THIRD HEALTH SECTOR DEVELOPMENT PROJECT

MINISTRY OF HEALTH OF MONGOLIA THIRD HEALTH SECTOR DEVELOPMENT PROJECT INCEPTION REPORT by the GVG consultancy team 8 September 2009 Gesellschaft fьr Versicherungswissenschaft und -gestaltung e.v. (GVG) Hansaring 43, 50670 Cologne, Germany Tel.: +49/ 221/ 912 867 17, Fax: +49/ 221/ 912 867 59 e-mail: m.wrede@gvg-koeln.de www.gvg-koeln.de

TABLE OF CONTENTS 1 INTRODUCTION... 3 2 RECENT BACKGROUND DOCUMENTS... 4 3 SITUATION ANALYSIS... 5 3.1 Situation in health services delivery, with emphasis on primary care... 5 3.2 Situation in health care financing... 6 3.3 Situation in human resource development... 7 3.4 Situation in privatisation... 8 4 DISCUSSION... 9 5 WORK PLAN... 12 5.1 General... 12 5.2 Work plan for Component 1 in 2009... 12 5.3 Work plan for Component 2 in 2009... 14 5.4 Work plan for Component 3 in 2009... 15 5.5 Work plan for Component 4 in 2009... 17 6 RISKS AND ASSUMPTIONS... 18 7 REFERENCES... 19 ANNEX A TERMS OF REFERENCE... 21 ANNEX B LIST OF ACTIVITIES, OUTPUTS AND INDICATORS... 27 ANNEX C AGREED LIST OF DELIVERABLES... 48 ANNEX D PROJECT TEAM... 50 ANNEX E OVERVIEW OF MEETINGS AND VISITS DURING INCEPTION PERIOD... 51 ANNEX F DEFINITIONS... 53 ANNEX G BASELINE DATA REQUIREMENTS... 55 ANNEX H PLANNED USE OF CONSULTANTS PERSON-MONTHS, 2009-2013... 57 ANNEX I INDICATIVE TIME SCHEDULE FOR THE ACTIVITIES OF THE 4 COMPONENTS... 59 1

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

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

2 RECENT BACKGROUND DOCUMENTS A comprehensive review of existing information on the Mongolian health care sector was published in 2004. This Synthesis Paper served as a tool to guide the development of the Health Sector Strategic Master Plan 2006-2015 published in 2005, and its Implementation Framework 2006-2010 published in 2007. These documents provide the framework for the Third Health Sector Development Project which is described in the Report and recommendation of the President to the Board of Directors of October 2007, and for the role that the GVG consultancy team will play within the THSDP. During the inception phase, the consultancy team profited from several recent evaluation reports, especially: World Bank. The Mongolian health system at a crossroads; an incomplete transition to a post-semashko model. Washington DC, January 2007. T. Bolormaa et al. Mongolia: Health system review. Health Systems in Transition, 2007; 9(4):1-151. World Bank. Public expenditure financial management review. Chapter: The health sector. September 2007. ADB. Mongolia HSDP: Performance evaluation report. February 2008. ADB. Health and social protection Rapid sector assessment. October 2008. The Synthesis Paper and the above-mentioned reports clearly describe the achievements of the health care reform process so far, and the remaining challenges, which will therefore not be repeated in this inception report. An important document for our work in the THSDP is the Memorandum of Understanding for the proposed Project Preparatory Technical Assistance for the Fourth Health Sector Development Project of March 2009 and its attachment 2.II, for the information on the hospital sector. Many of our activities will be related to the hospital sector, and co-operation and complementarity with the fourth Health Sector Development Project will be essential. The Health Systems in Transition document states that a radical hospital restructuring policy is essential in Ulaanbaatar, and the World Bank report (its annex 2) and the Memorandum of Understanding agree. Apart from the Master Plan and the THSDP project document, the Government Action Plan 2008-2012 has 22 health objectives that will also guide our project. At the moment, working groups are preparing amendments to the Health Law and the Health Insurance Law, but no firm recommendations have been formulated yet. It would be advisable to wait for some of the results of the THSDP before adopting such revision. The existing policy on human resources is laid down in Order nr. 277: Health sector human resource development policy 2004-2013 (2003). In 2008, the Ministry has also presented the Health professionals career development document which includes information on incentives schemes, but this document has not yet been translated and analysed by the consultancy team. A recent analysis by two Mongolian legal consultants has concluded that the present status of Family Group Practices as private but non-profit partnerships is not compatible with Mongolian law, and they propose options to resolve this situation. Various health financing reports, government documents, including official reports, resolutions and ministerial orders were used to prepare the health care financing inputs to this report and plan the further actions. The documents and articles that have so far been used to prepare the team for the tasks ahead are listed in Chapter 7. 4

