How To Improve Health Care In Mongolia

Transcription

1 Health Metrics Network Ministry of Health, Mongolia Mongolia Health Information System: Assessment Report March 2008 Ulaanbaatar, Mongolia

2 This report was prepared by the Department of Information, Monitoring and Evaluation, Ministry of Health, Mongolia in collaboration with Dr Tugsdelger Sovd, local consultant for HMN assessment. Edited by: Tugsdelger Sovd, MD, MPH Enkhbold Sereenen, MD, MPH Developed by: Tugsdelger Sovd, MD, MPH Oyuntsetseg Purev, MD Khongorzul Byambajav, MPH Enkhbold Sereenen, MD, MPH Bazarkhurel Gankhuyag 2008, Ulaanbaatar 1

3 List of acronyms Acknowledgement Table of contents Chapter I. Introduction: 1.1 Country Profile Demographics Political situation Socio-economic situation 1.2 Health situation and trends Epidemiological transition Outbreaks of communicable diseases Maternal, child and infant diseases 1.3 Health system Mission and strategic objectives of the Ministry of Health Organization of health services and delivery system Health policy planning and regulation framework Health care financing Human recourses for health Partnership 1.4 Health information system 1.5 How was the Health Information System Assessment done? Chapter II. Findings of Health Information System Assessment 2.1. Resources Policy and planning HIS institutions, human resources and financing HIS infrastructure 2.2 Indicators 2.3 Data source Census 2

4 2.3.2 Vital statistics Population-based surveys Health and disease records Health service records Administrative records 2.4 Data management 2.5 Information products Health status indicators Health system indicators Risk factor indicators 2.6 Dissemination and use Analysis and use of information Policy and advocacy Planning and priority setting Resource allocation Implementation Chapter III. Discussion and recommendations 3.1. Resources Policy and planning HIS institutions, human resources and financing HIS infrastructure 3.2 Indicators 3.3 Data source Census Vital statistics Population-based surveys Health and disease records Health service records Administrative records 3.4 Data management 3.5 Information products 3.6 Dissemination and use 3

5 References Organizational structure of Ministry of Health of Mongolia List of the assessment participants 4

6 LIST OF ACRONYMS ADB CRIC CSC DFE DHPP DIME DOTS DMS FGD FGP GAVI GDP GPS HIF HIS HMN HMIS HSMP HSU HSUM ICT ICD IMCI IT MICS MMR MOH MOF MISC MDG MSWL NSO Asian Development Bank Civil Registration and Information Center Civil Service Commission Department of Finance and Economics Department of Health Policy and Planning Department of Information, Monitoring and Evaluation Directly Observed Treatment and Surveillance Department of Medical Services Focus Group Discussion Family Group Practice Global Alliance for Vaccines and Immunization Gross Domestic Product Global Positioning Satellite Health Insurance Fund Health Information System Health Metrics Network Health Management Information System Health Sector Maser Plan Health Statistics Unity Health Sciences University of Mongolia Information Communication Technology International Classification of Diseases Integrated Management of Child illness Information Technology Multiple Indicator Cluster Survey Maternal Mortality Ratio Ministry of Health Ministry of Finance Multiple Indicator Cluster Survey Millennium Development Goals Ministry of Social Welfare and Labor National Statistical Office 5

7 NCCD NCD NCHD NHA NPHI PTRC STI TB UNFPA UNICEF WHO National Center for Communicable Diseases Non-Communicable Disease National Center for Health Development National Health Accounts National Public Health Institute Population Training and Research Centre Sexually Transmitted Infection Tuberculosis United Nations Population Fund United Nations Children s Fund World Health Organization 6

8 ACKNOWLEDGEMENT We would like to thank the Health Metrics Network (HMN) for its invaluable technical and financial support in conducting the current assessment. Special thanks to the health managers, health information officers and statisticians from Ministry of Health (MOH), Ministry of Social Welfare and Labor (MSWL), National Center for Health Development (NCHD), National Statistical Office (NSO), Civil Registration and Information Center (CRIC), National Public Health Institute (NPHI), Information Technology Agency of the Government of Mongolia, Health Sciences University of Mongolia (HSUM), aimag and city health organizations as well as international partners including WHO, ADB and UNFPA for their valuable time and intellectual contribution to the assessment. Your recommendations will be of great importance to the development of HMIS in Mongolia. We would also like to express our gratitude to the HMN consultants Ms Churnrurtai Kanchanachitra and Dr. Rohan Jayasuriya and domestic consultant Dr. Tugsdelger Sovd, for their technical assistance in conducting the assessment. 7

9 I. INTRODUCTION 1.1 COUNTRY PROFILE Demographics Situated in the Central Asia, Mongolia is a landlocked country between the Russian Federation to the north and the People s Republic of China to the south. It is the fifth largest country in Asia with a total area of 1,565 million square kilometers. In 2007, the population of Mongolia reached million, and the overall population density was 1.7 persons per square km, making it the least densely populated country in the world. The population is predominantly young. Children and youth under 15 years of age account for 28.9 percent of the population, while people aged 65 years and above account for only 4.1 percent of the population. The remaining 67.0 percent is between 15 to 64 years of age. Of the total population, 61.0 percent is urban and 39.0 percent is rural. Males comprise 48.7 percent of the total population. The adult literacy rate is reported as 97.80% (NCHD, 2007). Since 1990, Mongolia has been undergoing a demographic transition defined by reduction in fertility and death rates, and increase in life expectancy at birth. The growth rate of the population has decreased from 2.7% in 1990 to 1.17 in In 2007, the annual population growth rate reached 1.55, which was an increase compared to The crude birth rate per 1000 population decreased two-fold from 35.3 in 1990 to 18.0 in Since then, it had been quite stable until it increased to 21.7 in Similarly, the total fertility rate experienced a two-fold decline by 2003 compared to the rate (4.3) in The rate had been stable (1.9) in , and increased to 2.36 in 2007 (NCHD, 2007). Socio-economic changes during the transition from a centrally planned to a market economy were accompanied by increased rural-to-urban migration. As of 2007, 39.4% of the population of Mongolia resided in rural areas as compared to 42.8% in Political situation 8

10 Mongolia is a democratic parliamentary country. The centralized governmental structure is divided into three branches: the executive branch or the Government chaired by the Prime Minister; the legislative branch or the Ikh Khural (the Parliament); and the judicial branch led by the Supreme Court. The President of Mongolia is a figurehead for the country and is elected for a four-year term. Political parties that have seats in the Parliament are eligible to nominate their candidates to the Presidential election. Although most political power is held by the Prime Minister and the Parliament, the President of Mongolia is a commander-in-chief of the armed forces and heads the National Security Council as well as appoints all the judges, the Prosecutor General, the Deputy Prosecutor General and ambassadors. The parliamentary and presidential elections take place once every 4 years and next elections will be held in 2008 and 2009, respectively Socio-economic situation Mongolian Statistical Yearbook shows that in 2006, the total revenue of the Government budget exceeded the planned value by 23.9% due to price increase of gold and copper on the world market. Compared to 2005, social security fund and social assistance fund expenditures increased by 31 and 79.2 percent, respectively, owing to the growth of salary, pension and welfare benefits in the reporting year. The expenditure and net lending of the Government budget exceeded the planned value by 2.3 in the same year. The budget surplus had been increasing since 1999(NSO, 2006). Animal husbandry, which is the main pillar of Mongolia s economy, still plays an important role in the economy, employment and export revenues of the country. To date, 20.2% of GDP is produced by the agricultural sector, of which 90.1% is accounted for by animal husbandry. Preliminary estimations demonstrate that GDP rose by 8.4% or billion tugriks in 2006 compared to the previous year. The growth of 8.4% was provided by service sector contributing 4.4 points and industrial and agricultural sectors contributing 2.0 points each. Per capita GDP at current prices reached thousand tugriks (National currency unit) in 2006, which was thousand tugriks more compared to 2005 (NSO, 2006). 9

11 The Household Income and Expenditure Survey of 2006 indicated that monthly average income per household had increased by 16.4% in terms of current prices of According to comparison of poverty incidence based on the results of the Household Income and Expenditure Survey of 2006 and the Living Standard Measurement Survey of , the poverty headcount (32.2), poverty gap (10.1) and poverty severity (4.5) decreased since 2002 (NSO, 2006). The main indicator of labour market development and economic activities of the population is a labour force participation rate. The labour force participation rate reached 64.4% in 2006, which was 0.9 points above the level of The number of people registered as unemployed remained unchanged compared to the previous year with females accounting for 57.0% of the unemployed. 1.2 HEALTH SITUATION AND TRENDS Epidemiological transition Since the beginning of the 1990s the mortality pattern has shown a rapid epidemiological transition. Cardiovascular diseases, cancer and injuries and poisonings have increased, while deaths from communicable and respiratory diseases have declined. The end of the 1990s saw injuries and poisonings exceeding respiratory diseases as a cause of death. The Ministry of Health of Mongolia conducted a Mongolian Steps Survey on the Prevalence of Non-Communicable Disease Risk Factors in 2006, The results of the survey revealed that 9 in every 10 people (90.6% of the surveyed population) had at least one risk factor for developing non-communicable diseases (NCD). One in every 5 people (20.7) had three and more risk factors or were at high risk of developing NCDs. In particular, one in every 2 males aged 45 years and above were at high risk of developing NCDs. The overall prevalence of current smokers was 28%, of which 24.2% and 3.4% were current daily and non-daily smokers, respectively. When asked about alcohol consumption in the past 12 months, about 60.8 (±0.02) percent of the population (65.1% of males and 56.2% of females) reported drinking occasionally, 5 percent (8.8% of males and 1.0% of females) consumed in alcohol in moderate amounts, and 0.7 (±0.04) percent (1.1% of males and 0.2% of females) drank frequently. In addition, about 23 percent of the surveyed population reported low levels of physical activity. 10

