIRD HEALTH SECTOR DEVELOPMENT PROJECT

Transcription

1 MINISTRY OF HEALTH OF MONGOLIA THIRD HEALTH SECTOR DEVELOPMENT PROJECT INCEPTION REPORT by the GVG consultancy team 8 September 2009 Gesellschaft fьr Versicherungswissenschaft und -gestaltung e.v. (GVG) Hansaring 43, Cologne, Germany Tel.: +49/ 221/ , Fax: +49/ 221/ [email protected]

2 TABLE OF CONTENTS 1 INTRODUCTION RECENT BACKGROUND DOCUMENTS SITUATION ANALYSIS Situation in health services delivery, with emphasis on primary care Situation in health care financing Situation in human resource development Situation in privatisation DISCUSSION WORK PLAN General Work plan for Component 1 in Work plan for Component 2 in Work plan for Component 3 in Work plan for Component 4 in RISKS AND ASSUMPTIONS REFERENCES ANNEX A TERMS OF REFERENCE ANNEX B LIST OF ACTIVITIES, OUTPUTS AND INDICATORS ANNEX C AGREED LIST OF DELIVERABLES ANNEX D PROJECT TEAM ANNEX E OVERVIEW OF MEETINGS AND VISITS DURING INCEPTION PERIOD ANNEX F DEFINITIONS ANNEX G BASELINE DATA REQUIREMENTS ANNEX H PLANNED USE OF CONSULTANTS PERSON-MONTHS, ANNEX I INDICATIVE TIME SCHEDULE FOR THE ACTIVITIES OF THE 4 COMPONENTS

3 ABBREVIATIONS ADB CME CPD FGP GVG HIF MOH MOSWL PHC PIU THSDP UB = Asian Development Bank = Continuing medical education = Continuing professional development = Family group practice = Gesellschaft fьr Versicherungswissenschaft und -gestaltung e.v. = Health Insurance Fund = Ministry of Health = Ministry of Social Welfare and Labour = Primary Health Care = Project Implementation Unit = Third Health Sector Development Project = Ulaanbaatar 2

4 1 INTRODUCTION Since 1990, Mongolia has been going through rapid transformation from a centrally-planned to a market economy and towards a pluriform democratic society. In the difficult early stages of this transition period, quality and accessibility of health care declined and some health indicators deteriorated. A process of health care reform was initiated supported by a series of projects, including the present Asian Development Bank (ADB) supported Third Health Sector Development Project (THSDP). The overall goal of the THSDP is to improve the health status of the Mongolian population. The project has two major expected outcomes: strengthened primary care services, and improved financial protection of the population by health insurance. The project is building on the achievements of two previous Health Sector Development Projects, and will probably be followed by a fourth that will focus on rationalisation of the hospital sector and on drug safety. The THSDP has 4 components: strengthened health services; improved health care financing and health insurance; improved human resource development; sector capacity development and management. Details are described in the Proposed Asian Development Fund Grant - Mongolia THSDP (ADB, October 2007). It has been decided to have part of the activities of the THSDP carried out by a team of national and international consultants provided by one single consultancy company. After a tender procedure, GVG of Germany has been selected and started its work on 6 August The part of the THSDP for which the GVG consultancy team is responsible is described in: terms of reference (see Annex A); agreed list of activities, outputs, and indicators (see Annex B); agreed list of deliverables (see Annex C). The composition of the consultancy team fielded by GVG is presented in Annex D. The contribution of the GVG consultancy team to the THSDP has started with an inception period from 6 August until 7 September 2009, concluded with this inception report. The purpose of the inception period is to kick-start our contribution to the THSDP, to acquaint the consultancy team with the actual situation, and to ensure that all responsibilities are clearly understood. A preliminary draft of this inception report has been presented to and discussed by the THSDP Steering Committee on 2 September The relationships in the THSDP are clear. GVG has been contracted by the Project Implementation Unit (PIU) on behalf of the Mongolian Ministry of Health, and GVG reports to the PIU. A Steering Committee oversees the whole THSDP including the GVG contribution. The Ministry of Health has appointed four working groups, one for each component of the THSDP, chaired by the directors of the relevant departments of the Ministry, and including members from outside the Ministry. The GVG consultancy team will co-operate closely with the working groups so that all results of the project are firmly embedded in the structures of decision-makers and other stakeholders. Persons and institutions that have been visited by members of the GVG consultancy team during the inception phase are presented in Annex E. 3

5 2 RECENT BACKGROUND DOCUMENTS A comprehensive review of existing information on the Mongolian health care sector was published in This Synthesis Paper served as a tool to guide the development of the Health Sector Strategic Master Plan published in 2005, and its Implementation Framework published in These documents provide the framework for the Third Health Sector Development Project which is described in the Report and recommendation of the President to the Board of Directors of October 2007, and for the role that the GVG consultancy team will play within the THSDP. During the inception phase, the consultancy team profited from several recent evaluation reports, especially: World Bank. The Mongolian health system at a crossroads; an incomplete transition to a post-semashko model. Washington DC, January T. Bolormaa et al. Mongolia: Health system review. Health Systems in Transition, 2007; 9(4): World Bank. Public expenditure financial management review. Chapter: The health sector. September ADB. Mongolia HSDP: Performance evaluation report. February ADB. Health and social protection Rapid sector assessment. October The Synthesis Paper and the above-mentioned reports clearly describe the achievements of the health care reform process so far, and the remaining challenges, which will therefore not be repeated in this inception report. An important document for our work in the THSDP is the Memorandum of Understanding for the proposed Project Preparatory Technical Assistance for the Fourth Health Sector Development Project of March 2009 and its attachment 2.II, for the information on the hospital sector. Many of our activities will be related to the hospital sector, and co-operation and complementarity with the fourth Health Sector Development Project will be essential. The Health Systems in Transition document states that a radical hospital restructuring policy is essential in Ulaanbaatar, and the World Bank report (its annex 2) and the Memorandum of Understanding agree. Apart from the Master Plan and the THSDP project document, the Government Action Plan has 22 health objectives that will also guide our project. At the moment, working groups are preparing amendments to the Health Law and the Health Insurance Law, but no firm recommendations have been formulated yet. It would be advisable to wait for some of the results of the THSDP before adopting such revision. The existing policy on human resources is laid down in Order nr. 277: Health sector human resource development policy (2003). In 2008, the Ministry has also presented the Health professionals career development document which includes information on incentives schemes, but this document has not yet been translated and analysed by the consultancy team. A recent analysis by two Mongolian legal consultants has concluded that the present status of Family Group Practices as private but non-profit partnerships is not compatible with Mongolian law, and they propose options to resolve this situation. Various health financing reports, government documents, including official reports, resolutions and ministerial orders were used to prepare the health care financing inputs to this report and plan the further actions. The documents and articles that have so far been used to prepare the team for the tasks ahead are listed in Chapter 7. 4

6 3 SITUATION ANALYSIS This chapter summarises some results of the meetings, field visits and analysis of documents by the members of the consultancy team during the inception period. The findings are presented per project component. We shall not give a comprehensive overview of the achievements of health care reform and the remaining challenges facing Mongolian health care because they are well-known to all those concerned. For this we refer to the documents mentioned in chapter 2. Our situation analysis wants to highlight additional information or views from a different angle that we regard as important for our work. 3.1 Situation in health services delivery, with emphasis on primary care The team visited health care facilities in the two pilot districts (Chingeltei and Songinokhairkhan) and one pilot aimag (Dundgovi). Tertiary care was not yet analysed. Of course, such visits will be continuing and expanding in the coming months. Financing aspects are described in section 3.2. The situation of the level of initial training and continuing education of staff is described in section 3.3. An initial impression was gained about services provided in Family Group Practices (FGPs) in Ulaanbaatar and Mandalgov. The analysis included the number, type and skills of staff, and the premises and equipment. There appears to be no clear and standardised profile of family medicine and no clear definition of how a model FGP differs from an ordinary one. It was not clear how the existing performance measurement system worked nor how payment was related to it. No simple laboratory tests were available to the FGPs. However, staff appeared to perform well and tried to make the best of a difficult situation. Their major concerns were lack of revenues, problematic legal status, and insufficient continuing education. Services, staff, premises, and equipment were studied in the health care facilities in two sums of Dundgovi aimag, one of which was an inter-sum hospital. Contrary to what is written in most reports, both sum hospitals were heavily overstaffed by nursing and auxiliary staff. On the other hand, the inter-sum hospital had three doctors, but not of the recommended profile, and the other sum hospital only had one doctor practising traditional medicine. In all 15 (inter-)sum hospitals in Dundgovi together there are 37 doctors and 2 dentists working for a rural population of approximately 35,000 persons, i.e. roughly one doctor per 1,000 inhabitants which can certainly not be called underserved. The average age of the doctors is 42, but the age structure is in fact bimodal. One group of 12 basic doctors (25-30 years) are doing their compulsory two years public service before they can start specialisation in Ulaanbaatar. The average age of the remaining 25 doctors is 49 years; they have originally been trained as paediatricians (9), general physicians (4), internists (3), obstetricians/ gynaecologists (2), rehabilitation (2), surgery (1), tuberculosis control (1), radiology (1), earnose-throat specialist (1), and traditional medicine (1). The sum hospital beds were hardly used. Although very important in such remote places, simple laboratory equipment was almost absent. There is no appropriate ambulance service in Dundgovi aimag to transport critical patients from the sums to the aimag centre. We have to ask the question if inter-sum status is a reality. It seems that patients from other sums rather go to the aimag centre than to the inter-sum hospital if they need advanced care. 5

7 FGP primary care and sum primary care have several characteristics in common: A relatively high proportion of the patients are referred to secondary care, and many patients are allowed to consult secondary care doctors without a referral letter. Counter-referral was poor except in Mandalgov. Primary care doctors and nurses do not have many clear diagnosis and treatment guidelines. All primary care doctors and nurses complain about the mass of paperwork: filling out forms and registries etc. takes approximately half of their working time. There are outdated and inefficient planning norms for functional space in health facilities, such as the requirement for separate procedures and vaccination rooms in primary care, instead of creating a smaller number of multi-purpose rooms. There was a lot of interest in continuing education, but little scope of participating in it. There is no planned programme of continuing education. Family physicians are leaving the profession, approximately 30% in the last 10 years. In the opinion of the Mongolian Association of Family Clinics, major obstacles to planning a career in primary care/family medicine are problems with revenues, unclear legal status, lack of continuing professional development, and unregistered clients that do not count for the capitation fee. The Association has been established in 1997 but still has limited authority; for example, it cannot accredit CME courses or approve clinical guidelines. However, the Association s capacity will have to be strengthened to assume such tasks. Outpatient secondary care in Ulaanbaatar is provided by ambulatories and polyclinics. Ambulatories usually have only the basic specialties whereas polyclinics offer a fuller range. There are no general secondary hospitals: district hospitals are limited to one, two or three specialties, e.g. paediatrics and internal medicine. That means that patients who need secondary level surgery are often treated in tertiary hospitals which are consequently overburdened with cases that do not belong there. According to the Semashko model, polyclinics and ambulatories are separate from hospitals (physically and often also organisationally), also in the aimag centre. The aimag hospital in Mandalgov offers a rather full range of services of apparently good quality. It has 136 beds for an aimag population of 47,000 which is a good ratio, a large number of 41 doctors, and some very modern hospital equipment. There are many other initiatives targeting primary and secondary care. The major project is the Millennium Challenge Account Mongolia which is focussing on the prevention of and screening for chronic non-communicable diseases such as cardiovascular disease, diabetes and cancer. It is obvious that close co-ordination and collaboration between this project and the THSDP is essential. 3.2 Situation in health care financing Health care financing related problems such as inefficient allocation of health resources and poor purchasing and other challenges mentioned in existing reports still persist. Despite this, some progress has been made on output-based budgeting and on the process of setting payment rates. It should be noted that an awareness to strengthen purchasing through introducing a single purchasing scheme in health sector is supported by the key stakeholders such as the Ministry of Finance and the Ministry of Social Welfare and Labour. However, there are still different understandings and debates among stakeholders and experts about the single purchaser concept and the separation of the Health Insurance Fund from other social insurance funds. 6

8 There is no health insurance strategic document to make revisions and updating, but there is an early draft of health care financing policy. An inter-ministerial working group has been established to prepare a new draft of the Health Insurance Act. The draft law is expected to be submitted to the Government Cabinet and the Parliament this fall for approval. There is no baseline data to assess impoverishment, out-of-pocket payment and catastrophic health expenditures since According to amendments to the Health Insurance Law in 2006, the Ministry of Health decides which services, how and according to what tariffs will be financed from the Health Insurance Fund, and also how many hospitals and beds will be financed from the Health Insurance Fund. The State Social Insurance General Office (SSIGO) estimates the budget according to the number of beds approved by the Ministry of Health and defined tariffs. Recently, the Ministry of Health developed diagnosis-related groups (DRG), which were approved by the Minister of Health. New tariffs of inpatient and outpatient services were developed. 3.3 Situation in human resource development It is not the intention of this section to repeat all the previous discussions of the issues and challenges facing the health sector in the field of human resource development. This ground is already adequately covered in recent reports listed in chapter 2 and in the Information Package produced by the Intersectoral Committee on Health Sector Human Resources (2008). The number of stakeholders involved in any aspect of human resource standards, training and social security in the health sector in Mongolia is itself a matter for concern although beyond the scope of this report. It is axiomatic that the greater the number of organisations involved in any issue then the greater the difficulty of bringing about desired changes. This is demonstrated by the fact that it is acknowledged that there are too many physicians in Mongolia, indeed there is a problem of doctor unemployment. In the Synthesis Paper, 2004, p. 124 (English edition) reference is made to an agreement to decrease the number of entrants to the school of medicine of the Health Sciences University by 50% by the year 2010 and correspondingly increase the number of entrants to the allied health professional courses in accordance with the human resources planning policy. It is now still only 2009 but it appears that this agreement is not being implemented. The Intersectoral Committee had as one priority area to ensure compliance of postgraduate trainings with sector s human resource policy and strategy. Clearly this objective has yet to be achieved. There is said to be shortage of doctors in rural areas but the reported numbers do not support this view. It may well be that the standards set are too generous, and one of the activities of this consultancy is to review standards for all health sector workers, both in hospitals and in family medicine, in relation to national and international norms. It may also be that the competencies of the health care workers in rural areas are inappropriate for their duties or inappropriate to the requirements of the FGP concept. There is a relative lack of nurses and other allied health professionals throughout the healthcare delivery system, with a nurse to doctor ratio of slightly higher than 1:1 and the target (MOH Public Administration and Management, August 2009) is to raise this to slightly higher than 3:1.Although there is a system of registration linked to Continuous Professional Development, the number of health sector workers covered by professional degree studies and training is low by international standards and the system needs review. Human resource management training is organised by the Health Department and by the Ministry of Health and both have expressed a wish for integration of curricula and of training materials. Problems facing the health sector in this field are said to be a lack of continuity, with rapid movement of trained managers, no career pathways, inappropriate organisational structure and poor, and poorly used, information pathways. 7

