Free and universal access to primary healthcare in Mongolia: the service availability and readiness assessment

Medical education in Mongolia: Challenges and opportunities

In the early twentieth century, Mongolia saw the establishment of Western medicine and educational system, supplementing its pre-existing history of eastern medicine. As a lower-middle-income country with vast landmass and low population density, Mongolia's medical education landscape has evolved significantly. The inception of the Mongolian National University of Medical Sciences in 1942 marked a pivotal moment, initiating the modern era of medical sciences and specialized training programs in the country. Initially shaped by Soviet Union-styled medical curriculum, the system has undergone substantial reform since the constitutional shift to a market economy in the 1990s. This transformation aligned the curriculum with international standards and modern educational approach, focusing on producing skilled medical professionals. Presently, over 10 public and private institutions of higher education in Mongolia provide comprehensive undergraduate, graduate and post-graduate training for medical training. These institutions vary in student enrollment, teaching staff, learning environments, and program models, contributing to the diverse landscape of medical education in the country.

Perceived readiness for diabetes and cardiovascular care delivery in Mangochi, Malawi: multicentre study from healthcare providers' perspectives

BACKGROUND

Despite the expected prevalence rise of 98.1% for diabetes between 2010 and 2030 in sub-Saharan Africa (SSA) and the anticipated rise of both diabetes and cardiovascular diseases (CVDs) in Malawi from their current figures ( 5.6 and 8.9%; respectively), data on the readiness of health facilities to provide diabetes and cardiovascular diseases in Mangochi district is not available. Therefore, this study aimed to assess the readiness of health facilities to provide services for diabetes and cardiovascular diseases.

METHODS

An exploratory study was conducted from July to early September 2021 in 34 health facilities in Mangochi, Malawi. Forty-two participants were purposefully selected. They included medical officers, clinical officers, medical assistants, and registered nurses. The study used semi-structured interviews (for qualitative data) with a checklist (for quantitative data) to provide information about the readiness of services (such as guidelines and trained staff, drugs, diagnosis capacity and equipment, essential medicines, community services, and education/counseling).The thematic content analysis and basic descriptive statistics were carried out.

RESULTS

The following main theme emerged from the qualitative part: low use of diabetes-cardiovascular disease (CVD) services. This was due to: health facility factors (shortage of drugs and supplies, poor knowledge, few numbers and lack of training of providers, and absent copies of guidelines), patients factors (poor health-seeking behaviour, lack of education and counseling for many), and community factors (very limited community services for diabetes and CVDs, lack of transport policy and high transportation costs). Data from the checklists revealed low readiness scores across domains (below the 75% target) in diabetes and cardiovascular diseases: trained staff and guidelines (26.5% vs. 32.4%); diagnosis capacity and equipment (63.7% vs. 66.2%); essential medicines (33.5% vs. 41.9%), and community services, and education and counseling (37.5% vs. 42.5%).

CONCLUSION

There were several noticeable shortfalls identified in the readiness of health facilities to provide diabetes and cardiovascular disease services in Mangochi health facilities. Any future intervention in diabetes-cardiovascular disease care in these areas must include these elements in its basic package.

Human immunodeficiency virus, tuberculosis and malaria service readiness at the primary healthcare centers in Ekiti State, Nigeria

Introduction

access to services encompasses three components: availability, affordability, and acceptability. The physical presence of service delivery, which includes health infrastructure, core health staff, and aspects of service use, is referred to as service availability. This study was conducted to inform the health service availability and preparedness to deliver HIV, TB, and malaria prevention and control services in Ekiti State.

Methods

this is a descriptive cross-sectional study conducted among all the Primary Health Centres (177) in Ekiti State Nigeria between August and October 2020. Data were collected with the use of the World Health Organization Service Availability and Readiness Assessment tool and were analyzed using STATA SE 12.