12 The National Program on NCD Control and Prevention for has been approved by the Government of Mongolia. This program is aimed at reducing risk factors and contributing to the reduction of the non-communicable disease morbidity and mortality. Currently, circulatory system diseases called life style and behavior dependent diseases, cancer and injuries have become the leading causes of population morbidity and mortality in Mongolia. As of 2007, the leading causes of morbidity per 10,000 population were respiratory (883.82), digestive (793.42), genito-urinary (714.45) and circulatory (577.79) diseases and injuries and poisoning (409.12). The rates of the diseases of genito-urinary, circulatory and digestive systems have steadily increased over the past 5 years (NCHD, 2007). Diseases of the circulatory system, neoplasms and injuries remain the leading causes of population mortality since Each year 5,500-6,000 persons or one in three die due to diseases of the circulatory system, which remains the top leading cause of the population mortality. Neoplasms remain the second leading cause of population mortality over the past decade. Gender-specific cancer mortality rates per 10,000 are and 9.50 for males and females, respectively. Malignant neoplasms of liver, stomach, lung, esophagus and prostate are the leading types of cancer in males, while malignant neoplasms of liver, cervix, uterus, stomach, esophagus and lung are common among females. Mortality due to injuries and poisoning has increased sharply in the last few years. It was the fifth leading cause of the population mortality in 1990, then moved to the fourth place in 1994, and ranked as the third leading cause of mortality since The injury mortality rate per 10,000 population increased almost two-fold to in 2007 compared to 7.6 in In the last few years, there is an increase in suicide, homicide and traffic accident rates. According to the official health statistics of 2007, suicide, homicide and traffic accident rates were 5 or more times greater for men compared to women (NCHD 2007) Outbreaks of communicable diseases 11

13 An incidence rate of infectious diseases per 10,000 population increased from in 2006 to157.1 in 2007 when 41,082 cases of infectious diseases were registered. Sexually transmitted infections (STI), viral hepatitis, rubella and tuberculosis were the top infections, comprising 29.7, 24.4, 2.3 and 10.6 percent of all communicable diseases, respectively (NCHD, 2007). The HIV epidemic in Mongolia is classified by WHO as low prevalence epidemic. Although the prevalence of HIV/AIDS is low, Mongolia is a country at high risk of epidemic due to the relatively young population, steady increase in STIs in recent years, increased population migration, and growing epidemics of HIV/AIDS in neighboring China and Russia. Since the first HIV/AIDS case, which was reported in 1992, a total of 36 cases reported as of the end of Of all HIV/AIDS cases, 31 were registered during the years (NCHD, 2007). Four of the reported cases died of AIDS between 1992 and Mongolia is a one of the countries of the WHO Western Pacific Region with the highest tuberculosis (TB) incidence. In recent years, TB incidence has remained high, and according to official health statistics, incident TB cases comprised 10.6% of all reported communicable diseases in The incidence of TB increased from 79 per 100,000 population in 1990 to 166 in However, the country has succeeded in reducing TB case fatality as a result of the DOTS implementation since The proportion of TB cases cured under DOTS increased from 80.0% in 2000 to 83.8% in TB mortality rate per 10,000 population decreased to 2.5 in 2007 from 4.8 in TB sub-program of the National Program on Combating Communicable Diseases for has set targets to increase TB detection rate to 70% and TB cure rate - to 85%; thus, facilitating the goal of reducing TB morbidity and mortality two-folds by Despite improvements in the diagnosis and treatment of TB and decrease in the number of deaths due to tuberculosis, the incidences of the disease is on the rise, which makes the attainment of MDG targets by 2015 challenging Maternal, child and infant diseases Successful implementation of the State Policy on Population Development, the State Policy on Public Health, Maternal Mortality Reduction Strategy, National Program on 12

14 Reproductive Health, and Integrated Management of Childhood Illness Program contributes significantly to a continued decrease in maternal and child mortality in recent years. Mongolia was a country with high maternal mortality in the region in However, it succeeded in reducing the MMR per 100,000 live births to 69.7 in 2006, which was a significant decrease from in However, the MMR increased to 89.6 in 2007, which could be explained by the dramatic increase in the number of births in The total number of births increased from 47,361 in 2006 to 55,634 in A short program review for child health of 2007 revealed that the proportion of maternal deaths due to hemorrhage has fallen. Extragenital diseases such as heart and kidney problems were reported to be the main reason for maternal deaths, and eclampsia continued to be the second most important cause (NCHD, 2007). Under 5 mortality rate per 1,000 live births decreased almost fourfold from 87.5 in 1990 to 22.1 in Similarly, the infant mortality rate per 1,000 live births decreased to 17.8 in 2007 compared to 63.4 in These figures indicate that Mongolia has achieved its MDG goals for child health. As stated in the Short program review for child health (2007), the proportion of child deaths due to acute respiratory infections and diarrhea has fallen, and neonatal causes and injury have increased as proportional causes. Neonatal deaths represent 62% of infant deaths. Furthermore, 80% of newborn deaths occur in the first week of life. The prevalence rate of wasting, underweight and stunting have generally fallen since Nevertheless, 21% of children are still stunted. The prevalence rates of iodine and iron deficiency have fallen in the last 2-3 years, but remain a significant public health problem with 22% of children under 5 being anemic HEALTH SYSTEM Mission and strategic objectives of the Ministry of Health The Ministry of Health of Mongolia is the central governmental administrative body in charge of health policy formulation, planning, regulation and supervision. The mission of MoH is to build a favorable living condition for people by upgrading the quality of health care to international standards. Within the scope of its mission, the MoH implements the following strategic objectives: 13

15 - To formulate and prioritize health policies and actions - To expand international cooperation - To formulate and regulate drug and medical supply policies and actions - To improve health management, health service delivery, quality and effectiveness - To formulate policies and actions on health economics and financing - To evaluate the implementation and impact of health intervention - To provide information for clients and decision-makers Priority functions of the MOH include the following: - To provide technical assistance to the Minister of Health and the Government on health issues; - To build health sector management capacity; - To ensure equitable provision of and access to health care, and to ensure proper resource allocation; - To maintain proper ratio between public and private health organizations (MOH, 2007) Organization of health services and delivery systems Health care system in Mongolia is characterized by three levels of care, and its prevailing principle is to deliver equitable, accessible and quality health care services for every person. - Primary health care is mainly provided by family group practices in the capital city and aimag centers, and soum and inter-soum hospitals in remote rural areas - Secondary health care is provided by district general hospitals in Ulaanbaatar city and aimag general hospitals in aimags - Tertiary health care is provided by major hospitals and specialized centers in Ulaanbaatar city As of the end of 2007, 15 specialized hospitals, 3 regional diagnostic and treatment centers, 18 aimag general hospitals, 9 district general hospitals, 4 rural general hospitals, 35 intersoum hospitals, 288 soum hospitals, 229 family group practices and 857 private clinics delivered health care services for the population of Mongolia (NCHD, 2007). 14

16 1.3.3 Health policy, planning and regulation framework The Plan of Action of the Government of Mongolia sets the following health priorities, including provision of good quality primary health services, improving rural health care, developing private health sector and expanding health insurance coverage. Another important policy document is the State Public Health Policy, approved in November 2001, which had clearly defined the principles, directions and implementation mechanisms of the Public Health Policy. Overall, the following policies and national public health programs are implemented in the health sector of Mongolia: State policies and strategies: State Public Health Policy; State Policy to Develop Mongolian Traditional Medicine; Health Sector Master Plan for ; National Drug Policy; Health Sector Human Resource Development Policy for ; State Policy on Population; Maternal Mortality Reduction Strategy for ; National Strategy on HIV/AIDS Prevention in Mongolia for ; National Strategy for Prevention and Control of Avoidable Blindness and Visual Impairment for Health Management Information System Development Strategy for Health-related laws: Health Law of Mongolia, revised in 2007 Drug Law of Mongolia; revised in 2006 Citizen's Health Insurance Law of Mongolia; revised in 2006 Sanitation Law of Mongolia; Mental Health Law of Mongolia; Immunization Law of Mongolia; Donor Law of Mongolia; Tobacco Law of Mongolia; Anti-alcohol Law of Mongolia; 15

