Health Sector Reform and Sexual and Reproductive Health Services in Mongolia

Abstract

Since its transition to democracy, Mongolia has undergone a series of reforms, both at national level and in the health sector. This paper examines the pace and scope of these reforms, the ways in which they have impacted on sexual and reproductive health services and their implications for the health workforce. Formerly pro-natalist, Mongolia has made significant advances in contraceptive use, women's education and reductions in maternal mortality. However, rising adolescent pregnancy and sexually transmitted infections, and persisting high levels of abortion, remain challenges. The implementation of the National Reproductive Health Programme has targeted skills development, outreach and the provision of resources. Innovative adolescent-friendly health services have engaged urban youth, and the development of family group practices has created incentives to provide primary medical care for marginalised communities, including sexual and reproductive health services. The Health Sector Strategic Masterplan offers a platform for coordinated development in health, but is threatened by a lack of consensus in both government and donor communities, competing health priorities and the politicisation of emerging debates on fertility and abortion. With previous gains in sexual and reproductive health vulnerable to political change, these tensions risk the exacerbation of existing disparities and the development by default of a two-tiered health care system.

Résumé

Depuis sa transition vers la démocratie, la Mongolie a connu une série de réformes nationales et du secteur de la santé. Cet article examine le rythme et la portée de ces réformes, comment elles ont influencé les services de santé génésique et leurs conséquences sur les personnels sanitaires. Anciennement pronataliste, la Mongolie a sensiblement progressé dans l'utilisation de contraceptifs, l'éducation des femmes et la réduction de la mortalité maternelle. Néanmoins, le nombre croissant de grossesses d'adolescentes et d'IST, et la persistance de niveaux élevés d'avortement, continuent de poser problème. Le Programme national de santé génésique a ciblé le développement des compétences, les services mobiles et la dotation en ressources. Des services de santé novateurs adaptés aux adolescents ont recruté des jeunes urbains et le développement de pratiques de groupes familiaux a encouragé la prestation de soins, notamment de santé génésique, aux communautés marginalisées. Le Plan-cadre stratégique du secteur sanitaire offre une plateforme pour un développement coordonné, mais il est menacé par le manque de consensus au sein des pouvoirs publics et de la communauté des donateurs, la concurrence des priorités de santé et la politisation des débats émergents sur la fécondité et l'avortement. Les progrès antérieurs en santé génésique sont vulnérables au changement politique ; ces tensions risquent donc d'exacerber les disparités existantes et de créer par défaut un système de santé à deux vitesses.

Resumen

Desde su transición a la democracia, Mongolia ha experimentado una serie de reformas, tanto a nivel nacional como en el sector salud. En este artículo se examina el ritmo y alcance de estas reformas, su impacto en los servicios de salud sexual y reproductiva y sus implicaciones para los profesionales de la salud. Antiguamente natalista, Mongolia ha logrado considerables avances en el uso de los anticonceptivos, la educación de las mujeres y las reducciones en la mortalidad materna. Sin embargo, el aumento en embarazos de adolescentes e infecciones de transmisión sexual, y los niveles persistentemente altos de aborto, continúan siendo retos. La implementación del Programa Nacional de Salud Reproductiva se ha centrado en el desarrollo de habilidades, la extensión a la comunidad y el suministro de recursos. Innovadores servicios de salud amigables a los adolescentes han atraído a la juventud urbana, y las prácticas de grupos familiares han creado incentivos para prestar atención médica de primer nivel, incluidos los servicios de salud sexual y reproductiva, a las comunidades marginadas. El Plan Estratégico del Sector Salud ofrece una plataforma para el desarrollo coordinado en salud, pero se ve amenazado por la falta de consenso en el gobierno y entre los donantes, prioridades de salud conflictivas y la politización de los debates sobre la fertilidad y el aborto. Con la vulnerabilidad de dichos logros al cambio político, estas tensiones corren el riesgo de exacerbar las disparidades actuales y crear un sistema de salud de dos niveles.

Keywords:

• health sector reforms
• reproductive health services
• health policy and programmes
• abortion
• adolescents
• Mongolia

In 1992, its economy savaged by the collapse of the Soviet bloc, Mongolia adopted a democratic constitution, and embarked on a multi-sectoral reform process, much of it a condition of ongoing donor support.