9 There is a National Association of Medical Education that has a working group looking to establish a core curriculum for undergraduate medical education: this is still a work in progress. There is no nationally agreed curriculum for post-graduate medical education and apparently no discussion on the topic. Although private educational establishments need to be accredited by the Ministry of Education and Culture that accreditation process does not require compliance with national curricula nor do enrolment numbers have to match the stated needs of the health sector. The Ministry of Health has issued standards for postgraduate medical education and checking compliance with these standards is underway. 3.4 Situation in privatisation The selected international consultant for component 4 has not yet visited Mongolia mainly because there was a vacancy for the position of local consultant for this subject at the beginning of our consultancy, and because the total availability of the international consultant is limited to 3 person-months over a the project period of 4 years. Therefore, analysis for component 4 will follow in the coming months. The new local consultant for component 4 has started his activities on 1 September Important issues in component 4 will be the unclear private position of FGPs (recently analysed by two local legal consultants), and the lack of regulation of private primary and secondary level services and facilities in Ulaan Baatar and aimag centres. 8

10 4 DISCUSSION The results of our short situation analysis do not really differ from the description of the existing situation in the documents mentioned in chapter 2, but some remarks will clarify our understanding of the issues we will have to deal with. As there sometimes is some confusion about terminology in health system analysis, a list of definitions and short descriptions is presented in Annex F. An overview of the relation between major challenges mentioned in existing reports, the proposed strategies in the Master Plan, and the list of activities for which the consultants are responsible is presented in the table below. The conclusion of this table is that many remaining challenges in health care reform are covered by the Master Plan and by our planned contribution to the THSDP. However, there are some challenges that seem to have received less emphasis in existing documents and in some cases facts on the ground seem different. challenge/bottleneck according to existing reports and other documents Master Plan 2005 Annex B strategy nr. activities THSDP (C = component) health care delivery, with emphasis on primary care scope/quality of FGP services insufficient 1, 2, 12, 13 C1.6, (C1.10) gate-keeping/referral system not respected 3 C1.5, (C1.13), C1.20 hospital admission rate of 239/1,000 (3), 24 C1.5, C1.7, C1.20 too much paper work in primary care (13), 23 - unclear legal status of FGPs - - unclear profile of sum hospitals - C1.16, C1.17 insufficient rationalisation of UB hospitals 24 (C2.13) inappropriate use and shortages of drugs 4, 6-7 x 24 hours provision of primary care (1) - health care financing FGPs fully funded from the state budget - C1.3 inappropriate contracting and payment method for FGPs 18 C1.1, C1.2, C1.4 disproportionate funding of inpatient care (24) C inappropriate contracting and payment method for inpatient care 18 C2.13 unclear targeting of the poor/vulnerable - - functioning of the health insurance system 19 C unregistered patients - - one quarter of population not insured 19 C2.8 poor MOH-MOSWL-HIF coordination (19) C2.5 9

11 challenge/bottleneck according to existing reports and other documents human resources Master Plan 2005 Annex B strategy nr. activities THSDP (C = component) PHC training too short/inadequate (15) C1.7, C1.12, C1.18, C3.5 no effective CPD (CME) system in place 15 C1.21, C1.22 rural FGPs understaffed 14, 16 C1.4, C3.6 sum hospitals understaffed 14, 16 C1.4, C3.6 doctor-nurse ratio unbalanced in FGP - C3.1, C3.4 too many physicians in Mongolia - C3.1, C3.4 too many medical students in Mongolia - C3.1, C3.4 privatisation issues unclear private status of FGPs - - unregulated growth of private health sector 24 C4.1-2 Forcing primary care doctors and nurses to spend hours per day on paper work is one of the factors contributing to staff leaving primary care. The same situation occurs in some other transition countries and is difficult to rectify because all receiving institutions insist that their data are essential. However, a solution must be found if the profession is to become attractive to new doctors and nurses. It is obvious that the problem with unregistered patients is not the responsibility of the Ministry of Health. Often these people do not even want to be re-registered for various reasons. If a single purchasing agency should emerge in Mongolia, equalisation between aimags would be possible based on the unique identification number that every Mongolian citizen has, even without re-registering. The often repeated lack of doctors and nurses at sum level needs further examination. It may be that the major problem is not numbers but lack of skills and equipment. Of course, we do not know yet to what extent the situation in Dundgovi is representative for the other aimags. Shortage can be defined on the basis of existing but possibly outdated national norms, or on the basis of need and international comparison. Before upgrading sum, aimag and district hospitals, it would be useful to define which services they should be able to provide, which staff and equipment they need for this, and which are the criteria for referring a patient to the next highest level of the health care pyramid. The Ministry of Health has expressed its interest to receive support from the GVG consultancy team on the drafting of a new version of the Health Insurance Act. It is essential for a new Health Insurance Act to be in line with the proposed reforms in our agreed List of activities. Therefore, the health care financing sub-group of the GVG consultancy team needs to provide inputs to and co-operate with the Interministerial Working Group of the Ministries of Health, Finance, and Social Welfare & Labour despite the short time allowed for it. The GVG consultancy team can fully adhere to the official terms of reference (Annex A) except that a change has been made in the order of the activities of component 2. Although some deadlines are extremely tight, the GVG consultancy team expects to 10

12 implement the official List of activities and outputs and List of deliverables according to schedule. Some minor changes in the activities of component 2 have been agreed with the PIU. They are: In activity 1.1 to remove based on revised/updated health financing policy since there is no approved policy and it may become a constraint in developing a health financing model. If such a policy is to be approved it should be based on the health financing model. In activity 7.1 to remove word independent and just leave Separate national level purchasing entity. We cannot exclude options of the purchasing agency being under one of the ministries. to remove activity 7.2 because a single purchaser model does not necessarily imply separation of purchaser and provider. Activity 8.3 should be modified to Assist in developing and implementing a plan of action to conduct an education and enrolment campaign to improve overall health insurance coverage among the general population and with a particular emphasis on poor and vulnerable people. In activity 12.1 to remove the words managed competition since it is not consistent with a single purchasing model. The new versions of the lists of activities and deliverables are presented in Annex B and Annex C. There is no complete congruency between activities and deliverables, as is shown in chapter 5. The GVG consultancy team proposes to combine or at least co-ordinate the working groups 2 and 4 of the Ministry of Health because of their common relevance to health care financing and the need to involve some members of working group 4 in health care financing discussions. The GVG consultancy team hopes to cooperate with the consultants preparing the 4th Health Sector Development Project (planned to be effective by the end of 2010) and who will start their activities shortly. The area of co-operation is especially needed in the field of rationalisation of the hospital sector. Care should be taken to avoid overlap between the proposed working groups for the preparation of the 4th project and the working groups for the THSDP, as THSDP components 2, 3 and 4 cover the whole health care sector. The GVG consultancy team also will cooperate with the Millennium Challenge Account Mongolia project, and contact has already been established. With the planned strengthening of family medicine and restructuring of the hospital sector and the health financing system, the Mongolian health system has reached an important stage in its reform process. The THSDP will play a crucial role in further progress. 11

13 5 WORK PLAN 5.1 General It is the aim of the consultancy team to follow the lists of activities and deliverables presented in Annexes B and C. Some minor changes in the original lists have been agreed between the PIU and the consultancy team, and have been inserted in Annexes B and C. The detailed plan of work for the period September-December 2009 is described below. The next consultancy report will be a combination of a quarterly and an annual report, covering the period September-December It will be submitted as a draft before 31 December 2009 and will include a detailed work plan for the year A list of baseline data to be collected by the consultancy team is presented in Annex G. A preliminary overview of the planned use of consultants person-months is presented in Annex H. An indicative time schedule for the activities to be carried out under the four components is presented in Annex I. This shows that the project activities are (too) heavily concentrated in the period September 2009 until December 2010, probably because of the delay of the start of the project. The consultancy team will do its utmost to comply with the tight deadlines imposed by the List of deliverables. 5.2 Work plan for Component 1 in 2009 An overview of planned activities and deliverables is presented in the table. deliverables component 1 (see Annex C) 1. performance contract FGPs; approval of revised contract time line activities component 1 (see Annex B) end of 2009; first quarter improve performance contract 2. income/incentives FGPs first quarter develop FGP income package 3. risk-adjusted capitation first quarter FGP funding and FGP incentives 4. referral and gate keeping end of gate keeping and referral guidelines 5. clinical guidelines development end of develop PHC guidelines 6. assessment PHC equipment end of provide PHC equipment 7. training of PHC staff end of PHC and Ulaan Baatar Health Department training and CME 8. advocacy PHC end of FGP advocacy 9. delineating sum health centre role end of sum health care role delineated 10. extension of PHC end of extend PHC programmes 8. local government training 12

14 deliverables component 1 (see Annex C) time line activities component 1 (see Annex B) 10. development model FGPs 11. support UB Health Dept. 14. doctor choice guidelines 15. develop PHC support From this table, it is clear that several activities are not matched by deliverables, i.e. they are as yet without a time line. It also seems that the deadline for nearly all deliverables is before halfway the project. However, many deliverables appear to have been defined as the foundation for implementation during the period It will therefore be important not to use up most of consultants time before the end of A more precise distinction between development and implementation will be made before the end of 2009, matched by the estimated required consultants time for both. That means that Annexes H and I may have to be revised in the coming months after baseline data and other information have become available. During September, the consultants will collect the necessary baseline data (see Annex G) and documents. They will visit health facilities and other institutions, both in Ulaan Baatar and in the pilot aimags, and survey the international literature, especially on performance measurement and performance-based payment, and on the planning and provision of rural health services. In October and November, the consultants will analyse present Mongolian arrangements for performance measurement and performance-based payment, and prepare recommendations on an improved performance contract for FGPs (activity 1). The results of the analysis and the recommendations will be presented in a short technical report. A workshop will be organised around 1 December to discuss the draft recommendations with stakeholders. The final recommendations will be submitted not later than 31 December Also in October and November, the consultants will analyse the present situation in the sum and inter-sum hospitals in the five pilot aimags, and prepare recommendations on the possible future role and services to be provided by sum and inter-sum hospitals and/or sum health centres (activity 16; related to activity 17). The results of the analysis and the recommendations will be presented in a short technical report. A workshop will be organised around 1 December to discuss the draft recommendations on future sum health services with stakeholders. The final recommendations will be submitted not later than 31 December During the whole period September-December, the consultants will prepare for activities 2 and 3 which should lead to the next deliverables in the first quarter of

15 5.3 Work plan for Component 2 in 2009 Two documents define the activities and outcomes to be produced by the Health Financing component of the GVG Consultancy Team. Those documents are Annex B (List of activities, outputs and indicators) and Annex C (List of deliverables). deliverables component 2 (Annex C) time line activities component 2 (Annex B) 11. New health care financing model developed and approved Plan for main financial reform to be introduced in the health sector developed and approved. 12. Agreement on fund pooling mechanisms and single purchaser. Implementation of piloting of pooling of funds and single purchaser mechanisms. 13. Policy recommendation on overall health insurance policy. Recommendations on out-of-pocket, co-payment and payment methods. 14. Recommendation on mechanisms for mitigating the effect of financial barriers to access, outof-pocket expenses, and catastrophic payments. 15. Recommendation on private health insurance 16. Recommendation on improving hospital efficiency. Implementation of efficiency measures in pilot hospitals. mid 2010 mid 2010 end of 2009 end of 2012 mid 2010 mid 2010 end of 2010 first half of 2010 end of 2010 end of review and approve new financing model 3. health financing plan submitted to ADB 2. training on implementation of single purchaser system 4. develop single purchaser model and pooling 5. agreement on pooling and single purchaser 6. pilot single purchaser model 7. extend pooling and single purchaser model 8.1 and 8.2. review and revise health insurance principles and legal framework 9. review and revise health insurance rates and payment 10. awareness raising on financial barriers to access to health care 11. strengthen private health insurance regulation 12. review constraints to hospital efficiency 13. develop market options in the hospital sub-sector 14. introduce efficiency incentives 15. training on improved efficiency 8.3. Assist in developing and implementing a plan of action to conduct an education and enrolment campaign to improve overall health insurance coverage among the general population and with a particular emphasis on poor and vulnerable people. 14

16 The consultants propose to postpone the deadline for the first part of deliverable 12 from the end of 2009 to mid In September, the consultants will collect health care financing baseline data. In September and October, the consultants will assist the Inter-ministerial Working Groups of the Ministry of Health and the Ministry of Social Welfare & Labour on drafting a new version of the Health Insurance Act and amendments to the Health Act related to health care financing. In September and October, the consultants will review health care financing models, including single purchaser arrangements. In October, the consultants will also review documents to analyse the current health insurance situation and visit pilot aimags. In November, the consultants will continue to collaborate with the Ministries of Health, Social Welfare & Labour, and Finance and other stakeholders and organise meetings and interviews for the situation of health insurance and the development of health care financing models. In November, the consultants will analyse the current health insurance situation, and discuss with stakeholders and working groups through meetings and interviews for feedback. A short report of the work undertaken and the results to date will be presented at a stakeholder workshop, which will be organised at the end of November or in the beginning of December, to discuss with stakeholders the preferred health care financing model and the assessment of the health insurance situation. The final report will be submitted not later than 31 December. 5.4 Work plan for Component 3 in 2009 Two documents define the activities and outcomes to be produced by the Human Resources component of the GVG Consultancy Team. Those documents are Annex B (List of activities, outputs and indicators) and Annex C (List of deliverables). These two documents differ and it is necessary to clarify which of the two, or maybe a combination of the two, is the basis not only for the 2009/2010 work plan to be included in the inception report but also for the work to be undertaken in the following period. A chart comparing the two sets of requirements is given below and is largely selfexplanatory. Activities 1, 2, 6 and 7 in Annex B correspond sufficiently with deliverables 17 to 19 of Annex C for there to be reasonable clarity about the expected outcomes. Activity 3 of Annex B (Support long term fellowships), is compatible in part with deliverable 18 of Annex C and activity 6 of Annex B but quite clearly it would be inappropriate for the GVG Consultancy Team to be selecting candidates (activity 3.1) although it is appropriate for the GVG Consultancy Team to design criteria that will be used to make such selections. Activity 4 of Annex B (Support High Level Human Resource Committee), in line with the human resource strategies in the Implementation Framework of the Master Plan, outlines a series of activities, outcomes and indicators that are close to those set out on activity 1. Consideration may be given to combining these two activities into one. All the work of the GVG Consultancy Team on human resource development and policy can be discussed by the High Level Committee. Activity 5 of Annex B (Options for family medicine specialty structure) is more appropriate to, and will almost certainly be covered by, sub-group 1 of the GVG Consultancy Team. If activities 3, 4 and 5 of Annex B are to be undertaken by the human resources sub-group of the GVG Consultancy Team then a realistic timeline, congruent with other activities, needs to be applied. In any event the timeline in Annex C has the majority of the deliverables completed by the end of As the period of contract is until the first quarter of 2013 this seems to need some re-examination. 15

17 deliverables component 3 (Annex C) time line activities component 3 (Annex B) 17. Sector-wide workforce plan developed and approved. Report on implementation and evaluation of workforce plan in selected aimags 18. Recommendation on training materials and references in human resource management and organisational management. Recommendation for a residency programme on family medicine, training modules and materials 19. Policy paper (documentation) to promote training incentives or subsidies mechanisms for rural area medical staff. Plan of action for implementing the new training-incentive system end of 2010 end of 2012 end of 2010 end of 2010 end of 2010 end of Develop workforce plan model 2. Human resource training in pilot aimags 6. Training incentives/subsidies 7. Human resources incentive package 3. Support long-term fellowships 4. Support High Level Human Resources Committee in line with the human resources strategies in the Implementation Framework of the Master Plan 5. Options for family medicine specialty structure During September, the consultants will collect the necessary baseline data (see Annex G) and documents. They will continue to liaise with established contacts with the Health Department, Ministry of Health and other stakeholders to deepen the understanding of the data already received. They will, using internet searches, seek for accepted staffing standards, incentivisation of rural health staff and continuous professional development. In October and November, the consultants will analyse the current staffing situation in the health sector and specifically in the pilot aimags, some or all of which will be visited, and establish and secure confirmation of the current standards. The consultants will discuss with consultant sub-group 1 the direction of that sub-group s thinking on the model of delivery of health care. The model to be proposed may alter, possibly radically, the standards to be adopted when assisting to develop a sector wide work plan (activity 1.1). Comparisons will also be made with international norms, averages or standards. A short report of the work undertaken and the results to date will be presented at a stakeholder workshop organised in late November to discuss the draft recommendations with stakeholders. The final recommendations will be submitted not later than 31 December Also in October and November, the consultants will concentrate on securing details of the training in human resources management and Organisational Development, evaluating the curriculum and training methods and materials used and making recommendations for future training (activity 2.1). 16