17 Law on Salt Iodization and Prevention of Iodine Deficiency; HIV/AIDS Law of Mongolia, revised in 2004 Law on Welfare and Services for the Elderly; Law on Social Welfare for the Disabled; Law on Control of Narcotic Drugs and Other Psychotropic Substances; Spa Resort Law of Mongolia; National health programmes: Soum Hospital Development Programme, ; National Programme on Injury Prevention, ; National Programme on Health Technology Improvement, ; Healthy Mongolian, ; National Programme to Improve Health and Social Welfare of the Elderly, (the implementation plan for has been approved) National Programme to Combat Infectious Diseases, ; National Programme to Develop Spa Resorts, ; National Programme on Improving Children's Development and Protection, ; National Programme against Iodine Deficiency Disorder, ; National Programme on Food Supply, Safety and Nutrition, ; National Reproductive Health Programme, ; Oral Health Programme for ; National Programme on NCD Control and Prevention for ; National Programme on Environmental Health for Program on Development of National Sports, With the support of the Government of Japan, the MOH has developed the Health Sector Master Plan (HSMP), a long-term policy framework for which represents the Ministry s first comprehensive documentation of its future directions and incorporates the 16

18 Government s commitment to the MDGs. The Mid-Term Implementation Framework of the HSMP for the period of has been approved by the Health Minister s Order #43 of In the HSMP, seven key areas and twenty-four strategies have been incorporated to facilitate the delivery of socially responsive, equitable, accessible, and quality services to all. The overall outcomes to be achieved by 2015 include increased life expectancy; reduced infant mortality rate; reduced child mortality rate; reduced maternal mortality ratio; improved nutritional status, particularly micronutrient status among children and women; improved access to safe drinking water and basic sanitation; the prevention of HIV/AIDS; sustainable population growth; reduced household health expenditure, especially among the poor; a more effective, efficient and decentralized health system; and increased number of client-centered and user-friendly health facilities and institutions Health care financing In recent years, there has been a steady increase in public health expenditure both in terms of the percentage of GDP and of the government expenditure. Health expenditure as the percentage of GDP had been stable at 3.3% in and increased to 4.5% in 2007, resulting in per capita health expenditure of 51.3 USD. The total health expenditure increased 1.7 times in 2007 compared to The sources of health financing are the state budget (76.5 %), health insurance fund (20.2%) and other sources including out-of-pocket payments and other revenue (3.3%) (NCHD, 2007). Health insurance coverage (introduced in 1994) reached 78.3% of the population in 2007, a slight increase from 74.4% in the previous year. In 2007, over 83% of health insurance funds was spent on inpatient care, 8% - on outpatient care, and the remaining 9% - on discounted drugs, sanatoria and other costs (NCHD, 2007). A major share of the total health expenditure is spent on curative services. Almost 80% of health financing was allocated for curative care in If we look at the health expenditures by the level of care, 26.6 percent of total health expenditures incurred by the tertiary health care services, while 42.2 percent was spent for secondary and 28.8 percent for primary health care. 17

19 1.3.5 Human resources for health Despite the efforts of the Government of Mongolia, many challenging human resource issues remain in the health sector. There are great discrepancies in the distribution of health professionals leading to the deficit of health professionals in rural areas. Rural health facilities, soum and intersoum hospitals in particular, are experiencing critical shortage of doctors and other health professionals, which leaves almost 40 percent of the population without adequate access to primary health care. As of 2007, the number of physicians per 10,000 population was 18.1 in rural areas and 44.4 in Ulaanbaatar city. Seven soums had no medical doctors (NCHD, 2007). In addition, continued overproduction of physicians has resulted in a high physician-to-nurse ratio of 1:1.21, which is largely distorted compared to international standards. There is a shortage of nurses, mid-wives and other mid-personnel. The situation is further compounded by the over-specialization of medical doctors, which aggravates the shortage of physicians at the primary health care level. Social security of health workforce is weak. Low wages, harsh working conditions and a lack of proper incentive packages negatively affect ethics and productivity of the health workforce. These conditions could lead to the deterioration of the quality and availability of health services, failure to meet population health needs and the loss of confidence in health system. These factors have a potential to seriously affect the attainment of the MDGs. Most health sector human resource issues require involvement and cooperation of multiple sectors. With this view, a high level Inter-Sectoral Coordinating Committee on Health Sector Human Resources comprised of the representatives of the Government Secretariat, Ministries and international donors had been established with the purpose of improving political commitment, and donor support and funding to coordinate the implementation of the health sector human resource policies and strategies at the national level. Recently, the Committee s priority areas and strategic actions for the Committee have been approved by the Prime Minister and the Chairman of the Inter-Sectoral Coordinating Committee. Priority actions such as introducing a separate and independent labor-norm and performance-based salary system for health professionals, developing multiple choice incentive packages to encourage specialists to work in remote rural areas, and revising accreditation criteria for medical training institutions have been identified. 18

20 1.3.6 Partnerships As a developing country, Mongolia heavily relies on donor support in the health sector. The MOH has started initiatives to coordinate support rendered by international organizations and donor countries. The HSMP, a policy framework for the health sector, has included a strategy to strengthen and integrate on-going health sector reform using a Sector Wide Approach. Mongolia actively supports global iniatitives to protect and improve population s health status. In 2007, the Government of Mongolia joined the Statement of Committment acknowledging the importance of Global Elimination of Congenital Syphilis as vital to meet the MDGs for improving maternal health and reducing child mortality and combating HIV/AIDS. 1.4 HEALTH INFORMATION SYSTEM HMIS of Mongolia has evolved into a sector-wide system, which provides timely health information to policy and decision-makers in health organizations at all levels. It is a significant advancement compared to 1930, when the Ministry of Health Protection was first established with one officer in charge of information and reporting. The developmental processes in health information system of Mongolia can be divided in the following stages: o fundamental stages of simple records o incorporation of records into planning o establishment of health statistics unit o Since introduction of information technology advances At present, a centralized health statistics information system in charge of collection, transfer, processing and feedback of data and information on population health status, health services quality, accessibility, health institutions, resources and capacity is in place throughout the country (Chart 1) The Department of Information, Monitoring and Evaluation, MOH is in charge of coordinating overall functions of health information system and identifying further 19

21 improvements in accordance with the latest trends in health information and technology development. The Health Statistics Unit at the NCHD deals with processing health data and information calculating and analyzing core health indicators and providing methodological assistance to subordinate statistics units at the national level. The automation of health information has started since 1987, and MOH, NCHD, City and Aimag Health Departments, aimag/district general hospitals, specialized centers and hospitals were computerized in A routine health reporting software is used throughout the country, which had been tailored for the specific needs of the country. Chart 1. Health information system in Mongolia At the national level Ministry of Health Department of Information, Monitoring and Evaluation National Center for Health Development Health Statistics Unit At aimag and city level Statistcs Unit in Ulaanbaatar city Health Department Statistics units in specialized centers and hospitals Statistics Units in Aimag Health Departments Regional Diagnostic and Treatment Centers At soum and district level 20

22 District health centres District hospitals hospitals Private clinics and hospitals Soum and Intersoum hospitals Family group practices Statistics Units in Local hospitals The HMIS Development Strategy was approved in 2005 by the Health Minister s Order No The Strategy puts forward the following objectives: 1. To improve the structure, organization and management of HMIS 2. To foster evidence-based decision making by ensuring the transparency, availability and user-friendliness of health information 3. To develop human resources for HMIS 4. To improve the quality and content of health data and information 5. To enhance information technology infrastructure by automating data registration, collection, transfer, analysis and reporting at all levels of health sector Data and dataflow and feedback Currently, health data is collected and compiled on a monthly, semi-annual and annual basis and is provided for policy and decision-makers and other information users. Data content Reporting Means of Feedback frequency reporting 1 Birth and death rate, infant and under 5 mortality, maternal mortality, inpatient admissions, outpatient visits, incidence of injuries and 34 acute communicable diseases 2 Outpatient and inpatient morbidity according to ICD-10 3 Health indicators book in 4 volumes - by telephone - by Monthly Semi-annual - by - on flash disk Annual - using reporting Population morbidity and mortality booklet Database -Book -Website 21

23 forms HOW WAS THE HEALTH INFORMATION SYSTEM ASSESSMENT DONE? Objectives of the assessment: The assessment had the following objectives: - To provide baseline data on HIS inputs (resources), processes (selection of indicators and data sources; data collection and management) and outputs (information products and information dissemination and use) - To build consensus among stakeholders about the HIS aspects - To formulate policy recommendations for improvements of HIS Areas assessed: The assessment covered the following HIS components: А/ Resources - Policy and planning - HIS institutions, human resources and financing - HIS infrastructure B/ Indicators C/ Data sources - Census - Vital statistics - Population surveys - Health and disease record (Disease surveillance system) - Health service record D/ Administrative record - Infrastructure and health service databases /GIS - Human resources database - Health services financing and expenditures - Equipment and supplies E/ Data Management F/ Information product - Health status indicators - Health system indicators 22