The reforms have been broadly successful. From the mid-1990s, recovery was evident, and GDP growth reached 10.6% in 2004, with per capita income rising from US$384 in 1999 to US$604 in 2004.¹ Economic growth has been matched with improvements in human development; infant mortality dropped by more than half between 1990 and 2002 (from 64 to 30 deaths to 1,000 births), and by the year 2000, literacy levels had reached 98.5% among men and 97.5% among women.² Levels of education are high among all population groups; a third of Mongolians have completed either tertiary or vocational studies, and more than half the poor reach secondary school.

Despite these impressive gains, one-third of the population remains below the poverty line today. Poverty is higher in rural areas (43%) than urban areas (30%) though urban poverty remains a serious and dynamic problem. More than half the extreme poor, many of them recent urban migrants, live in the capital, Ulaanbaatar, or provincial centres. Economic development has exacerbated inequalities, with the Gini coefficient rising from 0.31 in 1995 to 0.44 in 2002, reflecting a 42% rise in income disparity.²

The geographical challenges of the country continue to confront development. As a landlocked country, the economy is dependent on bilateral cooperation with Russia and China for transit transportation. Internally, there are few sealed roads between rural Soum (district) facilities and the 21 rural Aimag (provincial) administrative centres. With the world's lowest population density (1.5 persons per square kilometre), and a semi-nomadic pastoral lifestyle, health status and access to health services for the rural population is compounded by severe climatic conditions. Temperatures remain below zero for more than two-thirds of the year, and health and development are further compromised by short growing seasons, blizzards, dust storms and drought.³

Reforms in the health sector have seen the maternal mortality rate fall from 210 to 100,000 live births in 1994 to 98.8 to 100,000 live births in 2004, progress consistent with its Millennium Development Goal (MDG) target of 50 in 2015.⁴ However, persisting social and economic disadvantage is reflected in the underlying pattern of maternal deaths: 50% of deaths are from nomadic herding families and 30% are unemployed women. More than two-thirds of the 44 maternal deaths in 2004 occurred in rural Mongolia, showing an uneven distribution between provinces. Of those dying in Ulaanbaatar, 22.7% were not registered for health care in the capital, and did not receive antenatal care.⁵

The interface between health and poverty has located sexual and reproductive health prominently in both economic and health reform agendas, with the reproductive health goals of the Millennium Development Goals (MDGs) a major focus for government attention. This study seeks to provide a broader understanding of the pace and scope of reform within the health (and related) sectors in Mongolia, and examines the ways in which these reforms have impacted on sexual and reproductive health services in Mongolia, and their implications for the health workforce.

Sexual and reproductive health is defined inclusively, consistent with the Government of Mongolia's endorsement of the 1994 International Conference on Population and Development.⁶ HIV policy in Mongolia is administered separately from reproductive health policy, and hence has not been included in this paper.

Methodology

The research findings are based on documentary analysis and 26 in-depth interviews with Ministry of Health and other key stakeholders in sexual and reproductive health, conducted in September 2005. These included the State Secretary for Health; current and former staff responsible for the Reproductive Health Programme within the Ministry of Health, in urban Ulaanbaatar and in a rural Aimag; senior staff of the Ministry of Social Welfare and Labour; representatives of WHO, UNFPA and UNICEF; the Asian Development Bank and key bilateral and NGO agencies involved in sexual and reproductive health. The semi-structured interviews were conducted by the researchers in English, with translation necessary in only four cases. Comprehensive notes from the interviews were taken by two of the research team, transcribed within 24 hours, and compared for completeness.

The available “grey” literature was identified and collated with the assistance of the WHO office in Ulaanbaatar, and Medline searches for Mongolia provided additional published resources. Prior to the study, the researchers undertook a content analysis of available documentation, summarised key findings and identified common themes. The thematic analysis was extended by triangulation with the transcripts of the interviews, and the incorporation of additional materials from the field.

