The health system of a country has to deliver three basic services: preventive, curative, and rehabilitative care. These services are delivered through primary, secondary and tertiary health care institutions, doctors, nurses and medical specialists. The foremost duty of a state is to provide good quality primary health care services to its people. Development of health services depends on health care policies pursued by the government.
The health care system of Mongolia is ranked first in the world for having the most number of physicians per 1,000 people. However, the quality of Mongolia’s health services is one of the worst internationally and preventive service is almost non-existent today, forcing Mongolian citizens to avoid receiving domestic health services and instead entrust their health to foreign hospitals. The health policy, which permits these things to happen, lacks clarity.
ANOMALY IN HEALTH CARE SYSTEM
Mongolia, population three million, has 600 state-owned hospitals and 1,200 private ones. Mongolia’s health industry has a total of 40,000 employees, 7,500 of which are doctors and 9,200 are nurses. Mongolia has 27 doctors, 36 nurses and 58 hospitals beds per 10,000 people. Although these numbers are higher than those of developed countries, the quality of medical services is worse than that of developing countries.
Private hospitals in Mongolia specialize in different organs of human body and have separate databases that have no interconnection. There are a total of 1,200 private hospitals and 1,000 of them have no beds for patients. The rest, 200 private hospitals, have 10 hospital beds on average and are located in residential apartments. Those hospitals have the same functions as recreational facilities and do not admit patients in critical conditions. If these private hospitals come across such patients, they just send them over to public hospitals.
Primary care is provided through 311 soum hospitals and 220 family group practice facilities. The funding for primary health care is allocated in relation to the local population. Currently, the yearly funding per capita is about 17,000 MNT, which is approximately 10 USD. It is six times less than the amount recommended by the World Health Organization to Mongolia.
Secondary care is supposed to be delivered through 22 aimag (provincial) hospitals and nine district hospitals. However, district hospitals do not perform the simplest of surgeries, deliver babies or provide child health services. That is why all treatments and surgeries that should be done at primary and secondary care institutions are currently being handed over to the tertiary care institutions – 17 specialized hospitals and four clinics. These tertiary care institutions are currently flooded with patients demanding treatments and surgeries that belong to primary and secondary levels. As a result, specialized hospitals are unable to fulfill their main responsibilities and only leave citizens the choice to travel abroad for medical treatment.
Mongolian hospitals still employ outdated equipment and operate in old buildings with planning and structure that are inadequate for the purposes of health institutions. Furthermore, they have weak infrastructure and are not able to meet the most basic hygienic and sanitary standards. Also, most hospitals falsely create congestion and make patients wait for many hours before providing medical services. Frustration towards medical institutions have reached an all time high as they allow some patients to stay in hospitals longer than required and tell those who desperately need hospital treatments that there are no beds available for them. In addition, unsatisfactory levels can be seen in the capacity of doctors and the general comfort of hospitals. Due to the lack of communication and professional ties between hospitals and the absence of a patient handoff system, people move between hospitals based on their own opinion without any professional recommendation about the kind of treatments needed next.
Hospitals have been spending most of their funding which are allocated from the public budget on maintenance costs of the old buildings that they operate in (heating, power… etc), purchase of mecine and medications, and hospital catering services. Only a small portion of funding goes into the actual health care and medical services. A total of 400 billion MNT was spent from the public budget on the health sector in 2013. It is absolutely not enough that they spent only 30 billion MNT on purchasing new equipment.
A 250-bed hospital is going to be built in Songinokhairkhan District in 2014 with a 35 million USD loan from the Asian Development Bank. In Bayanzurkh district, a hospital with 150 beds is going to be constructed with a non-refundable aid of 35 million USD from Japan International Cooperation Agency which will operate in cooperation with the Health Science University of Mongolia. However, in order to maintain the regular operations of a hospital, a turnover capital worth 30-70 percent of the initial investment is needed each year. Unless such turnover capital is available, it will not be possible to train the required personnel for the newly built hospitals and use the new equipment.
Mongolia is also ranked first in the world for having the most number of pharmacies per 1,000 people and the amount of counterfeit medications sold by them. According to a survey conducted by the Asian Development Bank in 2013, 28 percent of pharmacies in Mongolia were illegitimate. Local health authorities and inspection agencies who granted the permits to these illegitimate pharmacies should be making efforts to investigate such claims and stop counterfeit medication trade.
Furthermore, one fifth of the total drugs sold in Mongolia were not registered to the state. Is the State Specialized Inspection Agency aware of this? The fancy-named Mongolian Consumers’ Association, who claim to be protecting the rights of consumers in the country, appears to have failed to noticed that the person behind the counter in pharmacies have the prices of drugs and pills that they sell memorized without putting up any price tags.
WE NEED A CLIENT-CENTERED HEALTH SYSTEM RATHER THAN A HOSPITAL-CENTERED ONE
The reason for the pathetic situation of the health sector lies in its inefficient system and unwise management. The health industry is the only sector that has not been changed for the duration of 20 years since the democratic revolution. Its management is still hugely centralized that the ministry makes final decisions on everything such as how many beds and nurses a public hospital should have and how much its employees should earn. Public hospitals are funded from the public budget based on the number of their employees. Furthermore, the management of public hospitals is appointed directly by the political party in power. Therefore, public hospitals attach no significance to their labor productivity or the quality of their service.
All employees of public hospitals are public servants and the State Property Committee manages all properties of hospitals. Their funding is handled by the Ministry of Finance, which also makes the decision on what equipment it should purchased. The Ministry of Health also has a say in the purchases of public hospitals. For these reasons, public hospital management can never make business decisions quickly in urgent need.
All these anomalies in the system must be fixed immediately. Investment must be made in soum, aimag and district hospitals and their operations ought to be aligned with each other. The capacity of secondary care hospitals should be increased so that they can perform surgeries and provide basic services such as delivering babies. This way the tertiary care hospitals will have less pressure.
In light of the current discussions on the health insurance law, the health care system should be changed in order to reduce centralization, separate hospitals from political parties and turn public hospitals into state-owned companies with the ultimate goal to fully privatize them. It is time to have private hospitals more involved in the tertiary health care and take a smart, decisive step that engages the public and private health insurance companies.
The secondary care hospitals (aimag and district hospitals) need to be combined into health centers while the services provided under the primary care should be expanded to improved quality. The expanded services should include early diagnosis of cancer.
All hospitals should be freed from the management of the Ministry of Health. The ministry should only have the responsibilities to issue permits to hospitals and make sure that they operate in compliance with health standards. Hospitals should be independent of the state in decisions such as those regarding finance and human resources. The heads of hospitals should report to a board of directors, not to a minister.
The Mongolian people should be provided with an opportunity to receive 70 percent of their medical payment from their health insurance and the rest, 30 percent, from private insurances. It can be achieved through a step by step process, and insurance companies can provide scrutiny over the drugs sold by hospitals and pharmacies, and the quality of their services.
The current structure of the health sector will not allow any fundamental change even if twice the amount of funding for health care is received. Simply put, no difference can be made unless the whole system is changed.
Mongolian citizens are demanding their government to make a substantial reform in its health sector. Let us put our individual efforts for a healthier life.
Translated by B.AMAR
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