18 The consultants will examine the literature, and consult widely with stakeholders to elicit views and proposals for the promotion of training incentives or subsidy mechanisms for rural area medical staff (activity 6). A short report of the work undertaken and the results to date will be presented at a stakeholder workshop organised in late November to discuss the draft recommendations with stakeholders. The final recommendations will be submitted not later than 31 December During the whole period September-December, the consultants will prepare for activities 3, 4 and 7 which should lead to the next deliverables in the first half of Work plan for Component 4 in 2009 The detailed work plan will be made by the new local consultant and the international consultant in consultation with the (deputy-) team leader of the consultancy team. A report on activity 1 (Review of the private sector) can hopefully be completed before the end of 2009, and preparation for activities 2 and 3 be made. 17

19 6 RISKS AND ASSUMPTIONS It is assumed that the Master Plan and its Implementation Framework are the guiding documents for health care reform in Mongolia and that the government remains fully committed to them. However, there is a risk of political and other obstacles to stated objectives of health care reform, especially concerning sensitive subjects such as rationalisation of the hospital sector, strengthening of the position of PHC in the health care system, gate keeping, and health financing reform. In every country there are professionals, politicians and ordinary citizens who oppose such objectives, and such opposition will have to be managed. The THSDP is not the only vehicle for health care reform. Many reform activities are ongoing, by the Ministry of Health and by other ministries, institutions and projects, and they have different approaches and timelines, for example in primary care and in health financing reform. It is a risk that different reform activities follow parallel paths, and it is an assumption that all those involved in health care reform are ready to co-operate and co-ordinate. We assume that the Government of Mongolia and the Ministry of Health will remain committed to the strengthening of primary care in Mongolia, which includes a clarification of the legal status of primary care providers, improved technical capacity of primary care, and an increased share of the public budget for health care. There is a risk that hospital rationalisation in Ulaan Baatar will be delayed until well into the 4th Health Sector Development Project, leading to an insufficient shift of funds from the hospital sector to primary care during the THSDP. Consensus and co-ordination among the Ministries of Health, Social Welfare & Labour, and Finance will be a key risk/success factor for health financing reform. 18

20 7 REFERENCES ADB. Program Completion Report on the HSDP in Mongolia. September ADB. Proposed Asian Development Fund Grant - Mongolia THSDP. October ADB. Mongolia HSDP: Performance Evaluation Report. February ADB. THSDP Project Information Document, ADB. Health and Social Protection - Rapid Sector Assessment. October ADB, Ministry of Finance, World Bank. Manual on mid-term planning, output and program based budgeting for public organizations. Ulaan Baatar Bolormaa T et al. Mongolia: Health system review. Health Systems in Transition, 2007; 9(4): Byambaa R. Inappropriate admissions at hospitals of tertiary and secondary level of care in Ulaanbaatar. No date. Fuenzalida-Puelma HL. Private sector regulatory and institutional issues in Mongolian health reform. Ulaanbaatar, April-May Government of Mongolia, Ministry of Health. Health Sector Strategic Master Plan Ulaanbaatar, Government of Mongolia, Ministry of Health. The Implementation Framework of the Health Sector Strategic Master Plan Ulaanbaatar, Government of Mongolia. Millennium Development Goals-based comprehensive national development strategy of Mongolia. Ulaan Baatar Government Resolution no The guidelines on selection of health organisations to provide health services which are funded from government budget and Health Insurance Fund. Ulaan Baatar Healy J, McKee M. Chapter 4 - The role and functions of hospitals. In: McKee M, Healy J (eds). Hospitals in a changing Europe. Buckingham/Philadelphia, Open University Press, Hindle D, Khulan B. New payment model for rural health services in Mongolia. Rural and Remote Health, 2006;6:434 (online). Implementing Agency of the Government of Mongolia, Department of Health. Health indicators Ulaan Baatar, Intersectoral Committee on Health Sector Human Resource. Information package. Ulaan Baatar, Joint Ministerial order No 73/53/33: The payment rates for health services to be funded from the Health Insurance Fund. Ministries of Health, Finance, and Social Welfare & Labour, March Ministry of Health. Order nr Health sector human resource development policy November Ministry of Health, Government of Mongolia. Synthesis paper (second revised reprint). March Ministry of Health. Ministerial order no. 37. The list of health insurance funded health services to be provided by private health organizations and the evaluation criteria for selection of private health organizations to be funded from the Health Insurance Fund. February

21 Ministry of Health. Ministerial order no. 180: The list of DRGs to be funded from Health Insurance Fund and their cost weight (App.1). The payment methods for health insurance funded health services and the guidelines for estimating health insurance payment rates (App.2). June Ministry of Health and ADB. Memorandum of Understanding - proposed Project Preparatory Technical Assistance Mongolia - Fourth Health Sector Development Project. March National Audit Office. Report on health care financing and user charges. Ulaan Baatar, October 2008 Orgil B, Hindle D, O Rourke M, Batsuury R, Sonin S. Privatised family group practices in Mongolia: an initial survey of service access. Australian Health Review 2002;25(4): O Rourke M, Mira M, Orgil B, Jeugmans J. Developing family medicine in Mongolia. Asia Pacific Family Medicine 2003;2: Sodnom Bekhbat, Ross Sutton. Towards donor coordination in the health sector in Mongolia. No date. Ulikpan A, Mirzoev TN, Narula IS. Is the Mongolian health sector ready for a sector-wide approach? Asian Social Work and Policy Review 2008;2(2): WHO. Mongolia. Country Health Information Profiles, pp (online). World Bank. The Mongolian health system at a crossroads; an incomplete transition to a post-semashko model. Washington DC, January World Bank. Public expenditure financial management review. Chapter: the health sector. September Family medicine experiences in other countries with a Semashko background Atun R et al. Review of experience of family medicine in Europe and Central Asia: Moldova case study. World Bank, May Curochicin G et al. Management of human resources in primary care in Moldova. September Kalda R. The current system of primary care, role of the Estonian Society of Family Doctors. June Liseckiene I et al. Primary care in a post-communist country 10 years later. Comparison of service profiles of Lithuanian primary care physicians in 1994 and GPs in Health Policy 2007;83: Rese A et al. Implementing general practice in Russia: getting beyond the first steps. BMJ 2005;331: Schaapveld K. A comprehensive view of primary care reform in Georgia. April

22 ANNEX A TERMS OF REFERENCE Component 1. Strengthened health services Expected Outputs of THSDP (Ref pg 6-7 of RRP) Strengthened FGPs Strengthened SHCs in providing primary care Upgraded district and aimag general hospitals International Consultant for Component 1/Team Leader The international consultant responsible for the areas of expertise for Component 1 will also carry out the functions of a Team Leader and be responsible for the overall management. Under the direct supervision of the Project Manager and as a counterpart of the Planning and Human Resource Officer of the THSDP, the Team Leader will undertake the following managerial tasks 1 : 1. To manage the in-country consultant team and to coordinate, and supervise the activities of international and local experts/ consultants; 2. To assist the PIU to establish and operationalize appropriate procedures for ensuring effective collaboration with the relevant departments of the MoH and other partner agencies involved in the health sector for each project component. 3. To assist the PIU to ensure the timely undertaking of the planned project's activities using wherever possible a capacity building working group approach; 4. To assist the PIU with the programme internal monitoring using the PPMS; 5. To ensure that all reports mentioned in the section H of this Terms of Reference are prepared and submitted to the MoH/PIU and ADB Headquarters in a timely manner 6. To provide technical assistance and support in the relevant areas of expertise in addition to carrying out the team leader tasks. Activities to undertake: 2 A. Family group practice 1. Assist in consolidating family medicine in Mongolia by strengthening legal basis and performance contract arrangements for FGP. 2. Assist in institutionalizing FGP financing and remuneration via risk-adjusted capitation. 3. Assist in development of FGP gatekeeper role with appropriate referral arrangements and mechanisms. 4. Assist in development of FGP training programs with supporting clinical guides, standards, and materials to improve FGP staff clinical and practical skills. 5. Assist in identifying essential PHC equipment for FGP and district hospital support for PHC. 6. Assist in developing model FGPs to guide future family medicine service provision. 7. Assist in strengthening family doctor training and education at Health Science University of Mongolia and Ulaanbaatar City Health Department and in developing advocacy structures for FGP. 1 Please refer to the Annex at page 8 2 For Team Leader/International Consultant under Component 1 21

23 8. Assist in preparing a national information campaign on FGPs. 9. With HR consultant, help to develop vocational training and specialty arrangements for family medicine. B. Soum Health Centres and PHC 3 1. Assist in developing plans to restructure SHCs as ambulatory centers, based on provision of PHC, defined catchment populations, access and outreach, and role delineation for SHC staff and services. 2. Assist in developing training programs and structures for SHC staff with appropriate public health, health promotion, clinical, and management materials and guides to improve skills and practice. 3. Assist in developing admission and treatment guides, referral, and network arrangements between SHCs and specialists. 4. Assist in identifying essential PHC equipment for SHCs and aimag hospital support for PHC. 5. Assist in developing SHC primary care via trials and demonstration programs. 6. Assist in developing continuing medical education and clinical rotation programs for SHC staff to improve clinical and practice skills. 7. With HR consultant, help develop clinical fellowship programs to enhance skills. C. Hospital Support for Primary Health Care 4 1. Assist in identifying essential PHC equipment for FGPs and SHCs, and for aimag and district hospital support for PHC. 2. Assist in prioritizing and costing essential equipment and preparing procurement plans and documentation. National Consultants: In collaboration with the international consultant the national consultant will undertake the following tasks: 5 A. Family group practice 1. Assist in consolidating family medicine in Mongolia by strengthening legal basis and performance contract arrangements for FGP. 2. Assist in institutionalizing FGP financing and remuneration via risk-adjusted capitation. 3. Assist in development of FGP gatekeeper role with appropriate referral arrangements and mechanisms. 4. Assist in development of FGP training programs with supporting clinical guides, standards, and materials to improve FGP staff clinical and practical skills. 5. Assist in identifying essential PHC equipment for FGP and district hospital support for PHC. 6. Assist in developing model FGPs to guide future family medicine service provision. 7. Assist in strengthening family doctor training and education at Health Science University of Mongolia and Ulaanbaatar City Health Department and in developing advocacy structures for FGP. 8. Assist in preparing a national information campaign on FGPs. 3 Referred in Appendix 11 of RRP as Public Health/Health Management 4 Referred in Appendix 11 of RRP as Equipment and Procurement 5 For National Consultants/Local Experts under Component 1 22

24 9. With HR consultant, help to develop vocational training and specialty arrangements for family medicine. 10. To closely work with thematic working group established by MoH (Working group #1) to provide with guidance and facilitation of follow up actions. B. Soum Health Centres and PHC 6 : 1. Assist in developing plans to restructure SHCs as ambulatory centers, based on provision of PHC, defined catchment populations, access and outreach, and role delineation for SHC staff and services. 2. Assist in developing training programs and structures for SHC staff with appropriate public health, health promotion, clinical, and management materials and guides to improve skills and practice. 3. Assist in developing admission and treatment guides, referral, and network arrangements between SHCs and specialists. 4. Assist in identifying essential PHC equipment for SHCs and aimag hospital support for PHC. 5. Assist in developing SHC primary care via trials and demonstration programs. 6. Assist in developing continuing medical education and clinical rotation programs for SHC staff to improve clinical and practice skills. 7. With HR consultant, help develop clinical fellowship programs to enhance skills. 8. To closely work with thematic working group established by MoH (Working group#1) to provide with guidance and facilitation of follow up actions. C. Hospital Support for Primary Health Care 7 : 1. Assist in identifying essential PHC equipment for FGPs and SHCs, and for aimag and district hospital support for PHC. 2. Assist in prioritizing and costing essential equipment and preparing procurement plans and documentation. Component 2. Improved health care financing and health insurance Expected Outputs of THSDP (Ref pg 7-8 of RRP) Strengthened health resource allocation and purchasing Improved financial protection and expanded health insurance coverage International Consultant Activities to undertake: A. Health care financing and modelling 1. Develop, review and get an approval for national health financing model. 2. Develop the single purchaser model and pooling. 3. Assist in MOH/MOF/MSWL MOU signing on pooling and single purchaser. 4. Plan on health financing reform submitted to ADB to meet conditionality. 5. Assist to conduct training on implementation of a single purchaser mechanism. 6. Assist in designing conducting and evaluating of the single purchaser in pilot sites. 7. Assist in developing relevant guidelines for scaling up the application of the single purchaser model. 6 Referred in Appendix 11 of RRP as Public Health/Health Management 7 Referred in Appendix 11 of RRP as Equipment and Procurement 23

25 B. Health insurance system 1. Analyze and review health insurance situation and coverage. 2. Assist in developing options to increase and extend health insurance coverage to the uninsured and to promote participation in the Health Insurance Fund. 3. Develop and undertake training, with appropriate materials, on health insurance purchasing and optimal use. 4. Assist in developing regulation of private health insurance. 5. Assist in developing hospital financial efficiency mechanisms and processes. 6. Assist in implementing efficiency initiatives in pilot hospitals. 7. Organize and conduct workshops, training, and materials on improving hospital financial management and efficiency. National Consultant on Health Care financing and modelling In collaboration with the international consultant the national consultant will undertake the following tasks: 1. Develop, review and get an approval of national health financing model. 2. Assist in development of training materials and develop and implement capacity building plan on single purchaser mechanism. 3. Develop a plan on health financing reform submit to ADB to meet conditionality. 4. Assist to develop a single purchaser model and pooling. 5. Assist in MOH/MOF/MSWL MOU signing on pooling and single purchaser. 6. Assist in designing, conducting and evaluating of the single purchaser in pilot aimags. 7. Assist in developing relevant guidelines to scale up the single purchaser model. National Consultant on Health insurance system. In collaboration with the international consultant the national consultant will undertake the following tasks: 1. Analyze and review health insurance situation and health coverage 2. Develop options to increase health insurance coverage to the uninsured and to promote participation in Health Insurance Fund. 3. Develop appropriate training materials on health insurance and undertake trainings. 4. Assist in developing a regulation on private health insurance. 5. Assist in developing hospital financial efficiency mechanism and processes. 6. Assist and facilitate in implementing efficiency initiatives in pilot hospitals. 7. Develop, and facilitate training materials development and organize trainings on hospital financial management and efficiency. 8. To closely work with thematic working group established by MoH (Working group #2) to provide with guidance and facilitation of follow up actions Component 3. Improved human resources development Expected Outputs of THSDP (Ref pg 8 of RRP) Improved health HR management Upgraded incentives to improve rural health care International Consultant Activities to undertake: HR management and organizational development 1. Assist in developing workforce planning, as well as HR development plans and strategies. 24