Results

close to half (49%) of them had a condom in supply. More than 90% of them provided diagnosis and treatment of malaria. The HIV-specific service readiness index was approximately 40/0%. Only 26.6% of health facilities were ready to offer TB prevention and control services. Malaria specific service readiness index was 61.9%. There was a statistically significant difference in the HIV and TB-specific service readiness of facilities in the urban compared to rural locations. Health facilities located in the urban areas had higher mean readiness scores compared to those in the other residential areas (P=0.014).

Conclusion

it is evident that HIV and TB-specific service readiness is very poor among PHCs in Ekiti State. Malaria Service Readiness was fair. Ekiti State government needs to expand investments in PHCs by strengthening the diagnostic services, commodities and medicine supply, adequate equipment and staff training.

Crowding-Out Effect of Out-of-Pocket Health Expenditures on Consumption Among Households in Mongolia

BACKGROUND

High out-of-pocket (OOP) health expenditures are a common problem in developing countries. Studies rarely investigate the crowding-out effect of OOP health expenditures on other areas of household consumption. OOP health costs are a colossal burden on families and can lead to adjustments in other areas of consumption to cope with these costs.

METHODS

This cross-sectional study used self-reported household consumption data from the nationally representative Household Socioeconomic Survey (HSES), collected in 2018 by the National Statistical Office of Mongolia. We estimated a quadratic conditional Engel curves system to determine intrahousehold resource allocation among 12 consumption variables. The 3-stage least squared method was used to deal with heteroscedasticity and endogeneity problems to estimate the causal crowding-out effect of OOP.

RESULTS

The mean monthly OOP health expenditure per household was ₮64 673 (standard deviation [SD]=259 604), representing approximately 6.9% of total household expenditures. OOP health expenditures were associated with crowding out durables, communication, transportation, and rent, and with crowding in education and heating for all households. The crowding-out effect of ₮10 000 in OOP health expenditures was the largest for food (₮5149, 95% CI=-8582; -1695) and crowding-in effect was largest in heating (₮2691, 95% CI=737; 4649) in the lowest-income households. The effect of heating was more than 10 times greater than that in highest-income households (₮261, 95% CI=66; 454); in the highest-income households, food had a crowding-in effect (₮179, 95% CI=-445; 802) in absolute amounts. In terms of absolute amount, the crowding-out effect for food was up to 5 times greater in households without social health insurance (SHI) than in those with SHI.

CONCLUSION

Our findings suggest that Mongolia's OOP health expenses are associated with reduced essential expenditure on items such as durables, communication, transportation, rent, and food. The effect varies by household income level and SHI status, and the lowest-income families were most vulnerable. SHI in Mongolia may not protect households from large OOP health expenditures.

A pilot cost-benefit analysis of a children’s spectacle reimbursement scheme: Evidence for Including children’s spectacles in Mongolia’s Social Health Insurance

Background and aim

Globally, 12.8 million children have vision impairment due to uncorrected refractive error (URE). In Mongolia, one in five children needs but do not have access to spectacles. This pilot cost-benefit analysis aims to estimate the net benefits of a children’s spectacles reimbursement scheme in Mongolia.

Methods

A willingness-to-pay (WTP) survey using the contingent valuation method was administered to rural and urban Mongolia respondents. The survey assessed WTP in additional annual taxes for any child with refractive error to be provided government-subsidised spectacles. Net benefits were then calculated based on mean WTP (i.e. benefit) and cost of spectacles.

Results

The survey recruited 50 respondents (mean age 40.2 ± 9.86 years; 78.0% women; 100% response rate) from rural and urban Mongolia. Mean WTP was US$24.00 ± 5.15 (95% CI US$22.55 to 25.35). The average cost of a pair of spectacles in Mongolia is US$15.00. Subtracting the average cost of spectacles from mean WTP yielded a mean positive net benefit of US$9.00.

Conclusion

A spectacle reimbursement scheme is potentially a cost-effective intervention to address childhood vision impairment due to URE in Mongolia. These preliminary findings support the proposal of the inclusion of children’s spectacles into existing Social Health Insurance. A much larger random sample could be employed in future research to increase the precision and generalisability of findings.