The research is part of a four-country study undertaken by UNFPA and WHO examining the role of their country offices in national and sectoral development processes affecting sexual and reproductive health. A comparative analysis of the four studies was undertaken, and information on cross-cutting issues between the case studies (Mongolia, Nicaragua, Senegal, Yemen) is being published elsewhere.⁷

The health system in transition

The major legacy of the former socialist system was universal access to hospital-based medical services. Curative services were provided free of charge, commencing with informally trained Bag Feldshers (community-based health workers), through Soum (district) health centres to Aimag (provincial) hospitals and a series of tertiary facilities in Ulaanbaatar. Preventive and public health services were poorly developed, and economic, climatic and geographic conditions frequently disrupted the supply of essential drugs. There was a strong preference for in-patient rather than ambulant care, with the average length of hospital stay exceeding nine days, and hospital bed rates (9.9 per 1000 population) the highest in the Asia region.⁴ Prior to de-collectivisation, maternity homes provided accommodation for rural pregnant women, ensuring access to health facilities during the punitive winters.⁸ In the years immediately following the Soviet era, family planning was relatively unavailable and hormonal contraceptives were considered dangerous. This, combined with liberalised abortion legislation has resulted in a high ratio of surgical abortions, currently estimated at 23 to 100 live births.⁹

Unrestricted access to medical training and unregulated specialisation has resulted in a bloated and inefficient hospital-based workforce. In 2003, doctor–population ratios reached 26.7 per 10,000, of which 75% were specialist-trained, and almost two-thirds concentrated in Ulaanbaatar. The doctor–nurse ratio of 1:1.2 reflects the relatively low status of nursing, low salaries and the previously unregulated access to medical training. For reproductive health, this has created an imbalance between health professions within the health services, and as a result, an inappropriate skill mix for the implementation of key strategies. Although the majority of births (over 99%) are delivered in medical facilities, there is a limited cohort of midwives – a total of 593 in 2003, less than 1% of the total nursing workforce. The result has been an increased dependence on medical (frequently specialist obstetric) staff for uncomplicated care, rather than the development of midwifery as a more economic, technically appropriate and accessible first line of obstetric care.¹⁰

Reproductive health policy

The 1994 Cairo International Conference on Population and Development had a significant impact on the previously pro-natalist government, building momentum from an earlier local family planning conference, and legitimising moves to relax constraints on access to contraceptives and reduce financial incentives for having children. The National Population Policy was released in 1996, with a strong emphasis on containing population growth, reducing maternal and infant mortality and increasing life expectancy, and included clear commitments to the Cairo Programme of Action on Population and Development and the Beijing Platform of Action for the Improvement of the Status of Women.¹¹ The first National Reproductive Health Programme, supported by UNFPA, was initiated in 1997, with the second Programme commencing in 2002.

Interview respondents indicated that representation at these international forums had significantly influenced policy directions for reproductive health in Mongolia, as did the subsequent adoption of the Millennium Development Goals. This may be because Mongolia is one of the few Least Developed Countries that is well placed to achieve the goals: high levels of primary education, and the higher representation of girls than boys in secondary and tertiary education, gave Mongolia a relative advantage in the education and gender equality goals. There has also been good progress towards the child mortality goals. Significantly, Mongolia has added a reproductive health target – “Access for all individuals of appropriate age to required reproductive health services” – to its goals, going beyond global MDG commitments.¹² Maternal mortality rates have become icons for progress in the thinking of government officials, particularly in health, but also in finance and social welfare, with recent gains seen as crucial to recovery from the disruptions of the early post-Socialist period.⁵ The Maternal Mortality Reduction Strategy (2005–2010), developed in cooperation with all partners in reproductive health, embodies these goals and targets in its framework. It focuses primarily on inter-sectoral collaboration and secondarily on upgrading “management, organization, logistics and human resource capacity of health services providing maternal and newborn care”. Improved service quality and accessibility and targeted strategies for the remote, migrant and disadvantaged are addressed in the remaining objectives.⁵

The priority issues for the current (third) National Reproductive Health Programme reiterate this concern for a further reduction in maternal deaths, and the reduction of persisting high abortion rates. The systematic integration of sexual and reproductive health services, and the further strengthening of capacity and systems for their delivery are also targeted. Regional disparities, increasing adolescent pregnancy, rising sexually transmitted infection (STI) rates, and the lack of male participation have resulted from an unevenness in focus and outreach and the limited participation of non-governmental organisations. Policymakers described how competing political agendas are negatively influencing the implementation of the National Reproductive Health Programme, and impinging on the legal and administrative environment necessary to support it:

“There is no political and public consensus on gender equity, abortion, family planning and welfare measures and protection for families.”¹³