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

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

There is no health insurance strategic document to make revisions and updating, but there is an early draft of health care financing policy. An inter-ministerial working group has been established to prepare a new draft of the Health Insurance Act. The draft law is expected to be submitted to the Government Cabinet and the Parliament this fall for approval. There is no baseline data to assess impoverishment, out-of-pocket payment and catastrophic health expenditures since 2002. According to amendments to the Health Insurance Law in 2006, the Ministry of Health decides which services, how and according to what tariffs will be financed from the Health Insurance Fund, and also how many hospitals and beds will be financed from the Health Insurance Fund. The State Social Insurance General Office (SSIGO) estimates the budget according to the number of beds approved by the Ministry of Health and defined tariffs. Recently, the Ministry of Health developed diagnosis-related groups (DRG), which were approved by the Minister of Health. New tariffs of inpatient and outpatient services were developed. 3.3 Situation in human resource development It is not the intention of this section to repeat all the previous discussions of the issues and challenges facing the health sector in the field of human resource development. This ground is already adequately covered in recent reports listed in chapter 2 and in the Information Package produced by the Intersectoral Committee on Health Sector Human Resources (2008). The number of stakeholders involved in any aspect of human resource standards, training and social security in the health sector in Mongolia is itself a matter for concern although beyond the scope of this report. It is axiomatic that the greater the number of organisations involved in any issue then the greater the difficulty of bringing about desired changes. This is demonstrated by the fact that it is acknowledged that there are too many physicians in Mongolia, indeed there is a problem of doctor unemployment. In the Synthesis Paper, 2004, p. 124 (English edition) reference is made to an agreement to decrease the number of entrants to the school of medicine of the Health Sciences University by 50% by the year 2010 and correspondingly increase the number of entrants to the allied health professional courses in accordance with the human resources planning policy. It is now still only 2009 but it appears that this agreement is not being implemented. The Intersectoral Committee had as one priority area to ensure compliance of postgraduate trainings with sector s human resource policy and strategy. Clearly this objective has yet to be achieved. There is said to be shortage of doctors in rural areas but the reported numbers do not support this view. It may well be that the standards set are too generous, and one of the activities of this consultancy is to review standards for all health sector workers, both in hospitals and in family medicine, in relation to national and international norms. It may also be that the competencies of the health care workers in rural areas are inappropriate for their duties or inappropriate to the requirements of the FGP concept. There is a relative lack of nurses and other allied health professionals throughout the healthcare delivery system, with a nurse to doctor ratio of slightly higher than 1:1 and the target (MOH Public Administration and Management, August 2009) is to raise this to slightly higher than 3:1.Although there is a system of registration linked to Continuous Professional Development, the number of health sector workers covered by professional degree studies and training is low by international standards and the system needs review. Human resource management training is organised by the Health Department and by the Ministry of Health and both have expressed a wish for integration of curricula and of training materials. Problems facing the health sector in this field are said to be a lack of continuity, with rapid movement of trained managers, no career pathways, inappropriate organisational structure and poor, and poorly used, information pathways. 7