Quantifying geographical accessibility to cancer clinical trials in different income landscapes

Background

Clinical trials are increasingly perceived as a therapeutic opportunity for cancer patients. Favoring their concentration in few high-expertise academic centers maximizes quality of data collection but poses an issue of access equality. Analytical tools to quantify trial accessibility are needed to rationalize resources.

Materials and methods

We constructed a distance-based accessibility index (dAI) using publicly available data on demographics, cancer incidence and trials. Multiple strategies were applied to mitigate or quantify clear sources of bias: reporting biases by text mining multiple registries; reliability of simple geographical distance by comparison with high-quality travel cost data for Italy; index inflation due to highly heterogeneous cancer incidence by log-transformation. We studied inequalities by Gini index and time trend significance by Mann–Kendall test. We simulated different resource allocation models in representative countries and identified locations where new studies would maximally improve the national index.

Results

The dAI approximated well a more realistic but not widely applicable travel cost-based index. Accessibility was unevenly distributed across and within countries (Gini index ∼0.75), with maximal inequalities in high- and upper-middle-income countries (China, United States, Russian Federation). Over time, accessibility increased but less than the total number of trials, most evidently in upper-middle-income countries. Simulations in representative countries (Italy and Serbia) identified ideal locations able to maximally raise the national index.

Conclusions

Access to clinical trials is highly uneven across and within countries and is not mitigated by simple increase in the number of trials; a rational algorithmic approach can be used to mitigate inequalities.

•

Accessibility to cancer clinical trials grew less than total number of trials over time in upper-middle-income countries.

•

Accessibility is unevenly distributed, with maximal inequalities in high- and upper-middle-income countries.

•

Simulation of resource allocation can identify ideal locations able to raise the national accessibility index.

Sub-national variations in general service readiness of primary health care facilities in Ghana: Health policy and equity implications towards the attainment of Universal Health Coverage

Background

Service availability and readiness are critical for the delivery of quality and essential health care services. In Ghana, there is paucity of literature that describes general service readiness (GSR) of primary health care (PHC) facilities within the national context. This study therefore assessed the GSR of PHC facilities in Ghana to provide evidence to inform heath policy and drive action towards reducing health inequities.

Methods

We analysed data from 140 Service Delivery Points (SDPs) that were part of the Performance Monitoring and Accountability 2020 survey (PMA2020). GSR was computed using the Service Availability and Readiness Assessment (SARA) manual based on four out of five components. Descriptive statistics were computed for both continuous and categorical variables. A multivariable binary logistic regression model was fitted to assess predictors of scoring above the mean GSR. Analyses were performed using Stata version 16.0. Significance level was set at p<0.05.

Results

The average GSR index of SDPs in this study was 83.4%. Specifically, the mean GSR of hospitals was 92.8%, whereas health centres/clinics and CHPS compounds scored 78.0% and 64.3% respectively. The least average scores were observed in the essential medicines and standard precautions for infection prevention categories. We found significant sub-national, urban-rural and facility-related disparities in GSR. Compared to the Greater Accra Region, SDPs in the Eastern, Western, Upper East and Upper West Regions had significantly reduced odds of scoring above the overall GSR. Majority of SDPs with GSR below the average were from rural areas.

Conclusion

Overall, GSR among SDPs is appreciable as compared to other settings. The study highlights the existence of regional, urban-rural and facility-related differences in GSR of SDPs. The reality of health inequities has crucial policy implications which need to be addressed urgently to fast-track progress towards the achievement of the SDGs and UHC targets by 2030.