Despite the constraints on implementation brought about by inadequate resources and issues of quality management, there has been a documented improvement in access to contraception, and a shift in preferred methods since the first National Reproductive Health Programme began. Current use of modern family planning methods among married women increased from 46% in 1998 to 58% in 2003, with a 14% increase in hormonal methods coinciding with a 12% decrease in IUD usage.¹⁴

Adolescent-friendly health services

In response to rising adolescent pregnancy and STI rates, UNICEF, UNFPA, WHO and UNESCO collaborated with the Ministry of Health in a United Nations Foundation project addressing the needs of adolescents. However, policy and programme differences resulted in two models of adolescent-friendly services being piloted in several Aimags and urban districts: “adolescent future threshold centres” supported by UNFPA and “adolescent cabinets” supported by WHO. While both facilities provide sexual health counselling with links to sexual health education in secondary schools, the UNFPA-supported services also offer contraception, emergency contraception, STI treatment and post-abortion care. The training of staff in effective communication and counselling of adolescents, and their re-orientation towards adolescent outreach, have been important components of the development of these services.

Evaluation of the pilot projects has noted the improved advertising of services, greater receptivity of staff and improved interaction with adolescents themselves, though maintenance of contraceptive supplies remains a problem.¹⁵ The creation of a National Adolescent Board, and regional boards has provided innovative communication links between health services and adolescents, ensuring feedback to providers and in several reported cases, directly to provincial governors.¹⁶ This emphasis on communication is a direct response to earlier negative experiences with the adolescent cabinets, which provided an intrusive surveillance against STI and pregnancy, but offered no counselling, STI treatment or contraceptive services, and little encouragement for adolescents to access their services voluntarily.¹⁷

The introduction of adolescent-friendly health services embodies the strengths and constraints implicit in many of the reforms affecting sexual and reproductive health. It demonstrates the potential of collaboration between international agencies and governments to target specific sexual and reproductive health issues – including, in this case, adolescent pregnancy and rising rates of sexually transmitted disease. It captures the energy and innovation implicit in re-orienting health services towards a more participatory, health promotion paradigm. Despite these advances and generous goodwill between UN agencies, policy and technical constraints have resulted in parallel systems being established, with resulting compromises. Ensuring outreach beyond the focus Aimags into more remote rural communities and maintaining contraceptive supply systems remain problematic.

Abortion

The positioning of abortion within the health system has always been ambiguous. In common with other post-Soviet states, abortion rates have been historically high, associated with limited access to health services in rural areas and the unpredictable availability of hormonal methods. After the onset of liberalisation of the Mongolian economy in 1989, the laws governing abortion were relaxed.¹⁸²⁰¹ With first trimester abortion legalised since the mid-1980s and second trimester abortions available for special indications,² abortion rates have remained high despite significant increases in contraceptive use. Ratios established in the 2003 National Reproductive Health Survey (214 to 1,000 live births) approximate those reported by the Ministry of Health (230 to 1,000 live births),¹³ but despite this apparent congruence, official rates are believed to be underestimates. No data are collected from the private sector, and public providers are believed not to report a proportion of procedures, particularly if accepting unofficial payments, or if circumventing the complex administrative processes required to secure approval for late terminations.

Abortion is one of the few medical services in maternity hospitals for which patients must pay. The provider officially gets 35–50% of the fee and the nurse up to 10% if the case is registered, but reimbursement often takes longer than a month, if it occurs. However, it has become increasingly common for providers not to register abortions in order to keep the whole fee.¹⁸ This is not surprising given the extremely low salaries of medical staff in the public sector. While abortion is not excluded from the list of services provided by the public sector, and lawful second trimester abortions are technically free, in practice health insurance does not cover the procedure.¹¹ The result is that abortion care has effectively been privatised, with official and unofficial charges ranging from US$6–25. While procedures are largely (92%) undertaken by specialist gynaecologists,¹³ in a public or private clinic, the quality of care has been questionable, with inappropriate methods being used for second trimester abortions and few staff receiving ongoing in-service training until relatively recently (Personal communication, BR Johnson, P Fajans, Department of Reproductive Health and Research, WHO, 20 January 2006).