There is a National Association of Medical Education that has a working group looking to establish a core curriculum for undergraduate medical education: this is still a work in progress. There is no nationally agreed curriculum for post-graduate medical education and apparently no discussion on the topic. Although private educational establishments need to be accredited by the Ministry of Education and Culture that accreditation process does not require compliance with national curricula nor do enrolment numbers have to match the stated needs of the health sector. The Ministry of Health has issued standards for postgraduate medical education and checking compliance with these standards is underway. 3.4 Situation in privatisation The selected international consultant for component 4 has not yet visited Mongolia mainly because there was a vacancy for the position of local consultant for this subject at the beginning of our consultancy, and because the total availability of the international consultant is limited to 3 person-months over a the project period of 4 years. Therefore, analysis for component 4 will follow in the coming months. The new local consultant for component 4 has started his activities on 1 September 2009. Important issues in component 4 will be the unclear private position of FGPs (recently analysed by two local legal consultants), and the lack of regulation of private primary and secondary level services and facilities in Ulaan Baatar and aimag centres. 8

4 DISCUSSION The results of our short situation analysis do not really differ from the description of the existing situation in the documents mentioned in chapter 2, but some remarks will clarify our understanding of the issues we will have to deal with. As there sometimes is some confusion about terminology in health system analysis, a list of definitions and short descriptions is presented in Annex F. An overview of the relation between major challenges mentioned in existing reports, the proposed strategies in the Master Plan, and the list of activities for which the consultants are responsible is presented in the table below. The conclusion of this table is that many remaining challenges in health care reform are covered by the Master Plan and by our planned contribution to the THSDP. However, there are some challenges that seem to have received less emphasis in existing documents and in some cases facts on the ground seem different. challenge/bottleneck according to existing reports and other documents Master Plan 2005 Annex B strategy nr. activities THSDP (C = component) health care delivery, with emphasis on primary care scope/quality of FGP services insufficient 1, 2, 12, 13 C1.6, (C1.10) gate-keeping/referral system not respected 3 C1.5, (C1.13), C1.20 hospital admission rate of 239/1,000 (3), 24 C1.5, C1.7, C1.20 too much paper work in primary care (13), 23 - unclear legal status of FGPs - - unclear profile of sum hospitals - C1.16, C1.17 insufficient rationalisation of UB hospitals 24 (C2.13) inappropriate use and shortages of drugs 4, 6-7 x 24 hours provision of primary care (1) - health care financing FGPs fully funded from the state budget - C1.3 inappropriate contracting and payment method for FGPs 18 C1.1, C1.2, C1.4 disproportionate funding of inpatient care (24) C2.12-15 inappropriate contracting and payment method for inpatient care 18 C2.13 unclear targeting of the poor/vulnerable - - functioning of the health insurance system 19 C2.1-11 unregistered patients - - one quarter of population not insured 19 C2.8 poor MOH-MOSWL-HIF coordination (19) C2.5 9

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

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

5 WORK PLAN 5.1 General It is the aim of the consultancy team to follow the lists of activities and deliverables presented in Annexes B and C. Some minor changes in the original lists have been agreed between the PIU and the consultancy team, and have been inserted in Annexes B and C. The detailed plan of work for the period September-December 2009 is described below. The next consultancy report will be a combination of a quarterly and an annual report, covering the period September-December 2009. It will be submitted as a draft before 31 December 2009 and will include a detailed work plan for the year 2010. A list of baseline data to be collected by the consultancy team is presented in Annex G. A preliminary overview of the planned use of consultants person-months is presented in Annex H. An indicative time schedule for the activities to be carried out under the four components is presented in Annex I. This shows that the project activities are (too) heavily concentrated in the period September 2009 until December 2010, probably because of the delay of the start of the project. The consultancy team will do its utmost to comply with the tight deadlines imposed by the List of deliverables. 5.2 Work plan for Component 1 in 2009 An overview of planned activities and deliverables is presented in the table. deliverables component 1 (see Annex C) 1. performance contract FGPs; approval of revised contract time line activities component 1 (see Annex B) end of 2009; first quarter 2010 1. improve performance contract 2. income/incentives FGPs first quarter 2010 2. develop FGP income package 3. risk-adjusted capitation first quarter 2010 3. + 4. FGP funding and FGP incentives 4. referral and gate keeping end of 2010 5. + 20. gate keeping and referral guidelines 5. clinical guidelines development end of 2010 6. develop PHC guidelines 6. assessment PHC equipment end of 2010 9. provide PHC equipment 7. training of PHC staff end of 2010 7. + 12. + 18. + 21 + 22. PHC and Ulaan Baatar Health Department training and CME 8. advocacy PHC end of 2010 13. + 15. FGP advocacy 9. delineating sum health centre role end of 2009 16. + 17. sum health care role delineated 10. extension of PHC end of 2011 19. extend PHC programmes 8. local government training 12