24 - Risk factor indicators G/ Data dissemination and use - Data analysis and use - Policy and advocacy - Planning and priority setting - Resource allocation - Implementation and actions Methododology: The assessment was conducted using the HMN Assessment and Monitoring Tool, Version The tool was translated into Mongolian and validated during the first workshop facilitated by Dr. Jayasuriya in December Twenty-three workshop participants were trained as interviewers and focus group discussion facilitators. Six groups of key informants were identified as follows: - Health policy and decision-makers - Health information specialists - Health project and program coordinators - Specialists from National Statistical Office (NSO), Civil Registration and Information Center (CRIC), and Population Training and Research Center (PTRC) - Health finance specialists - Aimag and district informants The HMN Assessment and Monitoring Tool was tailored for each of the above six groups. Decision-makers and specialists from NSO, CRIC and PTRC were interviewed individually, and the rest underwent focus group discussions (FGDs). Data collection took place in February-July A total of 109 informants were interviewed or participated in FGDs (the list of the informants is attached). The assessment report was prepared following the discussion of the assessment findings at the Interim Committee on HMIS, the HMN Project Steering Committee and a national consensus-building seminar. 23

25 II. FINDINGS OF HEALTH INFORMATION SYSTEM ASSESSMENT Health Information System (HIS) was assessed in terms of its inputs (resources), processes (selection of indicators and data sources; data collection and management) and outputs (information products and information dissemination and use). Each of the assessment items was provided with a range of anticipated scenarios. The highest score was given for a scenario considered highly adequate, and the lowest score was given when the situation was regarded as not functional in terms of the ability to meet the HMN standard. Each question was rated by multiple respondents, and individual ratings were aggregated to come up with an overall score, which was compared to a maximum score to yield a percentage rating. The percentage ratings were interpreted as follows: Rating Result 0-19% Not functional 20-39% Not adequate at all 40-59% Present but not adequate 60-79% Adequate % Highly adequate Overall, the assessment of Mongolian HIS revealed that the selection of indicators and the information products were adequate, while HIS resources, data sources, and information dissemination and use components although present, were not adequate. Data management was found to be not adequate at all (Figure 1). 24

26 Return to Menu Resources Indicators Data sources Data management Information products Dissemination & use Not functional Not adequate at all Present but not adequate Adequate Highly adequate 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Figure 1. Overall assessment of HIS components for Mongolia 2.1 RESOURCES Assessment of HIS resources included evaluation of regulatory and planning context within which health information is generated and used, financial resources for HIS development, institutional and human resource capacity to support data collection, transmission, analysis and dissemination, and IT infrastructure to improve the timeliness, analysis and use of information. Overall, the assessment demonstrated that in Mongolian HIS these resources were present but not adequate (Table 1). 25

27 Table 1. Assessment of HIS resources in Mongolia Summary Result % Policy and Planning Present but not adequate 58% HIS institutions, human resources and financing Present but not adequate 56% HIS Infrastructure Adequate 64% Overall Present but not adequate 59% Policy and planning framework The country has Law on Statistics, Law on Civil Registration, Public Sector Management and Finance Law, Law on National Security, Law on Health, and Health Management Information System Development Strategy ( ), which cover fundamental principles of official statistics, vital registration, notifiable diseases and confidentiality, and provide the framework for health information. However, the policy framework for health information system to draw upon information from private health services and non-health sectors is still weak. Confidentiality issues in information exchange between health institutions have not been adequately addressed in effective laws and regulations. A written HMIS Development Strategy was approved by the Health Minister s Order No. 178 of 2005 to be implemented in However, some of the key informants were not even aware of its existence. The strategy addresses to some extent all HIS components as defined in the HMN Framework, except census and vital statistics as data sources. It also holds to foster evidence-based decision-making at all levels of health sector as one of its strategic objectives; thus, promoting a culture of information use throughout the health system. The key informants agreed that resources for the implementation of the strategy both at national and sub-national levels were severely inadequate. Health Management Information System Coordinating Committee (HMISCC) is established by the Health Minister s Order No. 286 of 30 August It is headed by the 26

28 Vice Minister of Health and includes representatives from MOH, Ministry of Finance, NSO, ICT Authority of the Government of Mongolia, (NCHD), Health Sciences University of Mongolia (HSUM) and World Health Organization (WHO). However, very few informants knew of the existence of the Committee, and it was rated as not functional. Similarly, a task force on health statistics between NSO and MOH was found to meet only occasionally on an ad hoc basis. There is no regular system in place for monitoring the performance of the HIS and its various sub-systems, apart from a well-established system for monitoring official health service records, and health and disease records. Although there are institutional policies to conduct regular meetings to review HIS information, they are rarely implemented. Overall, there is a policy framework for health information, which identifies main actors and coordinating mechanisms. However, it is not operational in many regards, and poorly facilitates accountability for health statistics HIS institutions, human resources and financing According to the assessment findings there is some national capacity in core health information sciences (epidemiology, demography, statistics, health planning), but it is not fully adequate to meet health information needs. In general, the public sector fails to retain specialists with adequate training in epidemiology, statistics and demography due to low salaries and the lack of other incentives. There is a functional central HIS administrative unit (DIME of MOH and Health Statistics Office of NCHD responsible for design, development and support of health information collection, management, analysis, dissemination and use for planning and management. However, it lacks adequate financial and human resources to carry out its functions properly. Although all health offices at sub-national level have full time health information officers, their turn-over is quite high especially in rural areas. Health information staff turnover rate at the national level is moderate, but manageable, while in rural areas it is quite problematic. Considerable staff turnover is attributable to high workload incomparable to inappropriate remuneration, and the lack of other incentives including inadequate opportunities for career 27

29 development. Limited HIS capacity building activities occurred over the past year for both HIS staff and other health facility staff. In-service training of health information specialists is essentially neglected. IT and database support services for health and HIS staff are adequate, usually available for occasional assistance and back-up at the national level, and limited, do not meet needs of staff at the sub-national level. Although written guidelines for HIS data collection, management and analysis exist and are used, they are not integrated into overall service supervision. Financial resources for the system are also quite limited. The analysis revealed that budget line items within the national budgets to provide adequately for a functioning HIS, are limited and do not allow for adequate function of all data sources HIS infrastructure The assessment demonstrated that computers are readily available to nearly all health managers at regional and national levels, and to some managers at district level. As to the availability of the basic communication technology infrastructure, telephone communication is in place at all levels allowing compilation of national and sub-national data as needed. However, internet access is only available at national and regional levels, and very few health facilities at district level have such an access. IT equipment maintenance support is also not always available, which sometimes prevents health institutions from meeting data and information reporting requirements. Availability of paper forms, paper, pencils, and supplies that are needed for recording of health information is fair with occasional "stock-outs", which however, does not affect the recording of health information. Although there is a complete list of public sector health facilities, it is not updated on an annual basis. The listing of private sector health facilities covers 50-79% of the latter and is not up to date. 28

30 The current assessment has demonstrated that infrastructure for the health information system is adequate in Mongolia. However, it should be noted that the implementation of information and communications technology often lacks careful planning, and computers are usually used as part of separate, often incompatible, vertical health information programs. 2.2 INDICATORS The assessment has demonstrated that there is an adequate nationally-defined minimum set of health-related indicators (Table 2). Table 2. Assessment of indicators Summary Result % Indicators Adequate 77% A minimum set of health indicators was approved by the Health Minister s Order No. 173 of A set of 123 core indicators has been defined in collaboration with relevant ministries, NSO, and major disease-focused programs. However, it does not cover such categories of health indicators as determinants of health, health system outcomes and wellbeing. Core indicators have been selected according to criteria of usefulness, reliability, representativeness, feasibility and accessibility. However, not all criteria for selection were clear and explicit. Efforts have been made to bring core indicator definitions in conformity with international technical standards and key indicators used in such global initiatives as MDGs, Stop TB, IMCI and GAVI. Although not all, but at least half of the health-related MDG indicators are included in the minimum core indicator set. Reporting on the minimum set of core indicators occurs regularly on an annual basis. For each core indicator suitable data sources and frequency of data collection have been identified. However, no medium and long-term targets have been set for the overwhelming 29

31 majority of these indicators, and no budget plan indicating sources and levels of financing for data collection has been developed. 2.3 DATA SOURCES Core data sources, including population-based health information sources (census, civil registration and population-based surveys) and health service-based information sources (health and disease records, health-service records and administrative records) were assessed in terms of procedures implemented to ensure data quality, appropriateness of indicator definitions and data collection methods, use of routine procedures to correct bias and confounding, and accessibility of primary data. According to the assessment findings vital statistics, health service records and health and disease records are functioning well, while census, population-based surveys and administrative records are present, but not adequate (Figure 2). Return to Menu Census Vital statistics Population-based surveys Health & diseases records Health service records Administrative records Not functional Not adequate at all Present but not adequate Adequate Highly adequate 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Figure 2. Assessment of data sources 30