The Ministry of Health, with support from WHO, has developed national standards and technical guidelines that seek to reduce abortion-related mortality and morbidity – including safe abortion care, post-abortion contraception and the introduction of medical abortion using mifepristone and misoprostol. Training funded by Marie Stopes International, German Technical Cooperation (GTZ) and UNFPA is addressing issues of quality of care, with an emphasis on improving patient–provider interactions, information provision and counselling, and post-abortion contraception.¹⁸ However, the 2003 strategic assessment of abortion services noted that quality of care in abortion and in associated contraceptive services was very weak. At the time of the assessment, there was a national stock-out of the injectable contraceptive DMPA.¹⁸ Similarly, in October 2005, programme managers reported that the most popular combined oral contraceptive in the family planning programme, Rigividon, had been out of stock since the previous March. All contraceptives are currently provided free of charge by the Ministry of Health, donated by UNFPA. While this removes economic barriers to access, it also removes any financial incentives for pharmacy staff to expedite re-supply when stocks are depleted (Personal communication, P Fajans, Department of Reproductive Health and Research, WHO, 1 December 2005).¹⁸

Public sector and health sector reforms

The collapse of the Soviet-linked, command economy and the transition to democratic governance have necessitated extensive reform. Decentralisation in the early 1990s transferred responsibility for health to the Aimag Departments of Health and Ulaanbaatar City Administration, constraining the Ministry of Health's capacity to drive the implementation of health strategy.¹⁰ The introduction of the Public Sector Finance and Management Law 2002 was intended to move sectors towards output-based budgeting, but the Ministry of Finance has been slow to undertake the necessary analysis and set appropriate output indicators for health. Given the prominence of selected reproductive health indicators in development planning, reproductive health would arguably benefit from this transition, particularly if output-based budgeting provided incentives for improved utilisation by marginal or at-risk groups. This would require further reforms of the Mongolian National Health Accounts, providing greater specificity in cost centres related to reproductive health outputs. At present, the identification of the sources of funding and actual expenditure on reproductive health services is problematic, with reproductive health aggregated with other health services.²¹

Compared to other countries at similar levels of development, the international donor presence is limited, accounting for only 13% of health expenditure, with 12 development donors and international agencies contributing more than US$1 million annually to the health sector.¹⁰²¹²⁶ Despite their limited numbers – or perhaps because of this – donor influence on reform processes affecting the Ministry of Health has been significant.

The first Mongolian health sector development programme (1997–2002)

The first Mongolian Health Sector Development Programme, funded through the Asian Development Bank, focused on the re-orientation of the health system away from hospital-based services towards primary health care through the development of Family Group Practices.²⁵ The model has implications for reproductive health services, with antenatal and post-natal care, family planning, treatment of STIs and sexual health counselling comprising much of these practices' services, provided free to registered patients. Capitation-based funding from the health departments has included incentives for practices to register patients from disadvantaged groups.²⁷ However, the requirement that patients be registered at their place of residence has meant that many urban migrants (typically very poor) cannot make use of these services, though health administrators in Ulaanbaatar indicated that there were some ad hoc initiatives to circumvent this problem. Thus, while the model is pro-poor in terms of its incentives, promotes quality and creates effective referral networks, the urban–rural disparities have not been effectively addressed, with the bulk of the 240 practices established in Ulaanbaatar, and only one practice in each Aimag.

Family Group Practices are largely independent of other government health structures (though physical infrastructure is provided by the health departments), and comprise, in effect, a privatised model whose sustainability is dependent on a number of variables, including the source of revenue. The status of the staff remains ambiguous: contracted to the Practice, their income is shared between the health department capitation and reimbursement from the Health Insurance Fund. With funding from both these sources neither regular nor timely, there is the potential for pressure towards a regulated private practice model, with the introduction of user fees, and the risk of reduced access for the poor.¹⁰ The Family Group Practice model has significant implications for human resources, linking improved quality and market forces to income sources that will effectively shape the primary health care workforce:

“Resources follow the registered patient via capitation. Doctors unable to attract patients have no option but to look for alternative employment.”²⁵

The second Mongolian health sector development programme (2003–2008)