26 2. Organize and conduct training on HR management and organizational development, supported by relevant guides and material. 3. With public health consultant, establish and support long-term clinical fellowships for AGH and district specialists. 4. Assist High Level HR Committee to develop HR strategies for the health sector. 5. Assist (with FGP consultants) in developing options and structures for institutionalizing postgraduate training and for development of family medicine as a vocational specialty. National Consultant on HR management, incentives and organizational development (1 st Position) In collaboration with the international consultant the national consultant will undertake the following tasks: 1. To develop workforce planning as well as HR development plans and strategies. 2. Organize and conduct training on HR management and organizational development, supported by relevant guides and materials. 3. With public health consultant, establish and support long-term clinical fellowships for AGH and district specialists. 4. Assist High level HR committee to develop HR strategies for the health sector. 5. Assist (with FGPs/SHC consultants) in developing options and structures for institutionalizing postgraduate training and for development of family medicine as a vocational specialty. 6. To closely work with thematic working group established by MOH (Working group #3) to provide with guidance and facilitation of follow up actions. 7. Review and develop training incentives and subsidies for places in training schools to increase rural health staff numbers. 8. Research and develop incentive packages with financing and welfare components to develop strategies to encourage staff transfers to rural areas and implement staff transfers via incentive funding. 9. To closely work with thematic working groups established by MOH (Working group #1,#3) National Consultant on HR management, incentives and organizational development (2 nd Position) In collaboration with the international consultant the national consultant will undertake the following tasks: 1. To develop workforce planning as well as HR development plans and strategies. 2. Organize and conduct training on HR management and organizational development, supported by relevant guides and materials. 3. With public health consultant, establish and support long-term clinical fellowships for AGH and district specialists. 4. Assist High level HR committee to develop HR strategies for the health sector. 5. Assist (with FGPs/SHC consultants) in developing options and structures for institutionalizing postgraduate training and for development of family medicine as a vocational specialty. 6. To closely work with thematic working group established by MOH (Working group #3) to provide with guidance and facilitation of follow up actions. 7. Review and develop training incentives and subsidies for places in training schools to increase rural health staff numbers. 8. Research and develop incentive packages with financing and welfare components to develop strategies to encourage staff transfers to rural areas and implement staff transfers via incentive funding. 9. To closely work with thematic working groups established by MOH (Working group #1, #3) 25

27 Component 4. Sector capacity development and management Expected Outputs of THSDP (Ref pg 8 of RRP) Improved private sector policy and guidelines International Consultant on Private sector management Activities to undertake: 1. Review private health sector situation and develop relevant regulatory mechanisms and processes to increase private sector accountability, licensing, monitoring, and quality control. 2. Assist in developing institutionalized regulatory frameworks for the private health sector. 3. Assist in identifying and developing options for increased public-private partnerships (PPP). 4. Assist in finalizing the regulatory framework (financing from HIF, accreditation system and contract services with private entities the State budget) for public private partnerships for sharing with MOF before submitting to ADB to ensure consistency in PPP approaches across sectors. 5. Plan and implement measures to promote well balanced private and state owned health care services. National Consultant In collaboration with the international consultant the national consultant will undertake the following tasks: 1. Review private sector health sector situation and develop relevant regulatory mechanisms and processes to increase private sector accountability, licensing, monitoring and quality control. 2. Assist in developing institutionalized regulatory frameworks for the private health sector. 3. Assist in identifying and developing options for increased public-private partnerships (PPP) 4. Assist in finalizing the regulatory framework (financing from HIF, accreditation system and contract services with private entities the State budget) for public private partnerships to share with MOF before submitting to ADB to ensure consistency in PPP approaches across sectors. 5. Plan and implement measures to promote well balanced private and state owned health care services. 6. To closely work with thematic working groups established by MOH (Working group #4) 26

28 ANNEX B LIST OF ACTIVITIES, OUTPUTS AND INDICATORS Component 1. Strengthened health services 1. Improve Performance Contract 1.1 Revise and modify the current performance contract and clinical, management, quality of care and public health tasks of FGP and obtain consensus on these tasks and as requirements of a performance contract Recommendation worked out - List of recommendations covering the clinical, management, quality of care and public health tasks of FGPs - List of tasks and requirements of FGP and agreed - List of duties in the existing Job description of FGP reviewed, examined revised and then approved - Number and types of stakeholders involved in the review and approval for agreeing on the list of clinical, management, quality of care and public health tasks of FGPs - List of agreed requirements and tasks to be included in the performance contract endorsed by the PSC (Project Steering 1.2 Review and revise the performance contract format of FGP to reflect the agreed clinical, management, quality of care and public health tasks/ duties and the other relevant legal and management performance contract (PC) requirements Performance contract format revised and approved 2. Develop FGP income package that can be sustained over the long-term Committee) or MOH s Management Board - Number and types of stakeholders involved in the revision of the PC format - Official document approving the revised PC format 2.1 Examine, recommend and approve an appropriate career pathways approach as part of the income package for FGP Recommendations developed - List of Recommendations, based on main concepts underlying the use of a career pathway approach as an incentive for FGPs (and health professionals) in rural areas, made - A Career pathways approach for health professionals including principles and methods suitable for the Mongolian context defined and recommended 2.2 Identify current income package of FGP and assess it appropriateness relative to the public health sector and make recommendations 2.3 Revise and modify the income package in line with the recommendations including risk adjusted and performance based incentive system Current income package of FGP identified and assessed and recommendations made to revise the income package Revised and modified financial and non-financial risk adjusted performance based incentive system in line with review recommendations approved - Official document approving the recommendation - Number of stakeholders involved in the review of the income package including the local government representatives - Number and types of recommendations in the following areas: Recommendations for an appropriate income package for FGPs Types and levels of financial incentives to supplement the income package for the risk adjusted performance based incentive system Types and levels of non-financial incentives to supplement the income package Changes required in various laws to authorize these incentives vis-а-vis the legal amendments and revisions and changes in policies and official procedures Guidelines and procedures for operating the income package review and risk adjusted performance based incentive management system - Official document approving the recommendations for modifying and improving the income package - Official document approving the implementation of and funding for financial and non-financial risk adjusted performance based incentive system - Plan of action and budget for implementing the financial and nonfinancial risk adjusted performance based incentive system prepared - Number and types of guidelines and procedures consistent with recommendations developed for the operation of the risk adjusted performance based incentive system 27

29 3. Institutionalize budget process for FGP funding 3.1 Support the identification and listing of the health services that will provided by FGPs based on the ECPS that will be sustainably funded from the state budget for FGP via risk adjusted capitation rate FGP health care services based on the ECPS currently funded from State budget identified, listed and agreed - Review of types of FGP health services currently funded from state budget and proportion of state budget allocated to the FGPs - Official document approving the list of health services to be provided by FGPs to be funded from State budget risk adjusted capitation rate - Range and number of participants and stakeholders involved in the development of and agreement on the list of services to be provided 3.2 Support in developing the guidelines for including FGPs budgets in the annual operational plans and state budget estimate of the MoH and its various agencies and provincial health departments. 3.3 Assist in standardizing and regularizing the interaction between local government and the treasury offices in line with the PSFML to ensure timely and adequate funding and asset management for the FGP - Annual operational plans and budget estimate of the various agencies and health departments of the MoH include FGP funding -State budget sustained over the implementation period of the HSMP - Report recommending changes to the guidelines and procedures in line with the PSFWL prepared and disseminated - Revised and standardized PSFML based financial and asset management guidelines and procedures to improve timeliness and adequacy of funds, applied by FGPs in accordance with the ECPS - Number of health facility annual plans and state budgets that reflect the funding for FGPs in their area of jurisdiction - Trends in the Annual budget of the MoH over the implementation plan period showing sustainability of the state funding for the FGPs - Range and number of recommended changes to the financial guidelines and procedures to be in line with the PSFML - Official document approving the PSFML based revised and standardized financial guidelines and procedures prepared - Number of local government and treasury offices and local health agencies that are applying the PSFML based standardized financial guidelines and procedures 4. Create FGP incentive/bonus fund 4.1 Review the existing incentive system for FGP with special emphasis to retain those working in rural and remote areas and make - Recommendations for revising the incentive package for FGP made - Number of stakeholders involved in the review for incentives package for FGP - Number and types of recommendations made in the following areas: recommendations Guidelines and procedures for operating the incentive package List of appropriate incentives in line with the related law and regulations Special emphasis on FGP in the rural and remote area including conditions such as exemption from compulsory army services - Official document approving the recommendations for revising the 4.2 Assist to develop, approve implement and periodically evaluate a revised incentive package with special emphasis on the FGP stationed in rural and remote areas in line with recommendations from the review. - A revised incentives package with special emphasis on rural FGP consistent with the recommendation of the review approved and implemented - Implementation of the approved incentives package periodically evaluated and recommendations for improvement made incentives scheme - Official document approving the revised incentive package - Number of provision and conditions that emphasize the status of the rural FGPs including exemption from compulsory army service - Number of incentive package implementation guidelines and procedures that are consistent with review recommendations - Number and types of incentives in line with the related law and regulations - Number and types of incentives in the package that are in line with the recommendations 28

30 5. Develop gate keeping function of the FGPs/SHCs 5.1 Examine the current referral system to identify the problems, issues and gaps affecting the system and make recommendations for redesigning the referral system to be based on the key principles of gate-keeping and the prevention of - Recommendations for redesigning the referral system based on key principles addressing the identified problems, issues and gaps, made - Number and types of stakeholders involved in the identification of problems, issues and gaps affecting the referral system and the key principles for redesigning the referral system - List of problems, issues and gaps in the current referral system identified - List of key principles that will underline the redesign of the referral system to include at least the following: duplication of services at the Gate keeping different levels Duplication of services Rights of the client Incentives and penalties for bypassing system - Number and types of recommendations for redesigning the referral system in the following areas: Legal framework for the referral system Definition of each referral level Referral Criteria for each level Rights of the client in terms of choice, access and information - Guidelines, procedures and forms for the referral system Incentives for adhering to the referral system Penalties for bypassing the referral system Indicators for measuring effectiveness of referral system - Official document approving the recommendations for redesigning 5.2 Review the various documents related to the duties, organization and operations of the FGP/SHC system and identify the gaps and issues related to its functioning and make recommendations for formulating an integrated FGP policy to carry out the gate keeping functions Recommendations to address the identified gaps and issues for formulating an integrated PHC policy to carry out the gate keeping functions made 6. Develop clinical standards, pathways and guidelines for FGPs a sector wide referral system - Number and types of stakeholders involved in the review of the various documents related to the duties, organization and operations of the FGP/SHC system - Number and types of gaps and issues identified in the following areas: Role of the FGP/SHC as gate keepers on the service delivery continuum Funding and remuneration of the FGP/SHCs as related to gate keeping functions Organisational and legal position of the FGPs and the FGP health centers vis-а-vis the referral system Performance of the FGP/SHCs as gate keepers 6.1 Review and categorize the existing diagnostic, treatment and facility standards, clinical pathways, procedures protocols and indicators in accordance with service categories in the ECPS in a matrix form using a working group approach. Existing diagnostic, treatment and facility standards clinical pathways, procedures protocols and indicators reviewed and categorized in a matrix form - Composition of the working group that will review and categorize the existing diagnostic, treatment and facility standards, clinical pathways, procedures protocols and indicators in accordance with service categories in the ECPS - List of service categories identified from the ECPS for which guidelines and formats have to be developed - Number and types of the diagnostic, treatment and facility standards clinical pathways, procedures protocols and indicators identified in 6.2 Review and select for revision those diagnostic, treatment and facility standards, clinical pathways, procedures, protocols and indicators critical for FGPs performance using agreed selection criteria and the ECPS 6.3 Revise and approve the selected list of diagnostic, treatment and facility standards clinical pathways, procedures protocols and indicators in line with international standards while reflecting country aspects stated in the ECPS using a peer review group approach Diagnostic, treatment and facility standards, clinical pathways, procedures, protocols and indicators from the matrices selected for revision Selected diagnostic, treatment and facility standards clinical pathways, procedures protocols and indicators revised in line with international standards and local requirements revised and approved each FGP service category in matrix format - Number and types of diagnostic, treatment and facility Standards, clinical pathways, procedures protocols and indicators selected from various matrices in accordance with approved selection criteria and ECPS - List of areas in which additional standards may be required - Number of stakeholders and professional associations actively involved in the review and selection - Proportion of the peer review working groups that used the guidelines, procedures, resource materials and international standards ECPS during the revision process - Number and types of diagnostic, treatment and facility Standards clinical pathways, procedures protocols and indicators revised in line with international standards and local requirements in the ECPS - Official documents approving the revised standards in the various service areas of the ECPS 29

31 7. Clinical/Public Health training of the SHC/FGP staff 7.1 Identify the training needs of the SHC/FGP health workers consistent with their work environment and their job description and develop the training objectives to guide the extraction of the relevant content, skills and attitudes from the integrated core curriculum for FGP health workers. List of training needs and objectives for SHC/FGP health workers identified - Number and types of stakeholders involved in the identification of the training needs and objectives of the SHC/FGP health workers. - List of the SHC/FGP health workers for which the essential knowledge, skills and attitudes will be approved. - List of Job Descriptions reviewed and analyzed - List of training needs and training objectives identified in the following areas: *Clinical services /Internal medicine /Surgery /Paediatrics/ OB&GYN/ Support services / Management /Public Health /Community Mobilization - List of instructions for extracting knowledge skills and attitudes from the integrated core curriculum - Official document approving the training needs and objectives for 7.2 Assist to develop and approve the curriculum, training approaches and the basic and distance learning training materials for the in-service training program for SHC/FGP staff 7.3 Assist to develop and approve guidelines and procedures for conducting local level in-service training programs for SHC/FGPs 8. Local government staff training The curriculum, the training approaches and the basic and distance learning training materials and instructions for the inservice training program approved Guidelines and procedures for conducting local level In-service training programs approved selected cadre of FGP health workers - List of skills, knowledge and attitudes identified for the selected cadre of rural health workers in the following areas Clinical services Internal medicine Surgery Paediatrics OB&GYN Support services Management Public Health Community Mobilization Rehabilitation Health services for disabled citizens - Number and types of stakeholders involved in the approval process. - Official document approving the in-service training curriculum in terms of the Essential knowledge, skills and attitudes for cadre of rural health workers - Number and types of basic training materials for in-service training - Number and types of distance learning training materials for inservice training - List of Guidelines and procedures for conducting IST and distance learning training activities at the local level and in remote locations in at least the following areas: Selection of candidates Preparation of the trainers/supervisors Adaptation of the in-service training materials Preparation of pre and post test assessment Developing schedule for IST Logistics for conducting and IST event Assessment of the IST event Supervision checklists for assessing impact of the IST and distance learning on practice Management of the distance learning training program - Official document approving the guidelines and procedures 8.1 Assist to develop and approve the curriculum, training approaches The curriculum, the training approaches and - List of skills, knowledge and attitudes identified for the selected cadre of local government staff in the following areas and training materials for the local training materials and Referral system in clinical services government staff on collaborative instructions for the local Support services working arrangements with Family government staff training Management Doctors and Nurses program approved Public Health Community Mobilization Performance contract - Number and types of stakeholders involved in the approval process. - Official document approving the training curriculum for local government staff - Number and types of basic training materials for local government 30