32 Results of a detailed assessment of each data source in terms of its content, capacity and practices, dissemination, integration and use are shown in Table 3. Table 3. Assessment of core dimensions of data sources Data Source Census Vital statistics Populationbased surveys Health and disease records Health service records Administrative records Contents Capacity Integration and Dissemination and use practices Total Present but Not Highly Present but Not not adequate adequate not adequate adequate adequate Highly Highly Highly Highly Adequate adequate adequate adequate adequate Present but Present but Adequate Adequate Not adequate not not adequate adequate Adequate Adequate Present but Highly not adequate adequate Adequate Present but Adequate not Adequate Adequate Adequate adequate Present but Present but Present but Not not not Not adequate not adequate adequate adequate adequate Census In Mongolia the population and housing census was carried out 9 times since the first census in The most recent census was carried out in 2000, and no mortality questions were included in it as civil registration had a good coverage (at least 90%) of deaths. The results of the last census were published as a hard copy in However, the report is not readily available, and only central health officials have immediate access to it. No electronic report has been released. 31

33 Population projections by age and sex are only available for provinces/regions, and not for smaller administrative units. The availability of population projections for HIS purposes is also quite limited. Therefore, census projections are seldom used for the estimation of coverage and the planning of health services at national level, and hardly ever at subnational level. Census sample re-interview has been completed and a written report is available, although not widely distributed. Similarly, census micro-data is not publicly accessible, and only available upon official request with restrictions. There is an adequate national capacity for census data collection and processing, but not for data analysis. In general, census data is inadequately used for health service planning, estimation of target population size and evaluation of service-coverage rates Vital statistics In Mongolia there is a well-established civil registration system, which covers almost 95% of all deaths. It is compulsory by law to always record cause of death on the death certificate, and ICD-10 Tabulation List is used for the registration of cause of death. Currently, about 5% of all deaths is coded to ill-defined causes. The completeness of civil registration is assessed every 2-4 years, and civil registration statistics disaggregated by sex, age and geographic region are produced within 1-2 years from the time of data collection. Both mortality rates and cause of death information from civil registration are used for national and sub-national analyses. There is an adequate national capacity for civil registration data collection and processing, but not for data analysis. In general, the civil registration system in Mongolia provides almost complete record of all births and deaths, and includes medically-certified causes of death. 32

34 2.3.3 Population-based surveys Population-based surveys have been used as a data source for estimation of the percentage of population receiving key maternal and child health services since mid-1990s. The first National Reproductive Health Survey was carried out by the NSO with the support from UNFPA in 1998, and repeated in Child and Development Survey, which employed Multiple Indicator Cluster Survey (MICS) methodology was carried out by the NSO with the support from UNICEF in 1996, 2000 and However, the Ministry of Health judges the MICS estimates of infant and under-five mortality as not accurate, and still relies on its official statistics for such estimates. In a nationally representative Steps Survey on NCD Risk Factors measured the prevalence of hypertension, diabetes and leading risk factors including smoking, alcohol use, diet, physical inactivity and obesity. The survey was conducted by the MOH with the support from WHO. Key informants agreed that for the above surveys, international standards for consent, confidentiality and access to personal data were followed. However, it has emerged from the discussions that for some other surveys such standards were not fully observed. According to the assessment findings, the country has adequate capacity to conduct population-based surveys and process survey data, but not to analyze the data. The survey data allows disaggregation by age, sex and geographical region. As for socio-economic status, disaggregation by income is not always possible. Metadata (survey design, sample implementation, questionnaires) and micro-data are not easily available for recent surveys. Although efforts are made by individual constituencies to coordinate the timing, key variables measured and funding of nationally representative population-based surveys, no formal coordination mechanism is in place and no effective coordination of surveys occurs. Collaboration of health and statistical constituencies on survey design, implementation and data analysis and use is not adequate. 33

35 Overall, the key informants agree that there is an over-reliance on health service-based data, and population-based surveys are underutilized as a source of health data, and they are not well integrated into the national HIS. It is important to acknowledge that population-based surveys are the single most important source of population health information especially the ones related to determinants of health, risk factors and household expenditures on health. The integration of population-based surveys into the overall health information system in Mongolia requires a sound mechanism for mapping population-based surveys with timing, clear indications of the role of national and international stakeholders, and sources and requirements for funding Health and disease records (including disease surveillance systems) The assessment indicated that for each of the key epidemic prone diseases and diseases targeted for eradication in Mongolia, appropriate case definitions have been established and cases can be reported on the current reporting format. Plans also exist for extending the coverage of disease surveillance to include additional conditions of public health importance. However, only a few public health risks are mapped. In Mongolia there is an adequate capacity to diagnose and record cases of notifiable diseases, and to report and transmit timely and complete data on these diseases. However, the capacity to analyze and act upon the data for outbreak response and planning of public health interventions is limited. It has been estimated that 75-89% of health workers making primary diagnoses could correctly cite the case definitions of the majority of notifiable diseases. At least 75% of epidemics noted at regional or national levels are first detected at district level, and 75-89% of investigated outbreaks have laboratory results. ICD-10 (Tabulation list) is currently used for reporting hospital discharge diagnoses. Routine reporting of weekly and monthly surveillance data is well-established with more than 90% of health facilities and 75-89% of districts submitting reports on time to the higher level. However, reporting for disease surveillance and other vertical public health programs is not integrated, and health workers and managers face a heavy burden completing and reviewing separate reports for numerous programs. Surveillance data are disseminated and fed back through regularly published monthly bulletins, which are distributed to district health offices. 34

36 Individual patient records are usually completed adequately, but are not easily retrievable to support quality and continuity of care Health service records The analysis shows that although there is a health services based information system that brings together data from public and private facilities, it covers only few private facilities. There are adequately operational mechanisms at national and sub-national levels for supervision and feedback on information practices, and for verification of completeness and consistency of data from facilities. Health offices at province level have full time health information specialists with at least two years of training in health information. However, at the district level health information officers usually have three-month training, and only 1-9% of districts have specialists with at least two years of training. There is no integrated training program in health information for health workers, and capacity-building is usually undertaken through special workshops. In the last 5 years only 5-24% of health workers received training in health information. Vertical reporting systems communicate adequately with the general health service reporting system. The data derived from health service records are always used to estimate coverage with key services such as antenatal care (ANC), delivery with a skilled attendant and immunization. However, health service records provide information on quality of services, but only from a convenience sample of health facilities. Summary of health service statistics is published annually with statistics disaggregated by major administrative regions. Sub-national units compile their own annual summary reports disaggregated by health facilities. Generally, health service records are quite well established in public sector in Mongolia. However, there is an over-reliance on health service-based data, which is rarely validated with statistics from other data sources. 35

37 2.3.6 Administrative records Mapping of infrastructure and health services There is a database of public health facilities, but the coding system does not permit integrated data management and no Global Positioning Satellite (GPS) coordinates are included. The database was first created in 2004, and updated in However, there are no adequate human resources, capacity-building initiatives and equipment for maintaining and updating the database. Maps showing the location of health infrastructure, health staff and key health services are not available in most districts. Managers and analysts at national and district levels do not routinely evaluate physical access to services by linking information about the location of health facilities and health services to the distribution of the population Database of human resources There is a national human resources database that tracks the number of health professionals working in the public sector by major professional categories. The database was first created in 2004, and last updated in However, there are no adequate human resources, capacity-building initiatives and equipment for maintaining and updating the database. The Civil Service Commission (CSC) of Mongolia has also developed a human resources database for civil servants and requires all public facilities to maintain this database. However, the CSC database is incompatible with the MOH human resources database, and there are initial talks underway to make the two databases compatible. There is a national database that tracks the annual numbers graduating from public, but not private health training institutions Information on financing of health services 36

38 The assessment has revealed that financial records are available only on public expenditures on health, and the system tracks only general government and health insurance expenditures disaggregated by sub-national level. A World Bank supported project on National Health Accounts (NHA) was implemented in , which produced Mongolia NHA Report for The work of the project team had been gradually transferred to the NCHD, where two full-time positions to work on NHA have been created. It is perceived that the number of NHA staff is adequate, but there is a strong need for external technical support and staff capacity-building. Second Mongolia NHA Report for has been produced recently. NHA provides information on the following three classifications sources, providers and functions. Estimates are available by geographical regions and some areas of policy concern, but they exclude major diseases, health program areas, target populations, and out-of-pocket expenditures. Findings of the last NHA have not been widely disseminated. Policy makers and other stakeholders are aware of the NHA findings, but there is no evidence that these findings have shaped policy and planning Database on equipment, supplies and commodities Although public facilities are required to report annually on the inventory and status of equipment, physical infrastructure and stock of health commodities, few facilities comply with the requirement. There is a considerable lack of adequately skilled human resources for logistics management, and managers rarely reconcile data on consumption of commodities with data on cases of disease reported. 2.4 DATA MANAGEMENT Data management component of HIS is rated as not adequate at all in Mongolia (Table 4). Although there is a written set of procedures for data management and is implemented throughout the country, it only includes procedures for data collection and storage, and not for data cleaning, quality control, analysis and presentation for target audiences. 37