deliverables component 1 (see Annex C) time line activities component 1 (see Annex B) 10. development model FGPs 11. support UB Health Dept. 14. doctor choice guidelines 15. develop PHC support From this table, it is clear that several activities are not matched by deliverables, i.e. they are as yet without a time line. It also seems that the deadline for nearly all deliverables is before halfway the project. However, many deliverables appear to have been defined as the foundation for implementation during the period 2011-2013. It will therefore be important not to use up most of consultants time before the end of 2010. A more precise distinction between development and implementation will be made before the end of 2009, matched by the estimated required consultants time for both. That means that Annexes H and I may have to be revised in the coming months after baseline data and other information have become available. During September, the consultants will collect the necessary baseline data (see Annex G) and documents. They will visit health facilities and other institutions, both in Ulaan Baatar and in the pilot aimags, and survey the international literature, especially on performance measurement and performance-based payment, and on the planning and provision of rural health services. In October and November, the consultants will analyse present Mongolian arrangements for performance measurement and performance-based payment, and prepare recommendations on an improved performance contract for FGPs (activity 1). The results of the analysis and the recommendations will be presented in a short technical report. A workshop will be organised around 1 December to discuss the draft recommendations with stakeholders. The final recommendations will be submitted not later than 31 December 2009. Also in October and November, the consultants will analyse the present situation in the sum and inter-sum hospitals in the five pilot aimags, and prepare recommendations on the possible future role and services to be provided by sum and inter-sum hospitals and/or sum health centres (activity 16; related to activity 17). The results of the analysis and the recommendations will be presented in a short technical report. A workshop will be organised around 1 December to discuss the draft recommendations on future sum health services with stakeholders. The final recommendations will be submitted not later than 31 December 2009. During the whole period September-December, the consultants will prepare for activities 2 and 3 which should lead to the next deliverables in the first quarter of 2010. 13

5.3 Work plan for Component 2 in 2009 Two documents define the activities and outcomes to be produced by the Health Financing component of the GVG Consultancy Team. Those documents are Annex B (List of activities, outputs and indicators) and Annex C (List of deliverables). deliverables component 2 (Annex C) time line activities component 2 (Annex B) 11. New health care financing model developed and approved Plan for main financial reform to be introduced in the health sector developed and approved. 12. Agreement on fund pooling mechanisms and single purchaser. Implementation of piloting of pooling of funds and single purchaser mechanisms. 13. Policy recommendation on overall health insurance policy. Recommendations on out-of-pocket, co-payment and payment methods. 14. Recommendation on mechanisms for mitigating the effect of financial barriers to access, outof-pocket expenses, and catastrophic payments. 15. Recommendation on private health insurance 16. Recommendation on improving hospital efficiency. Implementation of efficiency measures in pilot hospitals. mid 2010 mid 2010 end of 2009 end of 2012 mid 2010 mid 2010 end of 2010 first half of 2010 end of 2010 end of 2012 1. review and approve new financing model 3. health financing plan submitted to ADB 2. training on implementation of single purchaser system 4. develop single purchaser model and pooling 5. agreement on pooling and single purchaser 6. pilot single purchaser model 7. extend pooling and single purchaser model 8.1 and 8.2. review and revise health insurance principles and legal framework 9. review and revise health insurance rates and payment 10. awareness raising on financial barriers to access to health care 11. strengthen private health insurance regulation 12. review constraints to hospital efficiency 13. develop market options in the hospital sub-sector 14. introduce efficiency incentives 15. training on improved efficiency 8.3. Assist in developing and implementing a plan of action to conduct an education and enrolment campaign to improve overall health insurance coverage among the general population and with a particular emphasis on poor and vulnerable people. 14