Factors associated with the availability and affordability of essential cardiovascular disease medicines in low- and middle-income countries: A systematic review

Despite their potential to prevent or delay the onset and progression of cardiovascular disease (CVD), medicines for CVD remain unavailable and unaffordable to many in low- and middle-income countries (LMICs). We systematically reviewed the literature to identify factors associated with availability and affordability of CVD medicines in LMICs. A protocol for this study was registered on the PROSPERO register of systematic reviews (CRD42019135393). We searched Medline, EMBASE, Global Health, Cumulative Index to Nursing and Allied Health Literature, EconLit, Social Policy and Practice, and Africa Wide Information for studies analyzing factors associated with the presence of medicines (availability) or the price of these medicines as it relates to ability to pay (affordability) in LMICs. We performed a narrative synthesis of the results using an access to medicines framework that examines influences at different levels of the health system. We did not conduct a meta-analysis because of the differences in analytic approaches and outcome measures in different studies. The search was conducted in accordance with PRISMA guidelines. Of 43 studies meeting inclusion criteria, 41 were cross-sectional. Availability and affordability were defined and measured in different ways. A range of factors such as sociodemographic characteristics, facility tier, presence of medicines on national essential medicine lists, and international subsidy programs were examined. The studies had variable quality and findings were often inconsistent. We find gaps in the literature on factors associated with availability and affordability of CVD medicines, particularly at the health program level. We conclude that there is a need for experimental and quasi-experimental studies that could identify causal factors and effective responses. Such studies would help further our understanding of how complex multifactorial influences impact these outcomes, which could inform policy decisions. Along with this, greater standardization of definitions and measurement approaches of availability and affordability are needed to allow for more effective comparisons.

Disparities in outpatient and inpatient utilization by rural-urban areas among older Mongolians based on a modified WHO-SAGE instrument

Background

Mongolia has made significant progress towards achieving Universal Health Coverage (UHC), but there are still challenges ahead with population ageing and non-communicable diseases (NCDs). The purpose of this study was to investigate patterns and determinants of outpatient and inpatient health service use amongst older people in Mongolia.

Methods

Data were collected using a questionnaire developed for the World Health Organization’s Study on global AGEing and adult health (WHO SAGE). There were 478 participants from rural areas and 497 participants from Ulaanbaatar (further divided into 255 ger/yurt district and 242 apartment district residents). Multivariable logistic regression analyses were used to investigate determinants of outpatient and inpatient health service use with reported adjusted Odds Ratios (AORs) and 95 % Confidence Intervals (CIs).

Results

Participants were aged 60 to 93 years. About 55 % of respondents used outpatient services in the past 12 months and 51 % used inpatient services in the past three years. Hypertension was the most common reason for health service use. Rural residents had longer travel times and were more likely to incur out-of-pocket expenditure (OOP). Multivariable logistic regression revealed that women were more likely to use outpatient services (AOR 1.88; 1.34-2.63). Compared to apartment residents in urban areas, ger residents in urban areas were less likely to use outpatient services (AOR 0.54; 0.36-0.83). There was no statistically significant differences in inpatient service by location. Increasing numbers of chronic conditions (1 and 2+ compared to none) were associated with both outpatient (AORs 2.59 and 2.78) and inpatient (AORs 1.97 and 3.01) service use.

Conclusions

This study highlights the needs to address disparities in outpatient service use for rural and urban ger populations. Compared with other WHO-SAGE countries, older Mongolians have relatively higher use of inpatient health care services. With a high prevalence of hypertension and an ageing population, efforts to achieve UHC would benefit from reorienting care services towards prevention and primary care management of NCDs to reduce the costs from hospital-based care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07156-y.

'We had to manage what we had on hand, in whatever way we could': adaptive responses in policy for decentralized drug-resistant tuberculosis care in South Africa