32 9. Provide relevant clinical and office equipment for FGPs and SHCs staff training 9.1 Assist to conduct an infrastructure, equipment and transportation assessment of the existing FGP and SHC health facilities and identify needs to meet the MNS standards and Recommendations for meeting the infrastructure, equipment and transportation needs of the FGP/SHC health facilities in accordance with MNS - Number and types of stakeholders involved in the assessment of the infrastructure, equipment and transportation needs of the FGP/SHC health facilities. - List of the needs identified in accordance with MNS standards and FGP functions in the following areas - Infrastructure restructured SHC/FGP functions standards and FGP Renovation and make recommendations functions, made Rehabilitation Replacement - Equipment Repair Replace New items - Transportation Repair Replace Additional vehicles - Number and types of recommendations to meet the identified needs in the following areas : * Infrastructure (Renovate, Rehabilitate Replace) List of criteria for selecting a facility for renovation/ rehabilitation/replacement List of indicators for determining completion of the exercise. * Equipment (Repair, Replace, New items) List of criteria for selecting equipment for Repairing, Replacing and/or provision of New items Standardization of equipment specifications List of indicators for determining completion of the exercise *Transportation (Repair, Replace, Additional vehicles) List of criteria for selection of vehicles for Repairing, Replacing and/or provision of additional vehicles Standardization of vehicle specifications List of indicators for determining completion of the exercise - Official document approving the recommendations for developing a plan of action to provide the minimum required infrastructure, 9.2 Assist to develop and approve a plan of action to provide the minimum required infrastructure, equipment and transportation for FGP health facilities based on the recommendations Plan of action to provide the minimum required infrastructure, equipment and transportation for FGP health facilities approved equipment and transportation for FGP/SHC health facilities. - Number and types stakeholders involved in the development of the plan of action. - Proportion of the recommendations reflected in the plan of action. - Official document approving the plan of action based on the approved recommendations for providing the minimum required infrastructure, equipment and transportation for FGP health facilities consisting of at least the following components Development and approval of a Minimum package required for Infrastructure, equipment and transportation based on MNS standards and standardized specifications Determine the unit cost for a FGP health facility for providing the approved minimum package vis-a-vis the needs assessment results. Develop and/or adapt existing guidelines and procedures for the putting in place the approved minimum package for infrastructure, equipment and transportation 10. Develop model FGPs 10.1 Review the duties and functions of the restructured organisation and services of FGP in line with the ECPS and develop the required guidelines and procedures for the essential services and functions to be Guidelines and procedures (including appropriate already existing or newly developed clinical pathways) for delivering ECPS services at the restructured FGP health - Number and types of the stakeholders involved in development of the guidelines and procedures for delivering the essential services in line with the functions and duties of the restructured FGP health centers - Number and types of guidelines and procedures (including appropriate already existing or newly developed clinical pathways) developed to deliver essential services at the restructured FGP health 31

33 delivered centers developed centers in the following ECPS service components Child health Maternal Health *Communicable disease Non communicable diseases Eye care Oral Health Mental Health Health care for elderly, Health care disabled citizen - Number and types of services to be included in each of the ECPS components in the form of service clusters - Proportion of the national program activities that are included under the relevant ECPS components. - Official authorization for the application of the agreed guidelines and procedures Assist to orient/train the staff of the FGP health centers in the guidelines and procedures and related clinical pathways to deliver the agreed list of essential services using the new health center structure 11. Support for UB Health Dept FGP health Center staff oriented and trained in the application of the agreed guidelines and procedures 11.1 Assess current situation of FGP in UB city including FGP monitoring, training and development in line with institutional planning and capacity of UB City Health Department 11.2 Recommend and assist to approve action plan for FGP quality management, training and development 11.3 Assist to adapt and modify the training materials and training program for FGP already developed to the training needs of FGPs in UB city Current situation of FGP in UB city including FGP monitoring, training and development in line with institutional planning and capacity of UB City Health Department assessed Action plan for FGP quality management, training and development approved Adapted and modified training materials and training programs approved - Number and types of the stakeholders involved in the development of the orientation and training materials - Number and types of orientation and training materials developed - Number and types of the orientation and training events - Proportion of FGP health Center staff oriented and trained in the application of the agreed guidelines and procedures List of assessments of the FGP situation including SWOT analyze covering the following Quality management In- service training HRD planning Educational strategy Institutional capacity building PPP in health sector of UB city Equipment/facility support - Document approving the recommended action plan - Document approving the action plan by the City governor including: FGP quality management strategy HRD training and education Institutional capacity building PPP - Number and types of training materials and training programs adapted - Number and types of training activities for FGP carried out 12. Support for HSUM GP training 12.1 Assess the current situation Situation analysis about Situation analysis report covering the following areas: about GP training and the role of the Department of General Practice GP training and the role of the Department of General GP training including undergraduate, graduate and postgraduate training system at the Health Sciences University Practice carried out Role of GP department of HSUM of Mongolia in providing post Teaching and learning environment graduate education and training of Curriculum development family doctors Institutional capacity 12.2 Prepare recommendations for improving GP training and further developing the GP department using a capacity building approach based the findings in the situation analysis Recommendations for further developing GP training and the capacity of the HSUM GP department made and submitted to the HSUM Distance learning approach Number and types of recommendations in, at least, the following areas: GP training quality improvement in line with curriculum development Capacity building of the GP department of HSUM in terms of teaching and learning environment, staff development, curriculum development, training materials, distance education technology and approach 32

34 13. FGP advocacy for improving utilization and policy implementation 13.1 Assess current advocacy mechanisms for improving policy implementation support for FGP services within the MoH and in Mongolia and identify the needs for improving these policy implementation support mechanisms for implementing FGP policies and promoting utilization of FGP services by the local community - FGP policy implementation support advocacy mechanisms within the MoH and promoting utilization of FGP services by the local community assessed and needs for strengthening these mechanisms identified and listed - Report of the assessment - Number and types of stakeholders involved in the assessment of the FGP policy implementation support advocacy mechanisms within the MoH and promoting utilization of FGP services by the local community - Number of meetings and interviews conducted during the assessment exercise - List of documents reviewed - Number and types of feedback from relevant stakeholders (MoH divisions and departments) 13.2 Develop and implement the recommendations for strengthening advocacy mechanisms for improving policy implementation support for FGP services within the MoH and in Mongolia and promoting utilization of FGP services by the local community in response to the identified needs in the assessment carried out. prepared - Recommendations for strengthening advocacy mechanisms for improving policy implementation support for FGP services within the MoH and in Mongolia and promoting utilization of FGP services by the local community made - Action plan for implementing the recommendations prepared and approved 14. Review doctor of choice guidelines and procedures 14.1 Review current situation of doctor of choice guidelines and procedures for FGPs and make recommendations for revision and apply the revised guidelines. - Doctor of choice guidelines and procedures for FGPs recommendations for revision made - Revised Doctor of choice guidelines and procedures for FGPs applied - Number and types of the recommendation for strengthening advocacy mechanisms for improving policy implementation support for FGP services within the MoH and promoting utilization of FGP services by the local community made in the following areas: Strengthening advocacy mechanisms for FGP policy implementation support in the MoH Linkages with the referral system developing Advocacy campaigns for improving utilizations of the FGP by the local communities advocacy materials prepared for use for public information via TV, newspaper and other dissemination media - Number and types of feedback from relevant stakeholders (MoH divisions + departments, community, professional NGOs) - Official document approving the action plan for implementing the recommendations - Number and types of stakeholders involved in the situation analysis of current doctor of choice procedures - List of recommendation for revising doctor of choice guidelines and procedures in, at least, the following areas Access to information on FGPs in the client vicinity equity for clients physical access to the FGPs referral system operations registration procedures FGP Institutional capacity amendments in related legislations and regulations - Official document approving the revisions to the doctor of choice guidelines and procedures 15. Conduct a FGP Information Campaign 15.1 Assist to prepare and conduct a National Information Campaign on re-publicizing the FGP model, registration with doctor of choice and overall health reform A National Information Campaign on republicizing FGP model, registration with doctor of choice and overall health reform conducted Action plan for conducting a national campaign covering the following areas: - Strengthened FGP model, - revised registration procedures for doctor of choice; - Improved family doctor status and role; - benefits of the government s health reform agenda; - Awareness and support for ongoing health education and health promotion campaigns (e.g. healthy lifestyle programs). - Community and client education on the new referral system and its benefits and penalties 16. SHC role delineation/mapping 16.1 Analyze current situation of SHC in terms of its current role in health services and the operating institutional model and the premises, assumptions and - Situation analysis of the SHC s current role in health services and the operating institutional model and the premises, - Number and types of stakeholders involved in the development and selection of the mapping/access criteria - Number and types of mapping/access criteria in the following categories including categories/criteria already developed under the HSDP 2 33

35 mapping criteria on which this model is based and make recommendations for redelineating its future role in the health services and revising the premises and assumptions to upgrade the institutional model of the SHC 16.2 Assist to develop, approve and implement a plan of action to implement the recommendations for re-delineating SHC s future role in the health services and revising the premises and assumptions to upgrade the institutional model of the SHC restructuring the SHCs assumptions and mapping criteria on which this model is based carried out - Recommendations for redelineating SHC s future role in the health services and revising the premises and assumptions to upgrade the institutional model of the SHC made Plan of action to restructure SHCs based on the recommendations of the situation analysis implemented Distance of the client from a trained health worker a primary health care facility a referral facility Geographical location and proximity Total catchment Population Official registration with LG/FGP/Health facility Transportation, road network Communication modalities Ambulance services User charges Staff Attitudes and ethics Referral system Service mix and outreach - Official document approving the recommendations for redelineating SHC s future role in the health services and revising the premises and assumptions to upgrade the institutional model of the SHC - Approved plan of action for restructuring SHCs - Proportion of the selected SHCs that are restructured in line with the approved recommendations 17. Develop SHC admit/clinical criteria 17.1 Review the current SHC admission, treatment and referral clinical criteria in accordance with the composition of the catchment Accepted document on the review of SHC admission, treatment and referral clinical criteria - Number and type of stakeholders involved in review of SHC admission, treatment and referral clinical criteria - List of services from the SHC according to the SHC model in the following categories population and its epidemiological Preventive and promotive health services profile Curative services Rehabilitative services Diagnostic and support services -Official document approving the appropriate SHC admission, 17.2 Revise clinical standards, guidelines, clinical pathways and procedures to deliver the standardized health care services in SHC in line with the approved SHC institutional model and the recommendations from the review 18. Training/materials for SHCs staff training Clinical standards, guidelines, clinical pathways and procedures to deliver the standardized health care services in SHC revised and approved for application treatment and referral clinical criteria - Number and types of the revised clinical standards, pathways, clinical guidelines and procedures for delivering agreed standardized health care services, in the following service categories, in line with the approved SHC model Preventive and promotive health services Curative services Rehabilitative services Diagnostic and support services - Proportion of the SHC health facilities that have received the revised clinical standards, guidelines and procedures for delivering appropriate health care services. - Proportion of the SHC health facilities that have applied the revised clinical standards, guidelines and procedures for delivering appropriate health care services Assist to adapt and modify existing, and where necessary, develop training programs and materials for SHC/FGP staff with appropriate non-communicable Training programs and materials for SHC/FGP staff with appropriate public health, health promotion, clinical and - Number and types of the stakeholders involved in the development of the training programs and materials - Number and types training programs and materials developed using the adaptation guidelines and procedures including the following steps: diseases, public health, and chronic management content and List of local training needs care, health promotion, clinical and skill guides to improve Review of the training objectives management content and skill skills and practice adapted Review and updating of the content, skills and attitudes to guides to improve skills and and/or developed and reflect local context 34

36 practice approved Criteria for selection of the training approach suitable to the local context Selection of the appropriate training methods Review and revision of the training materials Structure and duration of the training program Criteria for the selection of the post graduate trainers Training environment suitable for the local context Review and revision of the assessment approach and methods linked to licensing and certification - Official document approving and authorizing the implementation of the training program and materials for SHC staff training 19. Extending PHC programs 19.1 Review and recommend for extending primary care via trials and demonstration programs Accepted recommendation made - Number and types of the stakeholders involved in the review and recommendation - List of recommendations including detailed action plan for implementing the extended primary care trials and demonstration programs - Accepted document for extending PHC programs 20. Develop referral guidelines 20.1 Examine the current referral system to identify the problems, issues and gaps affecting the system and make recommendations for redesigning the referral system Recommendations for redesigning the referral system based on key principles addressing the identified problems, issues and gaps, made - Number and types of stakeholders involved in the identification of problems, issues and gaps affecting the referral system - List of problems, issues and gaps in the referral system identified - Number and types of principles and recommendations for redesigning the referral system - Official document accepting the principles and recommendations 20.2 Assist to design the sector wide referral system based on the recommendations and main principles for an effective and responsive referral system 20.3 Assist to develop the required guidelines, procedures, criteria, forms incentives and penalties for the referral system in collaboration with various stakeholders 20.4 Assist to orient and train health facility staff at each referral health facility in the application and use of the required guidelines, procedures, criteria and forms for the referral systems 20.5 Support for conducting community and client education campaigns to inform the population of the new referral system and its benefits and penalties 21. Regular CME programs A redesigned sector wide referral system approved Guidelines, procedures, criteria, forms, incentives and penalties for the referral system developed Health staff at each referral health facility trained to use the approved guidelines, procedures, criteria, forms, incentives and penalties for the referral system. Community and client education campaigns to inform the population of the new referral system and its incentives and penalties conducted for redesigning the referral system - Number and types of stakeholder involved in the redesign of the sector-wide referral system - Official document approving the redesigned sector wide referral system - List of indicators for measuring the performance and effectiveness of the referral system. - Number and types of stakeholders involved in the development of the various management, administrative, incentives and penalties guidelines and procedures - List of management and administrative forms and formats and the related application guidelines and procedures - List of guidelines and procedures for applying the incentives and penalties - Number and types of health staff at all level health facilities trained to use the approved guidelines, procedures, criteria, forms, incentives and penalties for the referral system. - Proportion of the health referral facilities at all levels that have completed the orientation and training for the staff in their facilities - Number and types of training/orientation events conducted - Number and types of training materials developed for the training and orientation of the health staff. - Number and types of IEC and community education materials on the sector wide referral system - Number of health workers and community mobilizers oriented to the referral system to conduct IEC activities at the community level 21.1 Examine the current Continuing Medical Education (CME) programs for FGPs and SHC staff and make recommendations for further improvement Recommendations for further improvement of Continuing Medical Education (CME) programs for FGPs and SHC staff made - Number and types of stakeholders involved in making recommendations - Number and types of recommendations for improving CME programmes - Number of CME programs needing revision 35