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

deliverables component 3 (Annex C) time line activities component 3 (Annex B) 17. Sector-wide workforce plan developed and approved. Report on implementation and evaluation of workforce plan in selected aimags 18. Recommendation on training materials and references in human resource management and organisational management. Recommendation for a residency programme on family medicine, training modules and materials 19. Policy paper (documentation) to promote training incentives or subsidies mechanisms for rural area medical staff. Plan of action for implementing the new training-incentive system end of 2010 end of 2012 end of 2010 end of 2010 end of 2010 end of 2010 1. Develop workforce plan model 2. Human resource training in pilot aimags 6. Training incentives/subsidies 7. Human resources incentive package 3. Support long-term fellowships 4. Support High Level Human Resources Committee in line with the human resources strategies in the Implementation Framework of the Master Plan 5. Options for family medicine specialty structure During September, the consultants will collect the necessary baseline data (see Annex G) and documents. They will continue to liaise with established contacts with the Health Department, Ministry of Health and other stakeholders to deepen the understanding of the data already received. They will, using internet searches, seek for accepted staffing standards, incentivisation of rural health staff and continuous professional development. In October and November, the consultants will analyse the current staffing situation in the health sector and specifically in the pilot aimags, some or all of which will be visited, and establish and secure confirmation of the current standards. The consultants will discuss with consultant sub-group 1 the direction of that sub-group s thinking on the model of delivery of health care. The model to be proposed may alter, possibly radically, the standards to be adopted when assisting to develop a sector wide work plan (activity 1.1). Comparisons will also be made with international norms, averages or standards. A short report of the work undertaken and the results to date will be presented at a stakeholder workshop organised in late November to discuss the draft recommendations with stakeholders. The final recommendations will be submitted not later than 31 December 2009. Also in October and November, the consultants will concentrate on securing details of the training in human resources management and Organisational Development, evaluating the curriculum and training methods and materials used and making recommendations for future training (activity 2.1). 16

The consultants will examine the literature, and consult widely with stakeholders to elicit views and proposals for the promotion of training incentives or subsidy mechanisms for rural area medical staff (activity 6). A short report of the work undertaken and the results to date will be presented at a stakeholder workshop organised in late November to discuss the draft recommendations with stakeholders. The final recommendations will be submitted not later than 31 December 2009. During the whole period September-December, the consultants will prepare for activities 3, 4 and 7 which should lead to the next deliverables in the first half of 2010. 5.5 Work plan for Component 4 in 2009 The detailed work plan will be made by the new local consultant and the international consultant in consultation with the (deputy-) team leader of the consultancy team. A report on activity 1 (Review of the private sector) can hopefully be completed before the end of 2009, and preparation for activities 2 and 3 be made. 17