In 2011, the South African National TB Programme launched a policy of decentralized management of drug-resistant tuberculosis (DR-TB) in order to expand the capacity of facilities to treat patients with DR-TB, minimize delays to access care and improve patient outcomes. This policy directive was implemented to varying degrees within a rapidly evolving diagnostic and treatment landscape for DR-TB, placing new demands on already-stressed health systems. The variable readiness of district-level systems to implement the policy prompted questions not only about differences in health systems resources but also front-line actors' capacity to implement change in resource-constrained facilities. Using a grounded theory approach, we analysed data from in-depth interviews and small group discussions conducted between 2016 and 2018 with managers (n = 9), co-ordinators (n = 15), doctors (n = 7) and nurses (n = 18) providing DR-TB care. Data were collected over two phases in district-level decentralized sites of three South African provinces. While health systems readiness assessments conventionally map the availability of 'hardware', i.e. resources and skills to deliver an intervention, a notable absence of systems 'hardware' meant that systems 'software', i.e. health care workers (HCWs) agency, behaviours and interactions provided the basis of locally relevant strategies for decentralized DR-TB care. 'Software readiness' was manifest in four areas of DR-TB care: re-organization of service delivery, redressal of resource shortages, creation of treatment adherence support systems and extension of care parameters for vulnerable patients. These strategies demonstrate adaptive capacity and everyday resilience among HCW to withstand the demands of policy change and innovation in stressed systems. Our work suggests that a useful extension of health systems 'readiness' assessments would include definition and evaluation of HCW 'software' and adaptive capacities in the face of systems hardware gaps.

Does social health insurance prevent financial hardship in Mongolia? Inpatient care: A case in point

BACKGROUND

Protecting people from financial hardship and impoverishment due to health care costs is one of the fundamental purposes of the Mongolian health system. However, the inefficient, oversized hospital sector is considered one of the main shortcomings of the system. The aim of this study is to contribute to policy discussions by estimating the extent of catastrophic health expenditure and impoverishment due to inpatient care at secondary-level and tertiary-level public hospitals and private hospitals.

METHODS

Data were derived from a nationally representative survey, the Household Socio-Economic Survey 2012, conducted by the National Statistical Office of Mongolia. A total of 12,685 households were involved in the study. "Catastrophic health expenditure" is defined as out-of-pocket payments for inpatient care that exceed a threshold of 40% of households' non-discretionary expenditure. The "impoverishment" effect of out-of-pocket payments for inpatient care was estimated as the difference between the poverty level before health care payments and the poverty level after these payments.

RESULTS

At the threshold of 40% of capacity to pay, 0.31%, 0.07%, and 0.02% of Mongolian households suffered financially as a result of their member(s) staying in tertiary-level and secondary-level public hospitals and private hospitals respectively. About 0.13% of the total Mongolian population was impoverished owing to out-of-pocket payments for inpatient care at tertiary-level hospitals. Out-of-pocket payments for inpatient care at secondary-level hospitals and private hospitals were responsible for 0.10% and 0.09% respectively of the total population being pushed into poverty.

CONCLUSIONS

Although most inpatient care at public hospitals is covered by the social health insurance benefit package, patients who utilized inpatient care at tertiary-level public hospitals were more likely to push their households into financial hardship and poverty than the inpatients at private hospitals. Improving the hospital sector's efficiency and financial protection for inpatients would be a crucial means of attaining universal health coverage in Mongolia.

Essential Newborn Care Service Readiness and Barriers in Northwest Ethiopia: A Descriptive Survey and Qualitative Study

Background

Despite the efforts put forth in improving neonatal survival, there is still a high rate of neonatal morbidity and mortality in northwest Ethiopia. Therefore, this study aimed to determine the essential newborn care service readiness scores and explore the health facility-related barriers in North Gondar Zone, Northwest Ethiopia.

Methods

A cross-sectional survey of 16 health facilities (14 health centers and two hospitals) and twelve in-depth interviews were included in the study in three randomly selected districts of North Gondar Zone. A pretested health facility inventory questionnaire customized from the World Health Organization (WHO) service readiness assessment tool was used for a facility audit. Basic emergency and essential obstetric and newborn care (BEmONC), and child immunization service readiness scores were determined using unweighted averages according to the WHO guideline. Descriptive statistics were done for the quantitative data, and thematic content analysis was employed using NVivo 12 software for the qualitative data.