37 21.2 Facilitate the development and revision of the Continuing Medical Education (CME) programs for FGPs and SHC staff based on the recommendations 21.3 Assist to train FGPs and soum staff using revised Continuing Medical Education (CME) programs to improve clinical skills and practice 22. Clinical rotations/training Continuing Medical Education (CME) programs for FGPs and SHC staff developed and revised Rural FGPs and soum staff trained 22.1 Conduct needs assessment to identify clinical areas where clinical rotation needed and make recommendations including selection criteria Needs assessment to identify clinical areas needed clinical rotation carried out and recommendations made 22.2 Support for selection participants for rural health workers attending clinical rotation using agreed criteria 22.3 Assist to develop schedule and instruction for attending clinical rotation for FGP and Soum health centre staff 22.4 Assist to develop short term fellowship training programs and schedule for AGH staff 22.5 Assist to strengthen existing training facilities with equipment in pilot aimag and district centers to support clinical rotation program Selection criteria for rural health workers attending clinical rotation agreed and participants selected Schedule and instruction for attending clinical rotation for FGP and Soum health centre staff developed Short term fellowship training programs and schedule for AGH staff developed Training facilities in pilot aimags and district centres to support clinical rotation program strengthened with provision of equipment - Number and types of health professionals involved in development and revision of the CME programs - Number and types of new CME programs developed - Number and types of existing CME programs revised - Number of CME training events conducted - Number and types of SHC staff involved in the CME training - Number and types of FGP staff involved in the CME training - Number and types of health professionals involved in needs assessment for determining what clinical rotations are necessary - Needs assessment report - List of clinical areas rotation needed - List of selection criteria for selecting rural health workers - Number of consensus meetings to get agreed on selection criteria - Number and types of participants selected - Number and types of stakeholders involved in development of schedule and instruction for clinical rotations - Number of consensus meetings to get agreed on schedule and instruction for these clinical rotations - Agreed schedule and instruction for clinical rotations - Number and types of stakeholders involved in development of schedule and programs for fellowship training - Agreed programs and schedule - Number of existing training facilities strengthened - Number and types of training equipment provided by training facility - Number and type of training events that used strengthened/ existing training facilities 23. Develop PHC support incentives 23.1 Examine the current mechanism for collaboration and linkage between FGPs/SHC and district/aimag general hospitals in Current mechanism for collaboration and linkage between FGPs/ SHC and district/aimag general - Number and types of stakeholders involved in examining the current collaboration mechanisms - Number and types of the recommendations for revising and improving current collaboration mechanisms in the following areas: the areas of continuing medical hospitals examined and continuing medical education (CME), education (CME), skills transfer, recommendations made skills transfer, and consultation and consultation and communication communication and make - Official document approving final assessment report with recommendations recommendations for improving the collaboration and linkage 23.2 Revise current mechanisms for collaboration and linkage between FGPs/SHC and district/aimag general hospitals using the recommendations 23.3 Provide guidelines and procedures to get technical support from AGH and District health professionals and to access journals, research and clinical guides Current mechanism for collaboration and linkage between FGPs/SHC and district/aimag general hospitals revised Guidelines and procedures to get technical support from AGH and District health professionals and to access journals, research and clinical guides provided mechanisms - Number and types of revisions made to improve collaboration and linkage between FGPs/SHC and AGH/DH in the areas of continuing medical education (CME), skills transfer, and consultation and communication - Number of consensus meetings to finalize and recommend these revisions for approval -Number and types of stakeholders involved in developing guidelines and procedures to get technical support - Number and types of the guidelines and procedures to get technical support from AGH and District health professionals and from literature 36

38 Component 2. Improved health care financing and health insurance 1. Develop review and approve national health financing model 1.1 Assist to organize series of meetings involving all relevant stakeholders including MoH, MoF, MoSWL and other donor agencies on the development of a Mongolia specific health financing model Consultative process to prepare a draft health financing model based on a revised/updated health financing policy for approval undertaken - Number and range of stakeholders involved in the development of the financing model - Number of consensus meetings conducted to on the development of the financial model - The number of elements/components of the financial model that are in line with PSFML and SWAp 1.2 Assist to develop and approve the health financing model that is based on a revised/updated health financing policy which has the agreement of all relevant stakeholders 1.3 Assist to provide the implementation basis for the agreed health financing model for improving health care financing Health Financing model based on a revised/updated health financing policy approved Health financing model implementation plan developed 2. Conduct training on implementation of a single purchaser mechanism 2.1 Assist to prepare curriculum, training materials and references for training on implementing a single purchaser mechanism Curriculum, training materials and references developed and approved 2.2 Support for training on single purchasing mechanism by a team of trainer with support from an international expert Training on implementing a Single purchasing mechanism conducted - Draft policy prepared and reviewed by stakeholders for approval Official document approving the health financing model based on a revised updated health financing policy that will include at least: Purchaser and provider functions; Unified payment system; Basis of resource allocation; Financial and budgeting system and Accounting and reporting system - Official document authorizing the implementation Health financing model implementation plan - Number and types of training materials and references for training on implementing a single purchaser mechanism - Official document approving the curriculum for training - Number of participants trained at various levels and facilities 3. Plan on health financing reform submitted to ADB to meet conditionality 3.1 Assist to notify ADB of the approved implementation action ADB notified of the approval of the Official document notifying ADB along with the approved and budgeted plan of action plan for implementing the health financing model based on an revised/updated health financing policy to meet required conditionality Implementation plan 4. Develop the single purchaser model and pooling 4.1 Assist to organize a series of meetings among stakeholders including MoH, MoF, MoSWL and other donor agencies to develop a single purchaser model and pooling Consultative process undertaken to develop a draft single purchaser model and pooling for approval - Number and range of stakeholders involved in developing the single purchaser model and pooling - The extent to which the model is in line with PSFML and SWAp and health financing model and financing policy - Draft single purchaser model and pooling prepared; and reviewed by 4.2 Assist to develop and approve single purchaser model and pooling that will be agreed to by all stakeholders 4.3 Support for monitoring implementation of new model in practice and developing contingency plan in case the new financing system is not successful Single purchaser model and pooling agreed to by all stakeholders New model carefully monitored and contingency plan developed for the new system sustainability. stakeholders for approval Official document signed by stakeholders endorsing the single purchaser model and pooling for implementation - Number and types of monitoring activities - Number of sequential meetings with stakeholders - Number of acceptable feedback from main stakeholders including MoH, MoF and MoSWL - Accepted contingency plan 37

39 5. MOH/MOF/MSWL MOU Signing on pooling and single purchaser 5.1 Prepare a MOU for establishing - MOU Prepared - draft of MOU document ready and approved by relevant single purchasing and pooling stakeholders in integration with relevant laws and regulations (e.g. 5.2 Assist to obtain approval from relevant ministries and budget agencies for implementation of the single purchaser model in integration with relevant laws, policies and regulations (e.g. PSFML) - MOU signed by relevant stakeholders 6. Trial the Single purchaser model in the pilot sites PSFML) - MOU signed 6.1 Assist to develop a plan of action for conducting single purchaser trials, including relevant materials and required training - Single purchaser trials planned - Relevant materials for the trial and training - Official document approving the plan of action to conduct trails on applying the single purchaser model 6.2 Assist to conduct the trials on implementing the single purchaser model and evaluate the results and make recommendations for scaling up developed - Training with appropriate material to prepare for the trails conducted - Single purchaser model applied in pilot aimags - Application of the single purchaser model evaluated and recommendations for scaling up made - Number and types of training events to prepare staff for the application of the single purchaser model using the appropriate materials - Proportion of the relevant staff at the pilot sites trained for application of the single purchaser model - Monitoring and Evaluation report with list of recommendations for scaling up 7. Extending the application of the single purchaser model and pooling of funding sources 7.1 Assist to implement the plan of action for applying the single purchasing model in phases nationwide based on the result of - National level independent purchasing entity established - Official document establishing independent purchasing entity approved - Guidelines and procedures for the operation of the single purchasing entity developed and refined during the trials the evaluation and recommendations and in-line with the establishment of the sector wide management structure. 8. Expand HI cover/benefit packet 8.1 Conduct a review and analysis of the current situation of the health insurance (HI) coverage and operations with special emphasis on the poor people and make recommendations for improvement - Assessment of the current health insurance situation, coverage and operations carried out - Number and types of stakeholders involved in the review - Number of meetings and interviews held during the review exercise - List of documents reviewed - Number and types of assessments meetings held - Number and types of feedback received from relevant stakeholders (MoH divisions and departments) - Number and types of recommendations in the following areas Coverage of the poor and vulnerable Operations of the HIF in terms of records, financial management, disbursement procedures, reporting and procedures guiding the routine and periodic interactions with the MoH, MoSWL and the Insurance councils - Official document approving the Review report and 8.2 Review and revise the current principles and legal framework of the HIF based on the recommendations of the review exercise - The current principles and legal framework of the HIF revised and updated in line with the approved recommendations from the review exercise recommendations for action - Number and types of stakeholders involved in the revision of the various documents related to the legal status of the HIF - Number and types of revisions made that are based on the approved recommendations to formulate an integrated HIF legal issues - List of proposed amendments to the legal framework of the HI for stakeholder approval 8.3 Develop and implement a plan of action to conduct an education and enrolment campaign to A plan of action to conduct an education and enrolment campaign to - Number/ types of incentives and linkages during the campaign to encourage coverage of uninsured population to include at the least the following: 38

40 improve overall HI coverage among the general population and with a particular emphasis on poor and vulnerable people improve overall HI coverage implemented Obtaining Civil registration Obtaining/renewal of driving license Requirement of health insurance registration as basis for eligibility for pension or other social welfare subsidy and allowance schemes - Proportion of the total population covered by health insurance - Proportion of the population under the poverty line covered by health insurance - Proportion of the specific vulnerable groups covered by health insurance - Number and type of IEC materials on importance of health insurance coverage prepared and distributed 9. HI rates and payments 9.1 Assist to review, revise, approve and implement the existing policy that governs the purpose and operations of the HIF including linkages to the state budget, the PSFML, the National Health Accounts and other accounting and management information systems - Existing health insurance policy papers reviewed revised, approved and implemented - Linkages to the state budget, the PSFML, the National Health Accounts and other accounting and management information systems in the Revised health insurance policy - Number and types of consultative meetings held to review and revise the existing HIF policy - List of suggestions and revisions clearly documented and reflected in the revised HIF policy - List of linkages to state budget, PSFML, NHA, and the accounting and financial management systems clearly stated in the revised HIF policy - Number of stakeholders that gave feedback to draft policy document 9.2 Analyse how the current OOP/co-payment amounts and mechanisms for the insured people influences obtaining health services by the poor people and make recommendations for improvement of these mechanisms to enhance equity 9.3 Assist to revise, approve and implement the OOP/co-payment mechanisms in line with revised/updated HI policy and the recommendation from the review clearly defined - Recommendations for revising the OOP/copayment amounts and payment mechanisms made in the review report - Revised co-payment amounts and payment mechanisms approved and implemented - Number of stakeholders involved in the review - Number and types of recommendations about improving the copayment amounts and payment mechanisms - Co-payment and payment mechanisms review report - Official document approving the revised co-payment and payment mechanisms - Proportion of total outpatients and inpatients that are from the poor and vulnerable groups benefiting from this revision - Proportion of the health facilities and HIF offices that are implementing the revised co-payment amounts and payment mechanisms 10. Support for raising awareness among the population, health workers and policy makers on extent and effects of financial barriers to access to health care and catastrophic payments 10.1 Review and analyze the extent of the effect financial barriers to accessing health care, out of pocket and catastrophic payments in the health sector have on people especially the poor and vulnerable people and make recommendations on mitigating these effects 10.2 Assist to develop and implement the mechanisms for mitigating the effect of financial barriers to access, out of pockets expenses and catastrophic payment through the HIF and educate the Extent of the effect financial barriers to accessing health care, out of pocket and catastrophic payments in the health sector have on people especially the poor and vulnerable people analyzed and recommendations to mitigate these effect made - Mechanisms for mitigating the effect of financial barriers to access, out of pockets expenses and catastrophic payment developed and - Number and types of stakeholders involved in the review and analysis including the clients and target populations - Number and types of analyses carried out in the following areas: financial barriers to access; out of pocket payment and catastrophic payment of various categories of people, especially the poor and vulnerable - List of effects experienced by various categories of people especially the poor and vulnerable due to these financial barriers, OOPs and catastrophic payments - Number of meetings and interviews held during review to finalize the finding and agree on the recommendations - Number and types of recommendations made and agreed with to mitigate these effects in the above mentioned areas - Official document approving the recommendations and authorizing implementation of these agreed recommendations - Number and types of mechanism out in place to mitigate the effect of financial barriers to access and effects of catastrophic payment on people - Number and types of educational activities carried out for the general population, health workers and policy maters - Number and types of the training materials and references 39

41 general population, health workers and policy makers about the these effects and the mechanisms to mitigate these effects 11. Strengthen private HI regulation implemented - The general population, health workers and policy makers educated about the effects of financial barriers and catastrophic payments and the mechanisms to mitigate these effects 11.1 Review the current regulatory framework of policies and instruments that govern the regulation of the private health insurance and make recommendations for strengthening these regulatory framework policies and instruments Current regulatory policies and instruments that govern the regulation of the private health insurance reviewed and recommendations made 11.2 Strengthen state regulation for private HI based on the recommendations of the review. Regulation of private of health insurance strengthened and coverage increased developed for and used during these educational events - Number and types of stakeholders involved in the reviews - Number and types of recommendations made on different aspect of the regulatory framework - Official document approving the review report on the regulatory framework and recommendations and authorizing their implementation - Proportion of the population covered by private health insurance agencies 12. Review constraints to hospital efficiency 12.1 Conduct a systematic review of the current hospital management systems to identify the constraints to efficiency and factors that contribute especially to financial inefficiencies and make recommendations to address these constraints including issues related to managed competition A systematic review of the current hospital management systems to identify constraints to efficiency conducted and recommendations to address these constraints made - Number and types of stakeholders involved in the review - List of documents and reports reviewed -Number and types of feedback from relevant stakeholders (MoH divisions and departments) - List of constraints to efficiency identified and categorized - List of factors contributing to inefficiencies identified and categorized Number and types of recommendations made to address each category of constraints and factors. - Official document approving the report and recommendations and authorizing their implementation 13. Develop market element options for introducing competition and contracting in the hospital sub-sector 13.1 Conduct an options analysis on a range of potential options derived from international and local experience to introduce competition, contracting and other market elements in the provision of health services in the hospital subsector to guide the review of the existing policy on managed competition Options analysis to introduce managed competition into the health care sector carried out - Number and types of stakeholders involved in the options analysis - List of reports and documents reviewed - Number and types of potential options from international and local experiences examined - Number of types of criteria developed and agreed for doing the options analysis - List of recommended options with rationale/justifications. - Official document recommending the selection options and requiring a review of the existing policy on managed competition and for developing a plan of action for implementing these recommended 13.2 Review and further develop the existing policy on managed competition based on the recommended options and develop a plan of action for implementing these options Existing policy on managed competition reviewed and revised and recommended options implemented options - Number and types of stakeholder involved in the review and revision of the existing policy on managed competition - Number and types of revisions to the policy on managed competition based on the options analysis exercise - Official document approving a plan of action and budget estimate for implementing the recommended options - Proportion of the health facilities in which these recommended options have been implemented. 14. Introduce efficiency incentives 14.1 Review the existing efficiency incentives operating in the management of the hospitals and identify the gaps and recommend various mechanisms with associated financial incentives - Efficiency incentives operating in the management of the hospitals reviewed - Efficiency gaps identified and various - Number and types of stakeholders involved in the review - List of efficiency gaps identified in the current efficiencies in the hospitals and categorized - List of recommended mechanisms and associated financial incentives including RBM for addressing these identified gaps and improving efficiency 40