Having addressed models of Primary Health Care in urban Ulaanbaatar and the Aimag Family Group Practices, the second Asian Development Bank-funded Mongolian Health Sector Development Programme is focused on reforms to the first level of referral for rural health services – the Soum Hospital. The project targets Soum hospitals in five focus Aimags, down-sizing facilities and adopting energy-efficient designs to economise on heating and utility costs, while providing essential equipment similar to the Family Group Practices. Heating costs impinge directly on birthing outcomes, with severe winter conditions necessitating long antenatal stays in maternity homes often incorporated into Soum hospitals. Appropriate information technology will be introduced to assist in the management of facilities. The development of clinical and management capacity will lead to more efficient use of resources and decrease the dependence on in-patient care. Again, sexual and reproductive health services are targeted elements of the reform: by 2008 in the five focus Aimags, all deliveries are expected to be hospital-based, with women having had full antenatal care; contraceptive utilisation rates are targeted to reach 80%; and most importantly, staffing complements for the Soum hospitals will be filled as a result of career advancement, clinical support and capitation-based financial incentives. Improved links with Bag Feldshers, and development of their public health and referral roles will increase access to nomadic herding communities.²² With 38% of maternal deaths occurring at Soum Hospital level, and late referral contributing to deaths at higher levels, the interventions have the potential to significantly enhance reproductive health outcomes for the rural poor.

The health sector strategic masterplan

While the Asian Development Bank has been advocating comprehensive financing and budgetary reforms, a parallel policy process for the development of a Health Sector Strategic Masterplan has been initiated by the MOH with the support of the Japanese Incorporation for Welfare Services (JICWELS). Using a series of Ministry-based working groups, including representation from key international agencies, the Masterplan represents the Ministry's first comprehensive documentation of its future directions, its resource envelope expressed through the Mid-Term Expenditure Framework, and a monitoring and evaluation framework, and lays the foundations for the development of a sector-wide approach to health.²³

The Masterplan itself is solid, comprehensive and conservative – a consequence of the focus on ownership and consensus in the working groups responsible for its development. It incorporates the Government's commitment to the MDGs, and the health-related strategies put forward in the Economic Growth Poverty Reduction Strategy²⁴ and the Government Action Plan.²⁸ Although this contributes to the plan's political resilience, the Masterplan does not overtly drive the reform agenda, though it sees itself responsible for establishing the mechanisms of collaboration and enhanced governance required for effective reform:

“The Strategic Plan is, therefore, primarily a comprehensive technical long term planning document that can be implemented by any government whatever its ideology or political mandate. It takes a predominately primary health care and health promotion approach. There is no sudden, surprise big change to be introduced immediately and it is not prescriptive.”²³

While sexual and reproductive health are well represented in the detail of the Masterplan's strategies and outcomes, and substantial investment has been made in training of personnel and targeting of high risk populations, key informants expressed concern that the shift from a programmatic focus to a sectoral approach has the potential to dilute the Ministry's previous overt commitment to reproductive health. With under-resourcing a continuing problem for the implementation of sexual and reproductive health policy, the links of the Masterplan to the Mid-Term Expenditure Framework will be crucial. The purported “neutrality” of the Masterplan does little to reconcile the multiple divergent strands of reform currently being explored, and leaves a policy vacuum potentially exploitable by vested interests. With a staff of only 68 in the Ministry of Health, the cumulative demands of participation in the development of the Masterplan, while ensuring local ownership and building capacity in planning, have displaced policy focus on issues such as abortion reform or attention to technical aspects of reproductive health.

The political context of reform

The political context within Mongolia has had its own impact on both the reform processes in general and sexual and reproductive health in particular. While the Masterplan itself has retained ownership through the recent change of government, the post-election turnover of senior management positions in the Ministry of Health and Central and Aimag administrations has resulted in a loss of collective memory, blunting momentum and necessitating retraining for sexual and reproductive health programmes. Experienced and qualified staff are reluctant to work in what is seen to be an “unsafe environment”, vulnerable to political change. Key stakeholders in the Ministry are perceived to be influenced by donors' competing reforms, with the result that Ministry of Health priorities have become less clear. While the process of financing reform and the development of the Masterplan are proceeding in tandem, there is still no consensus around the final structures – in particular the financial structures – with uncertainty within the Ministry of Health and contested positions among donors.

Moreover, pro-natalist questioning of current fertility and appropriate population goals has re-emerged, with implications for family planning and abortion reform. As a coalition, the current government is also more vulnerable to factional agendas than its predecessor. Organisations offering abortion have recently been attacked in the media, and it is becoming increasingly difficult for private providers to obtain a licence to perform abortions (Personal communication, P Fajans, Department of Reproductive Health and Research, WHO, 1 December 2005).