39 Table 4. Assessment of data management Summary Result % Data management Not adequate 25% There are no national or sub-national data warehouses in Mongolia, which integrate data from such sources as routine service statistics, surveys, surveillance, vital registration, census and administrative records. Integrated data storage requires common identifier codes for health facilities and administrative geographic units to facilitate merging of multiple databases from different sources. However, identifier codes do not match between different databases in Mongolia. Another requirement for the establishment of a data warehouse is metadata dictionary, which defines data elements and their use in indicators, including numerators and denominators, data-collection method, periodicity, analysis techniques, estimation methods and possible biases of the data. In Mongolia there is a metadata dictionary, but with very incomplete set of definitions and specifications. 2.5 INFORMATION PRODUCTS Information products under assessment included health status indicators (mortality and morbidity), health system indicators and risk factor indicators. Overall, the quality of health indicators was rated as adequate (Figure 3). Health status indicators included under-five mortality, adult mortality, maternal mortality, HIV prevalence and underweight in children, and were found to be of adequate quality. Health system indicators (such as outpatient attendance, measles coverage by 12 months of age, deliveries attended by skilled health professionals, TB treatment success rate under DOTS, general government expenditure on health per capita, private expenditure on health per capita and density of health workforce) and risk factor indicators (such as smoking prevalence, condom use with higher risk sex and proportion of households using improved water supply) were present, but not adequate. 38

40 Selected Indicators & Results Return to Menu Health status - mortality Health status - morbidity Health system Risk factors Overall health indicators quality Not functional Not adequate at all Present but not adequate Adequate Highly adequate 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Figure 3. Assessment of information products by categories of health indicators The assessment evaluated the quality of health-related indicators in terms of technical soundness (methods used to estimate the indicators), timeliness (gap between data collection and publication of indicators), periodicity (frequency of indicator measurement); consistency (consistency of data points over time), representativeness (extent to which data adequately represent the population) and disaggregation (availability of indicator by sex, age, socioeconomic status and administrative region). In general, the selected indicators conformed well to the above quality criteria (Figure 4). 39

41 Return to Menu Мэдээ цуглуулах арга Шуурхай байдал Periodicity Consistency / completeness Representativeness / appropriateness Disaggregation Estimation method / transparency Not functional Not adequate at all Present but not adequate Adequate Highly adequate 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Figure 4. Assessment of health indicators according to criteria of quality The assessment results demonstrate that indicators produced by routine health service records, such as health status indicators and health system indicators have well-established internationally accepted data collection methods, are representative of a source population and produced periodically in a timely manner. In contrast, risk factor indicators, which mainly depend on population-based surveys as a data source, are inadequate in terms of periodicity, timeliness, consistency and representativeness (Table 5). For most indicators, data points are adequately disaggregated by age, sex and administrative regions, but disaggregation by socioeconomic status is essentially inexistent. 40

42 Table 5. Assessment of selected health indicators Marking Health status Indicators Health Elements for assessing selected indicators Mortality Morbidity Overall system indicators Data collection method Timeliness Periodicity Consistency / completeness Representativeness / appropriateness Present but Highly Highly Adequate not adequate adequate adequate Highly Highly Adequate adequate adequate Adequate Highly adequate Adequate Adequate Adequate Present but Adequate Adequate Adequate not adequate Highly adequate Adequate Adequate Adequate Present but Disaggregation Adequate Adequate Adequate not adequate Estimation method Highly Highly / transparency adequate adequate Adequate Overall Highly Highly assessment of Adequate adequate adequate results Adequate Risk factors indicators Adequate Present but not adequate Present but not adequate Present but not adequate Present but not adequate Present but not adequate Present but not adequate Overall health indicators quality Adequate Adequate Adequate Adequate Adequate Present but not adequate Highly adequate Adequate 41

43 2.5.1 Health status indicators Mortality indicators under assessment included under-five mortality (all cause), adult mortality (all cause) and maternal mortality. Mortality rates are estimated annually based on vital registration of at least 90% of deaths. The most recently reported mortality estimates are based on all deaths and disaggregated by age, sex and major administrative regions, but not socioeconomic status. Adult and maternal mortality rate data points in the last decade are consistent over time and between sources. However, there are major discrepancies in under-five mortality rates between official registration and MICS. Morbidity indicators under assessment include HIV prevalence and underweight in children (<24 months). Mongolia has a low prevalence HIV epidemic, and the most recent estimate of HIV prevalence is based on high risk population surveillance with purposive sampling. HIV surveillance is carried out once every two years. The most recently reported estimate of HIV prevalence is based on several low risk population groups in multiple locations, and two high risk groups (MSM and female sex workers) in two locations. Recent estimates are disaggregated by sex, age and major administrative regions, but not socioeconomic status. Underweight in children is estimated through nationally representative population-based survey with anthropometry. For the most recently published estimate, the data was collected 2 years ago, and in the last decade it was measured more than three times. The most recent data point is disaggregated by demographic characteristics (sex and age), socioeconomic status (education of parents) and by major administrative regions Health system indicators The health system indicators assessed were outpatient attendance, measles vaccination coverage by 12 months of age, deliveries attended by skilled health professionals, tuberculosis treatment success rate under DOTS, general government expenditure on health per capita, private expenditure on health per capita and density of health workforce. 42

44 Outpatient attendance is estimated annually based on facility reports, which are not validated (i.e. evaluation of completeness or reporting bias is limited). The most recent statistic includes data from teaching hospitals and more than 90% of other public sector health facilities, but does not include private sector health facilities. Outpatient attendance distinguishes curative from preventive visits, but fails to distinguish initial visits from follow-up visits for the same illness. Statistics on curative consultations are disaggregated by disease. Most recent data point is disaggregated by geographic region and sex. Measles vaccination coverage is estimated annually from routine administrative statistics submitted by at least 90% of immunizing health facilities. These statistics are systematically reviewed at each level for completeness and consistency, and inconsistencies are investigated and corrected. Population denominators are based upon full (>90%) birth registration. In addition, the coverage has been measured by two nationally representative household surveys in the last five years, during which immunization cards were shown for at least 2/3 of children. There are few discrepancies between recent surveys and administrative reports. For the most recently published estimate, data was collected collected less than 12 months ago, and disaggregated by age, sex and major administrative regions, but not socioeconomic status. The percentage of deliveries attended by a skilled health professional is estimated annually from routine administrative statistics submitted by all relevant health facilities. These statistics are evaluated for completeness and consistency. Population denominators are based on full birth registration. This indicator has also been measured by one nationally representative reproductive health survey in the last five years. There are few discrepancies between the survey and administrative reports. Estimates are based on at least 90% of professionally supervised deliveries and complete registration of births, and disaggregated by major administrative regions The most recent data on tuberculosis treatment success rate is obtained from national reports with limited evaluation of reporting bias. It is measured annually, and the last estimate is based on about 80% of sub national DOTS reports. The most recent data point is disaggregated by age and major administrative regions, but not socioeconomic status, HIV status or drug resistance. 43

45 Data for estimating general government expenditure on health per capita is compiled from various administrative sources including records of MOH, Health Insurance Fund (HIF) and sub-national governments. MOH and HIF expenditure is available by subnational level. Data on general government expenditure funded through external resources is limited to committed external resources from multilateral and bilateral partners. Private expenditure on health per capita is estimated using a nationally representative household survey for out-of-pocket expenditures. There is 2 year lag between most recent national publication and the time that the data were collected. Households' out-of-pocket expenditure is available by sub-national level. Density of health workforce is estimated annually from routine administrative records and health facility surveys. The data is disaggregated according to 14 occupations defined by a national classification. Most recent estimate disaggregated by gender, urban/rural and major administrative areas, but not by public/private sector Risk factors indicators In this assessment, three risk factor variables were used, namely smoking prevalence in population 15 years and older, condom use with higher risk sex and proportion of households using improved water supply. The most recent estimation of smoking prevalence is based on population survey with self report, which was conducted 2 years ago. The indicator has been estimated many times in the last 10 years. However, there are multiple discrepancies between surveys as they employed different sampling methods and data definitions. The last estimate is based upon nationally representative sample and disaggregated by demographic characteristics only. Condom use with higher risk sex is estimated based on the survey of high risk populations. For the most recently published estimate, the data was collected 2 years ago. The data point is disaggregated by demographic characteristics only. 44