42 including RBM for improving financial and management efficiencies listing criteria for selecting pilot hospitals for apply these mechanisms and incentives 14.2 Assist to develop and approve a plan of action for implementing the recommended efficiency mechanisms and financial incentives such as RBM and including organizational restructuring as appropriate in selected pilot hospitals 14.3 Assist to implement the recommended efficiency mechanisms and financial incentives such as RBM and including organizational restructuring as appropriate in selected pilot hospitals according to the plan of action and evaluate for scaling up to a national level mechanisms with associated financial incentives including RBM for improving financial and management efficiencies recommended - List of criteria for selecting hospitals as pilots for applying these incentives agreed Plan of action for implementing the recommended efficiency mechanisms and financial incentives such as RBM and including organizational restructuring as appropriate in selected pilot hospitals developed - Efficiency mechanisms and financial incentives Implemented in selected pilot hospitals - Evaluation of the implementation of the efficiency mechanisms carried out and recommendations for scaling up made. - Official document approving the recommended mechanisms and incentives for improving efficiencies in hospitals and the selection criteria - Number of stakeholder involved in the development of the plan of action for implementing the recommended efficiency mechanisms and financial incentives - Number of hospitals selected as pilot in accordance with selection criteria - Official document authorizing the plan of action for implementation - Proportion of the selected pilot hospitals implementing the efficiency mechanisms and financial incentives according to plan of action - Evaluation report of the implementation of the efficiency mechanisms and recommendations for scaling 15.Training on improved efficiency 15.1 Assist to prepare, organize and conduct a series of orientation and ongoing training events to prepare for and support the implementation of the efficiency mechanism and financial incentives for improving hospital finance management efficiency A series of orientation and ongoing training events to prepare for and support the implementation of the efficiency mechanism and financial incentives conducted - Number and type of stakeholders involved in the preparation and development of the training materials and the training of trainers - Number and type of training materials prepared - Number of master trainers trained - Number and type of orientation training conducted - Number and types of ongoing support type training conducted - Number and participants trained - Number of the pilot hospitals that have received orientation and ongoing training 41

43 Component 3. Improved human resources development 1. Develop Workforce Plan model 1.1 Assist to develop and approve a sector-wide workforce plan in line with the HRD policy and various national human resource standards (modified as needed) and international norms Sector-wide workforce plan in line with the HRD policy and various national human resource standards (modified as needed) and international norms approved - Number and type of stakeholders involved in the development of the sector-wide workforce plan - Number and types of national human resource standards that were revised and modified - Accepted evaluation/assessment for current HR component of the medical standard - Draft sector-wide Workforce plan endorsed and recommended for approval by high level HRD body. - Official document approving the sector wide workforce plan that includes at least the following: Consistency with HRD policy Plan for health sector workers training and development Plan for placement and allocation of health professionals in relation to the career pathways and development model in all levels of health care and services and by the category of specialty and subspecialty Management of Human resources Incentives Consistency with national standards and international norms List of guidelines and procedures for developing institutional workforce plans. List of guidelines and producers for reviewing and revising 1.2 Assist to develop implement and evaluate institutional workforce plans in the pilot aimags based on the sector-wide workforce plan to manage local human resources and reduce distribution disparities and make recommendations for scaling up - Local Human resources managed and disparities reduced through implementing institutional workforce plans in pilot aimags - Implementation of local workforce plan evaluated and recommendations for scaling up made 2. HR training in pilot areas 2.1 Assist to revise and develop material and references to aimag training in HR management and organizational development 2.2 Assist to conduct training for trainers in HR management in terms of capacity building in teaching and learning environment, curriculum development Training materials and references to aimag training in HR management and organizational development revised and developed HR management trainers trained and training capacity built national human resources standards and norms - Proportion of institutions which developed workforce plans in conformity with the sector-wide workforce plan and the revised standards and norms - Proportion of the institutions that are staffed in accordance with their institutional workforce plans - Proportion of the institutions that are reporting reduction in staffing disparities at their level - Proportion of the institutions that have human resource management and development units - Number of institutions that make recommendations for revision of selected national standards and norms - Number of recommendations in the evaluation report for scaling up local workforce planning nation-wide - Number and types of stakeholders involved in the development training materials and references for workforce planning, HR management and organizational development - Number and types of training materials and references for the above mentioned areas developed and approved - List of training skills and standards for HR trainers including: teaching and learning environment with required facilities, methodology and placement faculty staff trainees selection curriculum development extent of funding/expenditure - Number of training events for trainers - Proportion of the HR managers who have been trained as trainers in HR management 3. Support long term fellowships 3.1 Assist to develop and approve selection criteria and procedures for candidates in pilot areas for - Selection criteria and procedures developed and approved - Number and types of selection criteria developed and approved - Proportion of the candidates selected using the approved selection criteria and procedures 42

44 long term fellowship training and use these for selecting candidates - Long-term fellowship candidates selected by using approved selection criteria and procedures 4. Support High Level HR Committee in line with the HR strategies in the Implementation Framework of the HSMP 4.1 Review and identify priorities and support areas of the existing high level HR committee to plan that are consistent with the Implementation Framework of the HSMP to guide the implementation of the human resource development policy and HSMP strategies by the MoH. 4.2 Assist to develop and implement a plan of action for supporting the approved priorities of the High level committee in accordance with the official document approving these priorities Priorities that are consistent with the Implementation Framework of the HSMP to guide the implementation of the human resource development policy and HSMP strategies by the MoH of the current high level HR Committee identified and supported Plan of action for supporting the approved priorities of the High level committee in accordance with the official document approving these priorities implemented 5. Options for FM specialty structure 5.1 Revise, assess and recommend current medical curriculum in medical education institutions for preparing family group practitioners as a specialist medical training Current medical curriculum in medical education institutions for preparing family group practitioners as a specialist medical training assessed and revisions recommended - Number and types of stakeholders involved in the review and selection of the HR priorities for the High level committee to guide the MoH HR management - Number and types of the legal and policy framework documents reviewed - Number and types of priorities consistent with the HR policy and HSMP strategies identified in line with the following areas: *Functions training, recruitment deployment, career development, HRD Database development Incentives package Performance evaluation (Job Descriptions) Licensing Workforce planning and norms HRD research Ethics - Official document approving the priorities of the high level HRD committee for guiding the implementation of HR management by the MoH. - Number and types of stakeholders involved in the development of the plan of action to support the approved priorities - Number of priorities included in the plan of action - Proportion of the priorities actually implemented in accordance with the Action plan that are in line with the HR policy and implementation Framework of the HSMP. Number and types of HR policies and HSMP strategies implemented as a result of the support to the High level HR committee. - Number and types of stakeholders involved in the review of the medical curriculum for FM training. - Number and types of the job description and curriculum and related documents reviewed - Number and type of revisions to the curriculum proposed in the following areas: *Functions entrance requirements job description career development, Evaluation (Grading system) Licensing Incentives *Structure Curriculum standard and content Teaching and learning environment Number and quality of training institution Organizational structure linked to the FGP education system *Organization Linkage with the health and education sector Development of regulatory mechanism of institutionalized postgraduate training system of FGP - Official document approving the recommendation and revisions of the curriculum based on the functions structure and authority of the training institutions consistent with the legal and policy framework 43

45 5.2 Assist to upgrade and develop training standard and curriculum for family medicine that are essential to be demonstrated by FGP in relation to changing health needs 5.3 Assist to develop the professional training database of FGP of the integrated HR database for monitoring CE and IST plans 5.4 Assist to develop guidelines for accreditation for FGP training institutions Training standards and curriculum for family medicine Developed and approved The professional training database of FGP integrated HR database Developed Guidelines for accreditation of FGP training institutions developed and approved - Number and types of stakeholders involved in the development of the curriculum and implementation guidelines and procedures - List of curriculum implementation guidelines and procedures covering the following steps of the curriculum development and adaptation process. List of local training needs Review of the training objectives in light of the local training needs Review and updating of the content, skills and attitudes to reflect local context Criteria for selection of the training approach suitable to the local context Selection of the appropriate training methods Review and revision of the training materials Structure and duration of the training program Criteria for the selection of the post graduate trainers Training environment suitable for the local context Review and revision of the assessment approach and methods linked to licensing and certification - Official document approving the curriculum adaptation guidelines and procedures and funding their application to revise and develop the FM curriculum - Number of stakeholders involved in the design and structure of the database - Official document approving the design and establishment of the professional training database component of the HR Database including at least the following fields: Post graduate training /types/: Residential, Overseas, Seminar, International conferences, Others In-service training /types/: Online, regular on the job training, periodic training for CE credits, training during emergencies, new program orientation, others Distance learning /types/: Telemedicine, Online/ Internet, Post based, Others -Training related data items Duration of training Disciplines Level of training Type of health professional attending Selection criteria Curricula used Training approaches Training methods Types of training materials Assessment Grades Scheduled events Funding sources - List of software linkages with the other database components of the integrated HR database. - Guidelines and procedures for managing the professional training database - Number and types of stakeholders involved in development of guidelines for accreditation for FGP training institutions - Number and types of guidelines for accreditation of FGP training institutions including criteria such as: Number and types of educational institutions at the national level in line with HR policy and planning Experience of the institutions Organizational technical capacity Teaching and learning environment Teaching staff Student number and success Curriculum development Evaluation system 44

46 5.5 Assist to orient the post graduate medical education institutions and training agencies to the curriculum adaptation guidelines and procedures of FGP - Post graduate medical education institutions and training agencies oriented to the curriculum adaptation guidelines and procedures 6. Training incentives/subsidies 6.1 Assist to develop policy document on training incentives/subsidies mechanism for rural and remote area medical practitioners and increase capacity of the training fund 6.2 Review and develop training incentives and subsidies for places in training schools to increase rural health staff numbers 7. HR incentive packages Policy document to promote training incentives/subsidies mechanism for rural and remote area medical practitioner and increase capacity of the training fund Developed and approved Training incentives and subsidies for places in training schools to increase rural health staff numbers developed and approved - Number of orientation events on curriculum adaptation for medical education institutions and training agencies - Proportion of the post graduate medical education institutions and training agencies oriented. - List of orientation training materials developed - Document describing the content and structure of the orientation program - Number and types of stakeholders involved in development of policy document - Approved policy document in training incentives/subsidies mechanism for rural and remote area medical practitioner - Number of places reserved in medical schools and colleges for rural health staff for further education - Number of scholarships set aside for rural health workers for further education in medical colleges and schools 7.1 Assess the current financial and non financial staff incentive system to identify legal changes and system modifications needed Improvement and modifications to current financial and nonfinancial staff incentive - Number of stakeholders involved in the review of the financial and non-financial staff incentive system including local government representatives - Number and types of recommendations in the following areas to improve the system and make system recommended Guidelines and procedures for operating the system recommendations Local government and other funding sources Types and levels of financial incentives Types and levels of non-financial incentives Legal changes required in various laws Revisions and changes in polices and official documents Participation of community based organizations and NGOs - Official document approving the recommendations for modifying and 7.2 Revise and modify the incentives system in line with the recommendations including mechanisms for support from local government and obtain approval from HR high level committee 7.3 Assist to orient the local government and health agencies about the revised and approved financial and non-financial system including funding sources, intersectoral collaboration, local support, NGOs and community participation to prepare for its implementation Revised and modified financial and nonfinancial incentive system in line with review recommendations approved Local government community based organizations and health agencies especially in the rural areas mobilized and prepared to implement the financial and nonfinancial incentive system. improving the incentives system - Official document approving the implementation of and funding for financial and non-financial incentive system. - Plan of action and budget for implementing the financial and nonfinancial incentive system prepared. - Number and types of guidelines and procedures consistent with the recommendations - Proportion of the local governments and health facilities that received orientation and were mobilized - Range of training materials developed based on the guidelines and procedures for the orientation and mobilization for implementing the incentives package - Number and types of community based organizations and government agencies involved in mobilizing resources for the operation of the incentives scheme. 45

47 Component 4. Sector capacity development and management 1. Review Private Sector 1.1 Review private health sector situation and develop recommendations to improve the relevant regulatory mechanisms and processes to improve private sector accountability, licensing, monitoring and quality control Current situation of private health sector in assessed and recommendations made 1.2 Assess the current status of the PPP policy and its implementation in the health sector and make recommendations to improve the public private mix involving stakeholders and appropriate participants in situation analysis of PPP to be reflected in the revised PPP policy - Assist to obtain official approval for the recommendations Policy and guidelines on PPP developed and approved - Number and type of stakeholders/participants involved in the situation analysis of private sector regulatory framework including the current status of the PPP - Number and type of recommendations made - Official document approving the recommendations to be reflected in private health sector regulation policy - Number and types of stakeholders represented on the PPP working group. - Number and types of consultative meetings conducted in the process of developing and obtaining consensus on the policy elements and guidelines for PPP - Number and types of stakeholders participating in consultative meetings - Official document approving the recommendations for revising and updating the PPP policy and its implementation in the following areas: Legal framework Appropriate representation on relevant decision making bodies Range of services to be provided Authority for accreditation and licensing, Monitoring performance and maintenance of quality Management, legal and appropriate financial support to the providers in the private sector 2. Develop Regulatory Mechanisms 2.1 Assess the appropriateness of the current legal and financial regulatory mechanisms governing the private sector providers and make recommendations consistent with guidelines and mechanisms proposed in the quality of care, Recommendations, consistent with quality of care, health financing and PPP policies and guidelines, for improving the existing legal and financial regulatory - Number and types of stakeholders involved in the assessment of the current private sector legal and financial regulatory mechanisms in line with the relevant policies and procedural documents - Number and types of recommendations made - Official document approving the recommendations for revising the private sector legal and financial regulatory mechanisms in the following areas: health financing policy and the mechanisms for the Licensing and accreditation of private sector providers PPP policy and guidelines private sector made Criteria for subsidizing private sector providers Legal and tax status of private sector providers subsidized by the public sector Criteria for eligibility for HIF funding 2.2 Revise the existing private sector legal and financial regulatory mechanisms and the related guidelines and procedures in line with the recommendations. 2.3 Assist to implement the approved private sector legal and financial regulatory mechanisms Existing private sector legal and financial regulatory mechanisms and their guidelines and procedures revised. The approved legal and financial regulatory mechanisms for the private sector implemented. Reporting of performance, quality of care and financial data - Proportion of the approved recommendations used for the revision of the private sector regulatory mechanisms - List of the private sector legal and financial regulatory mechanisms that were revised along with their guidelines and procedures. - Official document approving the revised private sector legal and financial regulatory mechanisms and the related guidelines and procedures - Proportion of the private sector providers whose license and accreditation are periodically reviewed in accordance with the revised legal and financial regulatory guidelines and procedures - Proportion of the private sector providers eligible for HIF funding - Proportion of the private sector providers that actually receive HIF funding - Proportion of the private sector providers that routinely report performance, quality of care and financial data in accordance with the regulatory requirements using the prescribed formats. 46

48 3. Establish regulatory PPP Framework 3.1 Assist to implement PPP Policy and guidelines to achieve an optimal public private mix of services using the following steps: - Apply the officially approved legal framework for PPP - Obtain official approval for the Composition and ToR for a PPP oversight body - Release to the private sector a list of approved public sector services that could be provided by the private sector PPP policy and guidelines implemented - Official document approving the required legal framework for PPP - Official document approving the Composition and ToR of a PPP oversight body - Proportion of the private sector providers that have the approved list of types of approved public sector services that could be provided by the private sector - Proportion of the authorized private sector providers that are providing approved public sector health services - Proportion of the private sector providers that are accredited and licensed in accordance with the revised guidelines and procedures - Proportion of the Private sector providers that regularly submit performance and quality reports in accordance with the prescribed formats - Authorize appropriate private sector providers to provide approved public health sector services - Apply the list of mutually agreed indicators and mechanisms for monitoring performance and maintenance of quality - Review the reporting system of private sector providers and the frequency of performance and quality reports in accordance with the prescribed formats 4. Promote Implementation of PPP using appropriate privatization arrangements/options 4.1 Assist to implement PPP policy and guidelines to achieve an optimal public private mix of services. List of public health facilities to be privatized and/or contracted out approved - Number and types of criteria used for selection the public health facilities consistent with the policy and its guidelines and procedures. - Number and types of criteria used for selection the public health facilities consistent with the policy and its guidelines and procedures. - Number and types of consultative meetings held in the selection and endorsement of the public facilities to be privatized/ contracted out - Official document approving the list of public health facilities for 4.2. Assist to formulate and implement the privatization policy and guidelines for privatizing and/or contracting in/out selected public sector health facilities. List of eligible public health services to be contracted in or out approved privatization and/or contracting out - Number and types of criteria used for selection the public health facilities consistent with the policy and its guidelines and procedures. - Number and types of criteria used for selection the public health facilities consistent with the policy and its guidelines and procedures. - Number and types of consultative meetings held in the selection and endorsement of the public facilities to be privatized/ contracted out - Official document approving the list of public health facilities for privatization and/or contracting out in line with the policy. 47