Results

All the surveyed health facilities had no specialist medical doctors, and 50% (8/16) of them had no inpatient beds. The overall BEmONC service readiness score was 62.7% (10/16) (95% CI: 34.8, 83.8) and only one facility had all the tracer items. Trained staff and guidelines had a 27.5% (4/16) readiness score, followed by 71.9% (12/16) readiness score for equipment, and 88.6% (14/16) readiness score for medicine and commodities. The overall child immunization service readiness score was 90.3% (15/16) (95% CI: 51.4, 94.7) and eleven facilities (68.8%) had all the tracer items. The immunization service readiness score was higher; 84.4% (14/16) for trained staff and guidelines, 92.8% (15/16) for equipment, and 93.8% (15/16) for medicines and commodities. Unavailability of equipment, shortage of supplies, and lack of respectful and compassionate healthcare practices were the key facility-related barriers compromising essential newborn care service readiness.

Conclusions for Practice

The survey revealed that the essential newborn care service readiness score of the health facilities was low, and it calls for improving BEmONC service readiness in particular. Provision of timely training for newly recruited staff, fulfilling essential equipment, and steady supply is imperative.

Legislation and current developments in adverse drug reaction reporting in Mongolia: how far are we?

Monitoring adverse drug reactions is a vital issue to ensure drug safety and to protect the general public from medication-related harmful effects. In order to properly monitor drug safety, a regulatory system needs to be in place as well as an infrastructure that allows for analyzing national and international safety data. In Mongolia, adverse drug reaction (ADR) reporting activities have been implemented in the past decade. During this period, the basic structure and legal basis of an adverse drug reaction monitoring system was established. Because of the fragmented but growing healthcare system and the complexity of pharmaceutical issues in Mongolia, a sustainable process for the development of the adverse drug reaction reporting system is a key issue. The aim of this article is to disclose the Mongolian situation for the rest of the world and to share experiences on how an ADR reporting system can be developed towards a higher and more advanced level to contribute to both national and international drug safety issues. In this article, we review the features of the Mongolian health care and pharmaceutical systems, as well as the current development of the adverse drug reaction reporting system.

Geographic Accessibility, Readiness, and Barriers of Health Facilities to Offer Tuberculosis Services in East Gojjam Zone, Ethiopia: A Convergent Parallel Design

Background

Tuberculosis (TB) remains a foremost global public health threat. Active TB control needs geographically accessible health facilities that have quality diagnostics, equipment, supplies, medicines, and staff.

Objective

This study aimed at assessing the geographic distribution, physical accessibility, readiness and barriers of health facilities for TB services in East Gojjam zone, Ethiopia.

Methods

A convergent parallel design was applied using health facility and geographic data. Data on facility attributes, service availability and readiness were collected by inteviewing TB officers, laboratory heads and onsite facility visits. Coordinates of health facilities and kebele centroids were collected by GPS. We used ArcGIS 10.6 to measure Euclidean distance from each kebele centroids to the nearest health facility. Descriptive statistics were computed by using SPSS version 25. Barriers to TB service readiness were explored by in-depth interviews. NVivo12 was used to thematically analyze the qualitative data.

Results

The overall TB health service coverage (THSC) was 23% (ranging: 10–85%). The mean distance from the nearest health facility was 8km (ranging: 0.5–16km). About 132 (32%) kebeles had poor geographic accessibility to TB services (over 10km distance from the nearest health facility) and had poor facility readiness. Although 114 (95%) health facilities offered at least one TB service, 44 (38.6%) of them had no sputum smear microscopy. The overall TB readiness index was 63.5%: first-line anti-TB drugs (97%), diagnostics (63%), trained staffs, diagnostic and treatment guidelines (53%) and laboratory supplies (41%). Lack of health workers (laboratory personnel), inadequate budget, poor management practice and TB program support, inadequate TB commodity suppliers, and less accessible geographic locations of health facilities were identified as barriers to TB service readiness distribution.

Conclusion

Considerable proportion of the population in the study area  have poor access to quality TB diagnostic services due to low THSC and poor facility readiness. Barriers to TB service availability and readiness were health system related. Regular refresher training of health workers on TB, creating mechanisms to attract laboratory personnel to work in the study area and scaling up of sputum smear microscopy services, establishing an efficient mechanism for procurement, distribution, utilization and reporting of TB commodity supplies, and good management practices are crucial to enhance TB service readiness in the study zone.