46 Proportion of households using improved water supply is estimated based on household survey with non-random national sampling. The most recent data point is disaggregated by locality only. 2.6 DISSEMINATION AND USE Health data and information is of limited value until it is communicated to decision-makers in terms of issues confronting the health system, and is applied through the planning process to result in action and change. Therefore, dissemination and use of health information constituted an integral part of HIS assessment. This component was rated as present, but not adequate in Mongolia (Table 6). Table 6. Assessment of dissemination and use Summary Result % Analysis and Use of Information Present but not adequate 59% Policy and Advocacy Adequate 76% Planning and Priority Setting Adequate 66% Resource allocation Present but not adequate 41% Implementation / action Present but not adequate 53% Overall Present but not adequate 59% Analysis and use of information The assessment found that there is no continual demand for good quality and timely health information. It is usually demanded only on an ad-hoc basis, and even where requests are made, senior managers and policy-makers often lack the knowledge and skills to critically appraise the information provided. 45

47 Graphs and maps are used to display information at sub-national level, but these are poorly understood and rarely kept up-to-date. Health Statistics Office regularly provides information, but in-depth analysis is limited and the information does not regularly contribute to policy development and planning. HIS data and indicators collected by public agencies is not always available to all interested citizens. However, public access to health information is accepted in principle and largely implemented Policy and advocacy MOH produces a written annual report that pulls together critical health information from all subsystems, but the analysis is weak. This integrated HIS report is distributed regularly to relevant national and local partners. Key national health indicators such as under-five mortality rate, maternal mortality ratio, immunization rate and HIV prevalence are well known among among health-focused decision-makers. Policy and decision makers frequently use health information to evaluate performance and set policies on health, but have concerns about the validity of information Planning and priority setting Health information is commonly used for diagnostic purposes to describe health problems, but use of health information between different planning frameworks is not synchronised. Most health information is analysed by district health workers and reported to the next level, and only rarely activities are adjusted accordingly. About a half of indicators in the national minimum core indicator set have relevant short (1 year), medium (3-5 years), and long-term (10-15 years) targets Resource allocation The assessment found that health information is not being widely used to determine resource allocation at national and sub-national levels. Health information has had some degree of influence over annual budgets and resource allocation over the past 5 years, but links to information are not clear, as only few budget proposals and targets have been backed up by HIS-based evidence. 46

48 Health information is used to advocate for equity and increased resources to disadvantaged groups and communities only on an ad-hoc basis Implementation/action The analysis showed that managers and care providers at all levels rarely use health information for local health service delivery management and monitoring, but no real planning is done. Information on health risk factors is regularly used to promote healthy and safer behaviour in the general public, but it is generally not tailored to vulnerable groups. 47

49 III. DISCUSSION AND RECOMMENDATIONS Based on the findings of the current assessment the following recommendations are made for strengthening the Health Information System in Mongolia. The recommendations are grouped under the six components used in the assessment process. 3.1 RESOURCES Policy and planning There is a policy framework for health information, which identifies main actors and coordinating mechanisms. However, it does not adequately address confidentiality issues in information exchange, does not include census and vital statistics as major data source for HIS, and is weak in drawing upon information from private health services and non-health sectors. Resources for the implementation of the strategy both at national and sub-national levels are severely inadequate. HMIS Coordinating Committee is not functional. Institutional policies to conduct regular meetings to review HIS information are rarely implemented. Recommendations: To revise the HMIS Development Strategy to bring it in conformity with the HMN Framework and Standards for the Development of Country HIS. It should include clear strategies for integrating different data sources including private and non-health sectors, and improving data management, and dissemination and use. To develop, as part of the HMIS Development Strategy, a roadmap to guide HIS investments, with indications of the timeline and anticipated budget of activities. To provide necessary support and resources to make the HMIS Coordinating Committee operational, and to broaden the representation of international multi- and bilateral agencies on the Committee. To increase resource allocation for the implementation of the HMIS Development Strategy both at national and sub-national levels. 48

50 3.1.2 HIS institutions, human resources and financing According to the assessment findings the public sector fails to retain specialists with adequate training core health information sciences (epidemiology, demography, statistics, health planning). Health information staff turnover rate at the national level is moderate, but manageable, while in rural areas it is quite problematic. Considerable staff turnover is attributable to high workload incomparable to inappropriate remuneration, and the lack of other incentives including inadequate opportunities for career development. In-service training of health information specialists is essentially neglected. Central HIS administrative unit lacks adequate financial and human resources to carry out its functions properly. IT and database support services for health and HIS staff are limited and do not meet needs of staff. Financial resources for the system are limited and do not allow for adequate function of all data sources. Recommendations: To develop and implement HIS Human Resource Development Plan, which should clearly define career pathway for health information specialists and strategies to retain well-trained staff. To conduct a health information training needs assessment. To develop and implement a targeted capacity building program in health information management, use, design and application. To undertake an institutional analysis to identify constraints for HIS development. To increase budget allocations for various sectors to provide adequately for a functioning HIS for all data sources HIS infrastructure The current assessment has demonstrated that infrastructure for the health information system is adequate in Mongolia. However, the implementation of information and communications technology often lacks adequate IT human resources and careful planning, 49

51 and computers are usually used as part of separate, often incompatible, vertical health information programs. Recommendations: To include in HIS Human Resource Development Plan strategies to attract and retain IT specialists in health sector. To assess information technology deployment in health sector annually in order to inform budget proposals to ensure sustainable supply, maintenance and continuous operation of IT. To enforce common technical requirements and specifications for hard- and software in health sector in order to ensure the compatibility of health information systems. 3.2 INDICATORS A minimum core set of health indicators does not cover determinants of health, health system outcomes and well-being. Furthermore, some of the health-related MDG indicators are not included in the minimum core. The majority of the indicators do not have medium and long-term targets, and there is no budget plan for data collection. Recommendations: To include health-related MDG indicators, and indicators of determinants of health, health system outcomes and well-being in the minimum core set of health indicators. To set medium and long-term targets for core indicators, where appropriate. To develop a budget plan indicate likely sources and levels of financing for data collection and reporting on the minimum core set of health indicators. 3.3 DATA SOURCES Census The assessment has demonstrated that census data is under-utilized for health service planning, estimation of target population size and evaluation of service-coverage rates, 50

52 which could be due to the limited availability of census reports, census micro-data and population projections for HIS purposes especially at sub-national level. Recommendations: To improve the availability of census reports, census micro-data and population projections for HIS purposes. To prepare joint plan for the next round of censuses and determine its health-related contents as appropriate. To improve national capacity for census data analysis Population-based surveys There is an over-reliance on health service-based data, and population-based surveys are underutilized as a source of health data, and they are not well integrated into the national HIS. The integration of population-based surveys into the overall health information system in Mongolia requires a sound mechanism for mapping population-based surveys with timing, clear indications of the role of national and international stakeholders, and sources and requirements for funding. Recommendations: To increase the utilization of surveys as the prime source of health information on risk factors. To establish a formal mechanism for coordination of surveys and develop an integrated plan of surveys to be conducted in the next 10 years. To ensure adherence to internationally-accepted standards for conducting surveys regarding ethical issues, design and implementation, analysis and dissemination. To improve the availability of survey meta and micro-data. To improve national capacity for survey data analysis. 51

53 3.3.3 Vital statistics In Mongolia there is a well-established civil registration system, which provides almost complete record of all births and deaths, and includes medically-certified causes of death. Recommendations: To improve national capacity in analytical methods for evaluating and adjusting data from vital registration Health and disease records In Mongolia there is an adequate capacity to diagnose and record cases of notifiable diseases, and to report and transmit timely and complete data on these diseases. However, the capacity to analyze and act upon the data for outbreak response and planning of public health interventions is limited. Routine reporting of weekly and monthly surveillance data is although well-established not integrated with reporting for vertical public health programs. Recommendations: To develop and implement a comprehensive plan to produce an integrated disease surveillance system, including behavioural surveillance and mapping of public health risks. To strengthen human capacity for surveillance Health service records Health service records are quite well established in public sector in Mongolia. However, there is an over-reliance on health service-based data, which is rarely validated with statistics from other data sources. There is no integrated training program in health information for information specialists as well as health workers. 52

54 Recommendations: To enhance the use of facility-based health service records in the management of local health services through capacity-building of health staff in information management and use. To improve the coverage of service records from private health facilities. To utilize nationally representative health facility survey in evaluating the quality of services Administrative records Initiatives to establish databases of health infrastructure, human and other resources have been initiated recently in Mongolia. However, coding systems do not permit integrated data management, and there are no adequate human resources, capacity-building initiatives and equipment for maintaining and updating the databases. Health managers rarely reconcile data on health infrastructure with population and morbidity/mortality data. There is a need for technical support and staff capacity-building in National Health Accounts (NHA). Recommendations: To introduce unique identifier coding systems to permit integrated management of health infrastructure and human resource databases. To build institutional and human capacity for maintaining and updating the databases. To reconcile the Civil Service Commission database with the MOH Human Resource database. To increase number and improve qualifications of staff working for NHA. To widely distribute findings of the last NHA. 3.4 DATA MANAGEMENT Data management component of HIS is rated as not adequate at all in Mongolia. It has been highlighted that a written set of procedures for data management only includes procedures for data collection and storage. There are no national or sub-national data 53