49 ANNEX C AGREED LIST OF DELIVERABLES 1. Revised and developed Performance Contract of FGPs Approval of revised performance contract of FGPs 2 Recommendation for income package for FGPs Recommendation for performance based incentive systems for FGPs 3 Report on establishment a risk-adjusted capitation process for FGPs and SHCs to ensure adequate remuneration and incentives to carry out primary level health services 4 Recommendation for re-designing the referral system Guidelines, procedures, forms, incentives and penalties for referral system Recommendation to strengthen gate-keeping function of FGPs and SHCs 5 Methodology for clinical guidelines development Selected clinical guidelines revised in accordance with international standards Admission, treatment and referral clinical criteria by the end of 2009 By first quarter 2010 by first quarter of 2010 First quarter of 2010 by the end of 2010 by the end of Equipment needs assessment for FGPs and SHCs by the end of Knowledge, skills, attitudes and practices of general practitioners reviewed and defined Training needs assessment, for FGPs and SHCs health workers Guidelines and procedures for conducting in-service training and distance learning activities at the local level Curriculum, training modules and training materials for undergraduate, postgraduate and in-service training CME and clinical rotation program for SHC staff 8 Advocacy strategy and action plan is developed for national information campaign on PHC reform 9 Recommendation for re-delineating SHC s future role in health services and restructuring of SHCs Priorities and core activities of SHCs 10 Results and impact of implementing the extended primary care trials and demonstration programs at SHCs 11 New Health care Financing model developed and approved Plan for main financial reform to be introduced in the health sector developed and approved 12 Agreement on fund pooling mechanisms and single purchaser for financing the health care signed by all stakeholders by the end of 2010 by the end of 2010 by the end of 2009 by the end of 2011 by mid 2010 by the end of

50 Report on implementation and results of the piloting of pooling of funds and single purchaser mechanisms 13 Policy recommendations (strategy paper) on overall Health Insurance policy, coverage and benefit packages Recommendation on out-of-pocket, copayments and payment mechanisms 14 Recommendation on mechanisms for mitigating the effect of financial barriers to access, out-of-pocket expenses and catastrophic payments 15 Recommendation on policy and legislative framework governing private health insurance 16 Recommendation on improving hospital efficiency Report on implementation and results of efficiency mechanisms in pilot hospitals 17 Sector-wide workforce plan developed and approved Report on implementation and evaluation of workforce plan in selected aimags 18 Recommendation on training materials and references in HR management and organizational development Recommendation for a residency programme on family medicine, training modules and materials 19 Policy paper (documentation)to promote training incentives or subsidies mechanisms for rural area medical staff Plan of action for implementing the new training-incentive system 20 Recommendation on improved legal and financial regulatory systems for the private sector Recommendations on new policy and guidelines on PPP by the end of 2012 by mid 2010 by mid 2010 by the end of 2010 First half of 2010 by the end of 2010 by the end of 2012 by the end of 2010 by the end of 2012 by the end of 2010 by the end of 2010 by the end of 2010 by the end of 2010 First half of 2010 First half of

51 ANNEX D PROJECT TEAM Position Tasks / Expertise Name of Expert Assignment Component 1. Strengthened health services International Consultant for Component 1 / Team Leader National Consultant / Deputy Team Leader A) Family group practice B) Soum Health Centres and primary health care C) Hospital support for primary health care Soum Health Centres and primary health care Mr Kees Schaapveld Ms Byambaa Batsereedene 17 months field 4 months home 48 months National Consultant Family group practice Ms Tovuu Navchaa 36 months National Consultant National Consultant Soum Health Centres and primary health care Hospital support for primary health care Mr Orgil Bunijav Mr Avirmed Bayar Component 2. Improved health care financing and health insurance International Consultant National Consultant A) Health care financing and modelling B) Health insurance system Health care financing and modelling Mr Soonman Kwon Mr Natsagdorj Tserendorj 24 months 7 months 8 months field 3 months home 30 months National Consultant Health insurance system Ms Kainyam Tungalag 18 months Component 3. Improved human resources development International Consultant National Consultant National Consultant Human resources management and organizational development Human resources management, incentives and organizational development (1 st Position) Human resources management, incentives and organizational development (2 nd Position) Mr Philip John Constable Ms Dulamsuren Samdan Component 4. Sector capacity development and management International Consultant 6 months 18 months Ms Otgonbayar Radnaa 18 months Private sector management Mr Hernan Fuenzalida 3 months National Consultant Private sector management Mr Batsaikhan Zagdragchaa 11 months 50

52 ANNEX E OVERVIEW OF MEETINGS AND VISITS DURING INCEPTION PERIOD 7 August: Arrival Kees Schaapveld. 10 August: Mr Enkhbat (MOH); 1st team meeting; Ms Bayart (MOH) 11 August: Ms Otgonjargal (MOH); Ms Tsolmon (MOH); Ms Yanjmaa (MOH); UB Health Department 12 August: Mr Tumendemberel (MOH); Mongolian Association of Family Clinics; Mr Enkhbat (MOH) 13 August: 1 polyclinic, 2 FGPs and 1 district hospital in the two pilot districts of UB; VSO team 14 August: 2 nd team meeting August: Field trip Dondgovi: 1 inter-sum hospital, 1 sum hospital, aimag Health Department, 1 FGP, aimag hospital, deputy-governor 18 August: Working Group PHC; Ms. Otgonjargal (MOH); Mr. Otgonbaatar (MOH); Ms. Tumurbat (MOH); Mr. Nymaa (Ministry of Finance) 19 August: Mr I. Narula (JICWELS); Mr Y. Mazumder (Unicef); Mr W. Rojanapithayakorn (WHO); Mr Otgonhundaga (Ministry of Social Welfare & Labour); Mr Bishindee (SSIGO); Ms. Tungalag (Chingeltei District Public Hospital); Ms Tsolmongerel, Ms. Bulganchimeg and Ms. Erdenechimeg (Project on Strengthening intersectorial cooperation capacity to improve health insurance in Mongolia. GTZ); Ms Erdenetuya (MOH) 20 August: UNFPA team; Mr Takahiro Ishizaki and Ms Kato Yoshiko (Japan embassy); Ms. Enhjin (MOH) 21 August: Arrival Phil Constable; interviews with applicants; 3 rd team meeting 22 August: Interviews with applicants 24 August: Dept. of Human Resources (MOH); Ms Evlegsuren, Ms Tsatsral, Ms Bayarmaa, Mr Battulga (MOH) 25 August: Ms Bayarmaa (ADB); Mr Munkhtaivan (MCA); Mr Sodnompil, Ms Avirmed, Ms Narangerel, Ms Nyamkhorol, Ms Baigalmaa, Ms Enkhtuya (Implementing Agency, Dept. of Health); Mr P. Finch and Mr G. Sheridan (VSO); arrival Soonman Kwon 26 August: Interministerial working group on amendments to the health insurance law; MCA-EPOS team; Mr. Amarsaikhan, Mr Altaisaikhan (Health Sciences University) 27 August: 4 th team meeting; Working Group Health Financing 31 August: Ms Nyamkhorol and Ms Gamchimeg (Dept. of Health); Ms Gankhuu, Ms oyunbileg, and Mr Munkhsuld (Ulaan Baatar City Health Dept.) 1 September: Ms Odontuya (Health Sciences University, Dept. of Family Medicine); Mr Lambaa (Minister of Health); Mr Tseredagva and Ms Bandi Solongo (Health Sciences University) 2 September: THSDP Steering Committee; team meeting; Ms Ayush (chair of Interministerial Working Group) and other MOSWL staff ( workshop on health financing models) 51

53 3 September: Departure Kees Schaapveld 4 September: Human Resources Working Group (MOH); workshop on health financing models and private health insurance, attended by MOH (Mr Lambaa, Ms Tsolmon, Mr Batsaikhan, and all advisors and directors) and Ministry of Finance (Mr Batjargal, director Budget Policy dept.) 6 September: Departure Phil Constable 8 September: Departure Soonman Kwon 52

54 ANNEX F DEFINITIONS The term of Primary Health Care (PHC) has been coined at the Alma-Ata (now Almaty) conference organised by the World Health Organisation in It is defined as essential health care based on practical, scientifically sound and socially accepted methods and technology, made universally available to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. Such a lofty definition does not easily explain what services are included here. Since Alma-Ata, no international consensus has been developed on how PHC facilities should be organised and which PHC services they should deliver. PHC and primary care are often used as equivalents, but they are not. Primary care is more limited, but then PHC is more an ideal then a reality. Primary care services can be defined as the preventive and curative services delivered by providers who are accessible without referral. According to the situation on the ground, this can mean anything in between the old Semashko situation and a new situation with general practitioners and allied services. It does not include secondary care, either specialist ambulatory care or inpatient care. It should be realised, however, that other services such as pharmacies, dentists and midwives are also part of primary care. In many western and transition countries, primary care has become more or less understood as general practice or family medicine, which is characterised by the key-words: accessibility, comprehensiveness, patient-centeredness, co-ordination and continuity. General practice or family medicine services are provided by teams of family doctors and family nurses. Family medicine is a medical specialisation which in most western countries lasts three years after graduation from medical school. In some countries such as the United Kingdom, family medicine is called general practice. This sometimes leads to confusion in transition countries where a general practitioner may be understood as a (basic) physician who has completed his or her 6 years of medical school. In Mongolia, such basic physicians are often employed as doctors responsible for primary care, but they are not qualified as family physicians and they should not be labelled as such. Nearly all transition countries are strengthening first-level services at the expense of secondary care, by having a family physician as the key provider in primary care who can offer comprehensive and continuous care to a circumscribed number of citizens who preferably have enrolled themselves with that doctor. Most countries have implemented projects in this field, some with remarkable success. However, developing new training curricula, retraining large numbers of existing staff, providing the material base for family medicine, and changing the mind of citizens and professionals will be a long-term effort. Post-graduate training and re-training in family medicine is at first often limited to one year, with a long-time vision of expansion to two or three years. Strong primary care is seen as a solution against overuse of expensive and unnecessary specialist care, but also as a means to improve the quality of care by providing personalised, comprehensive and continuous care to citizens that have selected their own family physician. An important function of family medicine is gate keeping. This means that access to narrow specialists is restricted to those with a referral letter from their personal family doctor. Family doctors will refer those patients whose pathology is too complex to diagnose and/or treat at the primary level. In countries with well-established family medicine, the referral rate is 53

55 approximately 10%. In transition countries with emerging family medicine this could be 20-25% but this percentage should decrease gradually. Narrow specialists provide services with a specific skill (e.g. surgery, anaesthesiology) or for a specific organ (e.g. ophthalmology, dermatology) or type of disease (e.g. psychiatry, tuberculosis) or age category (e.g. paediatrics, geriatrics). They work at secondary or tertiary level, for ambulatory patients and for inpatients. Narrow specialist care is usually divided into secondary and tertiary level, although the difference is arbitrary to some extent. Tertiary care is more complex, requires more sophisticated equipment, and is often also used for teaching and research purposes. Secondary and tertiary care can be provided as both outpatient and inpatient services. Under the Semashko system, outpatient narrow specialist services were usually provided in a separate institution from inpatient services, often also at a different location. This is not efficient, because laboratories and equipment cannot be shared, and specialists in outpatient care lose their skills in inpatient care. A hospital is an institution where patients who cannot be treated in an ambulatory setting (at either primary or secondary level) receive constant nursing care and hotel services while they undergo medical therapy by narrow specialists. The more complex nature of the pathology of these patients requires equipment for diagnostics and treatment at a certain level of sophistication, such as a laboratory and an operation theatre. Hospitals can be specialised in a single type of disease, skill, or age category, either at secondary or tertiary level. In transition countries one often finds such hospitals: paediatric hospital, cardiology hospital, tuberculosis hospital, etc. However, it is more efficient to operate general hospitals where all or most specialities are available. In small community/provincial general hospitals, at least the basic specialties of paediatrics, obstetrics/gynaecology, surgery and internal medicine should be present. It is doubtful if a small hospital without narrow specialists and without a minimum of technical tools can be considered a viable option. In remote areas, one could envisage health centres with family doctors and a few observation beds, and a possibility to evacuate more serious patients to a provincial hospital. 54

56 ANNEX G BASELINE DATA REQUIREMENTS Component 1 For each of the pilot districts and aimags: demographic data list of health facilities: primary, secondary and tertiary care, public and private number, type and age of staff in FGPs and Sum hospitals/health centres number of activities (consultations, admissions, deliveries, etc.) 2008 and 2009 public budgets for health services per district/aimag (primary/secondary) patient satisfaction rate referral rate to secondary and tertiary level type and number of equipment at Family Group Practices number and percentage of staff who have received CME training for the last 5 years number, and type of clinical standards, pathways and guidelines for Family Group Practices number of performance indicators, performance rate staff turn over rate Component 2 health expenditure data National Health Accounts data including all sources of financing government health expenditure as % of Public Expenditure on Health social health insurance expenditure as % of Public Expenditure on Health health expenditure on primary health care as % of Public Expenditure on Health primary health care expenditure per capita (tugriks) government subsidy to the Health Insurance Fund as % of the Health Insurance Fund total income health insurance coverage data by population groups health insurance expenditure by type of services household composition including size, each member age sex, education occupation, percentage of poor population percentage of specific population groups (e.g. nomads) utilisation of health services by population groups and households (different socioeconomic groups) health insurance status and cost by household members out-of-pocket expenses by population groups and households catastrophic expenditure data by household members 55

57 pharmaceuticals: utilisation and payment costing data of hospitals Component 3 all health sector staff, as in table 34 of the Synthesis Report but updated to as recently as possible an age distribution for each type of health care profess a list of stakeholders all the above for pilot aimags approved human resource standards for Mongolia, both numerical and definitions/job descriptions Health Sector Human Resource Development Policy a) and b) draft update. estimates of population growth by year and by gender, next 10 years. epidemiological projections, next 10 years. list of public and private educational establishments and their enrolments existing training incentives 56

58 ANNEX H PLANNED USE OF CONSULTANTS PERSON-MONTHS, Aug-Dec st Q nd Q rd Q th Q Kees Schaapveld (Mongolia + home) B. Batsereedene B. Orgil T. Navchaa A. Bayar Soonman Kwon (Mongolia + home) (home) (home) Ts. Natsagdorj K. Tungalag Phil Constable R. Otgonbayar S. Dulamsuren Hernan Fuenzalida Z. Batsaikhan

59 PLANNED USE OF CONSULTANTS PERSON-MONTHS, 2009 August September October November December total 2009 Kees Schaapveld (Mongolia + home) B. Batsereedene B. Orgil T. Navchaa A. Bayar Soonman Kwon (home) (home) Ts. Natsagdorj K. Tungalag Phil Constable R. Otgonbayar S. Dulamsuren Hernan Fuenzalida Z. Batsaikhan

60 ANNEX I INDICATIVE TIME SCHEDULE FOR THE ACTIVITIES OF THE 4 COMPONENTS (Component 4 not yet included) quarter: activity: component

61 quarter: activity: component component component