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

7 REFERENCES ADB. Program Completion Report on the HSDP in Mongolia. September 2004. ADB. Proposed Asian Development Fund Grant - Mongolia THSDP. October 2007. ADB. Mongolia HSDP: Performance Evaluation Report. February 2008. ADB. THSDP Project Information Document, 2008. ADB. Health and Social Protection - Rapid Sector Assessment. October 2008. ADB, Ministry of Finance, World Bank. Manual on mid-term planning, output and program based budgeting for public organizations. Ulaan Baatar 2009. Bolormaa T et al. Mongolia: Health system review. Health Systems in Transition, 2007; 9(4):1-151. Byambaa R. Inappropriate admissions at hospitals of tertiary and secondary level of care in Ulaanbaatar. No date. Fuenzalida-Puelma HL. Private sector regulatory and institutional issues in Mongolian health reform. Ulaanbaatar, April-May 2004. Government of Mongolia, Ministry of Health. Health Sector Strategic Master Plan 2006-2015. Ulaanbaatar, 2005. Government of Mongolia, Ministry of Health. The Implementation Framework of the Health Sector Strategic Master Plan 2006-2010. Ulaanbaatar, 2007. Government of Mongolia. Millennium Development Goals-based comprehensive national development strategy of Mongolia. Ulaan Baatar 2008. Government Resolution no. 172. The guidelines on selection of health organisations to provide health services which are funded from government budget and Health Insurance Fund. Ulaan Baatar 2008. Healy J, McKee M. Chapter 4 - The role and functions of hospitals. In: McKee M, Healy J (eds). Hospitals in a changing Europe. Buckingham/Philadelphia, Open University Press, 2002. Hindle D, Khulan B. New payment model for rural health services in Mongolia. Rural and Remote Health, 2006;6:434 (online). Implementing Agency of the Government of Mongolia, Department of Health. Health indicators 2008. Ulaan Baatar, 2009. Intersectoral Committee on Health Sector Human Resource. Information package. Ulaan Baatar, 2008. Joint Ministerial order No 73/53/33: The payment rates for health services to be funded from the Health Insurance Fund. Ministries of Health, Finance, and Social Welfare & Labour, March 2009. Ministry of Health. Order nr. 277. Health sector human resource development policy 2004-2013. 27 November 2003. Ministry of Health, Government of Mongolia. Synthesis paper (second revised reprint). March 2004. Ministry of Health. Ministerial order no. 37. The list of health insurance funded health services to be provided by private health organizations and the evaluation criteria for selection of private health organizations to be funded from the Health Insurance Fund. February 2009. 19

Ministry of Health. Ministerial order no. 180: The list of DRGs to be funded from Health Insurance Fund and their cost weight (App.1). The payment methods for health insurance funded health services and the guidelines for estimating health insurance payment rates (App.2). June 2009. Ministry of Health and ADB. Memorandum of Understanding - proposed Project Preparatory Technical Assistance Mongolia - Fourth Health Sector Development Project. March 2009. National Audit Office. Report on health care financing and user charges. Ulaan Baatar, October 2008 Orgil B, Hindle D, O Rourke M, Batsuury R, Sonin S. Privatised family group practices in Mongolia: an initial survey of service access. Australian Health Review 2002;25(4):19-30. O Rourke M, Mira M, Orgil B, Jeugmans J. Developing family medicine in Mongolia. Asia Pacific Family Medicine 2003;2:65-70. Sodnom Bekhbat, Ross Sutton. Towards donor coordination in the health sector in Mongolia. No date. Ulikpan A, Mirzoev TN, Narula IS. Is the Mongolian health sector ready for a sector-wide approach? Asian Social Work and Policy Review 2008;2(2):111-25. WHO. Mongolia. Country Health Information Profiles, pp. 243-258 (online). World Bank. The Mongolian health system at a crossroads; an incomplete transition to a post-semashko model. Washington DC, January 2007. World Bank. Public expenditure financial management review. Chapter: the health sector. September 2007. Family medicine experiences in other countries with a Semashko background Atun R et al. Review of experience of family medicine in Europe and Central Asia: Moldova case study. World Bank, May 2005. Curochicin G et al. Management of human resources in primary care in Moldova. September 2008. Kalda R. The current system of primary care, role of the Estonian Society of Family Doctors. June 2006. Liseckiene I et al. Primary care in a post-communist country 10 years later. Comparison of service profiles of Lithuanian primary care physicians in 1994 and GPs in 2004. Health Policy 2007;83:105-13. Rese A et al. Implementing general practice in Russia: getting beyond the first steps. BMJ 2005;331:204-7. Schaapveld K. A comprehensive view of primary care reform in Georgia. April 2005. 20