55 warehouses, identifier codes do not match between different databases, and a metadata dictionary exists, but with very incomplete set of definitions and specifications. Recommendations: To revise written procedures for data management to include procedures for data cleaning, quality control, analysis and presentation for target audiences. To develop a comprehensive metadata dictionary, which should define data elements and their use in indicators, and specify data collection method, periodicity, analysis techniques, estimation methods and possible biases of the data. To establish a national data and information repository in order to improve information practices and enable high-quality data analyses. 3.5 INFORMATION PRODUCTS The current assessment has highlighted that risk factor indicators are inadequate in terms of periodicity, timeliness, consistency and representativeness. For most indicators, disaggregation by socioeconomic status is essentially inexistent. Recommendations: To bring data collection methods for risk factor indicators in conformity with internationally accepted standards. To improve disaggregation of health-related indicators by socioeconomic status. 3.6 DISSEMINATION AND USE The assessment has found that links between demand, supply and quality of information are weak, and there is no continual demand for good quality and timely health information. Health data analysis is weak, and decision makers frequently have concerns about the validity of information. Health information is not widely used to determine resource allocation at national and sub-national levels, and health managers and care providers at all levels rarely use health information for health service delivery management and monitoring. 54

56 Recommendations: To encourage an information culture where information is demanded and the use of information promoted. This could be done through the establishment of institutional mechanisms for information use such as linking information to resource allocation and developing indicator-driven planning. To improve the skills of health managers and providers to critically appraise health information. 55

57 REFERENCES 1. MOH, Health Sector Strategic Master Plan, NSO, Statistical Yearbook, NCHD, Health Indicator s Book, B Bayart et al. Health Management Information System Development Strategy, Ulaanbaatar, WHO, MOH, The first national representative survey on prevalence of NCD risk factors, Ulaanbaatar, MOH, Brochure of Ministry of Health, Mongolia, WHO, Short programme review for child health, Meeting report, Memorandum of understanding on health sector human resource development in Mongolia, Priority areas and strategy for action for intersectoral coordinating committee on health sector human resource development,

58 Chart 2. ORGANIZATIONAL CHART OF THE MINISTRY OF HEALTH Health Minister s Council Minister of Health Minister s Secretariat Vice minister State Secretary Division of Public Administration and Management Division of Finance and Economics Division of Health Policy Planning Division of Medical Services Management Division of Information, Monitoring and Evaluation Department of International Cooperation Department of Pharmacy and Medical Devices

59 LIST OF ASSESSMENT PARTICIPANTS: 1. Policy and decision-makers Name Position of interviewee Name of organization Bayart B. Director, DPAM MOH Bayar O. Director, DIME MOH Sodnompil Ts. Director NCHD Dulamsuren S. Deputy Director NCHD Bat-Erdene I. Deputy Director, DMS MOH Erdenetuya S. Deputy Director, DPAM MOH Navchaa S. Assistant Representative UNFPA Burmaa B. Officer, DHPP MOH Tsogzolmaa Officer WHO Alagaa D. Head Bayanhongor Aimag Health Department Dulamsuren P. Director Uvurkhangai Aimag Regional Diagnostic and Treatment Center Buyankhishig D. Deputy Head Khovd Aimag Health Department Dulamjav M. Deputy Director Khovd Aimag Regional Diagnostic and Treatment Center Tsagaan B. Head Bayankhongor Aimag General Hospital Zolboot L. Head Darkhan-Uul Aimag Health Department Oyunsuren Head Omnogobi Aimag Health Department Enkhtsetseg G. Head Dornogobi Aimag Health Department Dornod aimag Health Doljin D. Head Department

60 Ochirbat D. Head Tuv Aimag Health Department Enkhsaihan Ts. Head Dundgobi Aimag Health Department Tserendolgor B. Head Selenge Aimag Health Department Ishdorj Director Zavhan Aimag General Hospital 59

61 2. Health information specialists Oyuntsetseg P. Officer, DIME MOH Khongorzul B. Officer, DIME MOH Tsogzolmaa N. Officer, DIME MOH Nyamkhorol D. Head, HSU NCHD Ariuntuya S. Officer, HSU NCHD Narantuya Kh. Officer, HSU NCHD 3. Health finance specialists Bazarkhurel G. Officer, DIME MOH Chuluunzagd B. Officer, DFE MOH Amar D. Officer, DFE MOH Munkhtsetseg B. Officer, DFE MOH Bayartogtokh Ya. Officer, DFE MOH Zorigoo Officer, DFE MOH Ulzii-Orshikh Kh. Officer, DHPP MOH Ganchimeg T. Officer in charge of NHA NCHD Suvdaa Officer in charge of health insurance MSWL 4. Project and program coordinators 60

62 Altankhuyag P. Project manager ADB project Introducing information technology in improving population health status Barkhas O. Reproductive Health Project UNFPA Gantulga D. Medical doctor, Immunization Unit NCCD Undraa N. Director in charge of research National Center for Diseases with Natural Foci Tuul Ts. Statistician NCC Narantuya N. Director in charge of health research NPHI Byambaa N. Officer in charge of STI/HIV/AIDS Global Fund Soyol-Erdene G. Statistician National Mental Health Center Nansalmaa Sh. Officer, Research Center National Traumatology and Orthopedics Research Center Davaadorj I. Officer, DHPP MOH Tsetsegdary G. Officer, DHPP MOH Otgonjargal P. Officer, DHPP MOH Officer, Department of MOH Tumurbat B. Medical Services Officer, Department of MOH Soyolgerel G. Medical Services Bold A. Implementation management unit HSMP Tumurtogoo D. Implementation management unit HSMP Oyunchimeg D. Head, Health Information Unit NCC 61

63 Oyuntsetseg L. Statistician NCCD Naranbat N. Head, TB Unit NCCD Tserendulam Project coordinator Zavkhan aimag Ganzorig D. Officer, Nutrition Research Centre NPHI 62

64 5. NSO, CRIC and PTRC informants Chief, Population and Oyunchimeg D. Social Statistics Division NSO Chief, Methodology and NSO Demberel A. Analysis Division Officer, Monitoring and NSO Tseveennyam Ts. Evaluation Division Senior officer, Population NSO Davaakhuu B. and Social Statistics Division Bolormaa S. Officer NSO Oyuntsetseg M. Officer NSO Gavaasuren L. Head, Registration and Information Division CRIC Senior officer, Registration CRIC Yanjmaa and Information Division Officer, Registration and CRIC Selenge Information Division Munkhtsetseg Assistant officer CRIC Badamkhand D. Senior soft ware developer CRIC Solongo Kh. Demographer PTRC 63

65 6. Aimag and district informants Tuul S. Head Bayangol District Health Center Rina B. Statistician Bayangol District Health Center Puntsag B. Head Bayanzurkh District Health Center Oyungerel N. Statistician Bayanzurkh District Health Center Byambaa O. Head Sukhbaatar District Health Center Jargalsaikhan S. Statistician Sukhbaatar District Health Center Ganshur Statistician Chingeltei District Health Center Ulambayar Ch. Head in charge of public health Chingeltei District Health Center Buyanmandakh E. Head Khan-Uul District Health Center Tuya Statistician Health Center, Khan-Uul District Unur J. Statistician Selenge Aimag Health Department Tsolmon N. Physician Baruunburen Soum Hospital, Selenge Aimag Tsend-Ayush "Itgel Ugtah FGP Sukhbaatar district Jigden "Melmii hurts" FGP Sukhbaatar district Bold Ts. "Manai emneleg" FGP Sukhbaatar district Davaasuren I. "Tracter" FGP Bayangol district Tsetsegmaa D. "Tegshmend" FGP Bayangol district Byambajav T. "Manai emch" FGP Bayngol district Unurjargal G. "Egneshgui" FGP Selenge aimag Chimgee D. Nomthan" FGP Selenge aimag Khaltar D. "Khadanhui" FGP Selenge aimag Togoo L. "TONE" FGP Songinokhairkhan district 64

66 Batchimeg Kh. "Sanhun" FGP Songinokhairkhan district Altantsetseg Z. "Sanhun" FGP Songinokhairkhan district Bayasgalan Statistician Arkhangai Aimag Health Department Batchimeg B. Statistician Khuvsgul Aimag Health Department Chimgee Statistician Uvs Aimag Health Department Odgerel B. Officer Dornogobi Aimag Health Department Davaakhuu N. Statistician Huvsgul Aimag General Hospital Enkhjargal T. Statistician Huvsgul Aimag Health Department Dungaamaa Deputy Director Regional Diagnostic and Treatment Center, Khovd aimag Tungaamaa Statistician Military Hospital Otgonbayar Deputy Director Uvs Aimag General Hospital Ganchimeg Deputy Head Zavkhan aimag Health Department Sunjidmaa J. FGP Khuvsgul aimag Togtokhsuren FGP Khuvsgul aimag 65