The recent proposal to the Millennium Challenge Account will test the Masterplan's resilience and the Ministry's commitment to it. The proposal is, in part, a reaction to the concentration of donor attention on public health services and primary health care. It advocates the establishment of a tertiary diagnostic and treatment centre in the capital Ulaanbaatar, in an attempt to reduce levels of medical tourism into Russia and China, and the resulting loss of income for health services.²⁹ While higher-level services have clearly suffered erosion, the public–private partnership proposed risks increasing the focus on specialised technology, widening the gap in access to health services and potentially between inefficient state-run services and an emerging private sector, unless substantial subsidisation of the poor by the government is guaranteed. The funding being sought of US$51.7 million is equivalent to more than two-thirds of total health expenditure for 2002.²¹²⁹ It has significant potential to skew health priorities away from the primary focus expressed in the Masterplan.

Conclusions

Sexual and reproductive health outcomes are extremely sensitive to their political and socio-economic context. This has been evident in Mongolia through the escalation of maternal mortality rates in the early democratic transition as a result of the loss of the protective infrastructure of socialist collectives, and the disruption of health services.⁸ The negative impacts of the transition have largely been negotiated, and economic development seems established, though the social transition has brought with it increasing adolescent pregnancy and high STI rates, with significant implications, given the HIV epidemics in neighbouring Russia and China.¹⁹ In addition to addressing widening income differentials, Mongolia needs to reform its registration system to ensure urban migrants have ready access to health and social services.

Despite issues of resourcing and the physical and climatic constraints on health service coverage in rural areas, the targeted support of key donors, including WHO, UNFPA, and GTZ have maintained sexual and reproductive health as a focus for the Ministry of Health and the associated health workforce. The high profile of the MDGs has strengthened political support across government.

The Health Sector Strategic Masterplan has developed competence in planning processes and policy development, documented the Ministry's resources and responsibilities, and lays the groundwork for coordinated development of the sector. Despite this, the centripetal forces concentrating human, financial and technical resources in the capital are strong, and the necessary incentives and commitment to substantially redistribute personnel and resources to rural centres are not yet evident.

Sexual and reproductive health services are vulnerable in this. With a highly medicalised workforce, an inappropriate skill mix, and with limited resources at Soum level, there is limited capacity to address the challenges of making safe motherhood available to vulnerable groups, reducing STIs and containing HIV, engaging adolescent sexuality, and building capacity and a supportive political and socio-economic environment for reproductive health.¹⁴ While the second Health Sector Development Programme offers infrastructural support at the Soum level, sexual and reproductive health needs to be integral to the implementation process to consolidate the gains. The necessary rationalisation of hospital-based services must avoid compromising access, particularly for the poor. The current climate reveals a lack of consensus on health financing, changes in the Health Insurance Fund, shifts towards privatisation of the health workforce and rising income gaps, and tensions between aspirations for technical excellence and universal coverage. Unless greater policy integration and cohesion can be achieved, an unmanaged transition risks the development of a two-tiered system, with greater disparity in access to and quality of care.

Acknowledgements

This research was undertaken as part of a UNFPA/WHO project to strengthen regional and country office capacity to engage in national health and development planning processes in support of reproductive health. The authors acknowledge the assistance provided by Dr Sodnompil, Secretary of State; staff of the Ministry of Health in Mongolia; Dr Salik Govind, WHO Mongolia; Ms Delia Barcelona and the UNFPA country office; and key stakeholders in reproductive health who assisted in the research. The views presented in this paper are those of the authors alone, and not of the institutions they work for.

Notes

1 The indications for legal abortion were expanded to include some social factors in the mid-1980s, e.g. on request for women who have five or more children, pregnancies within one year of the previous one, unmarried women who have three or more children, and women with a disabled husband. In 1989 there was an amendment to Article 56 of the Health Protection Law which states that “a woman has the right to decide on her motherhood”, thus legalising abortion on request.¹⁸²⁰

2 Second trimester abortion is permitted by law from 13–24 weeks LMP if: 1) the pregnancy threatens the life of the woman or fetus, 2) at the request of the woman if she is under 16 or over 45 years of age, 3) where the woman has a psychological disorder, or 4) where the pregnancy is a result of rape or incest.¹⁸²⁰