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Improving Access to Health Services for Disadvantaged Groups Investment Program: Technical Report Output 1: Strengthening Primar

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Improving Access to Health Services for Disadvantaged Groups Investment Program: Technical Report Output 1: Strengthening Primar Improving Access to Health Services for Disadvantaged Groups Investment Program (RRP MON 49173) TECHNICAL REPORT OUTPUT 1: STRENGTHENING PRIMARY HEALTH CARE A. Current Structure, Organization, Financing, and Performance of Primary Health Care Services Primary Health Care (PHC) in Mongolia is provided by Family Health Centers (FHCs) in urban areas and by Soum Health Centers (SHCs) in rural areas. SHCs also have some beds for basic inpatient care. In the City of Ulaanbaatar, PHC is also being provided by District Health Centers (DHCs). In general, PHC suffers from underfunding, low quality of services, poor maintenance of infrastructure and equipment and lack of skills and motivation of staff. This was confirmed by the Service Availability and Readiness Assessment (SARA) and a household survey conducted in July and August 2017 under the PPTA. In 2002, the government transformed public PHC facilities in urban areas into private Family Group Practices (FGPs) operating as FHCs. FGP practitioners, who before had been civil servants, were now contracted for the provision of clinical services and paid by the state through a capitation fee adjusted for key risk factors of the population registered with the center, such as housing conditions (ger or apartment area), sex, and age group. However, both the FHC building and the equipment remain public property. In 2018, Ulaanbaatar is being served by 129 FHCs and 13 satellite facilities and Table 1 for key performance indicators of FHCs in the Chingeltei and the Khan-Uul districts of Ulaanbaatar used as example). Legislation requires the catchment population per FHC to be at least 8 000 and not to exceed 14,000 person in Ulaanbaatar; in reality, however, the numbers vary between 4,700 (14th khoroo, Khan Uul District) and 21,600 (15th khoroo, Khan Uul District). Table 1: Khan Uul District, Subdistricts and their Family Health Centers Key Data 2016*1 OPD OPD Capitation Fee p.a. Khoroos and Catchment visits Patients % refer- visits FHCs population per referred rals Per cap- Per capita 2016 (MNT) capita ita (MNT) (USD) st 1 khoroo FHC 10,358 32,390 3.13 256 0.79% 116,116,800 11,210 5.38 2nd khoroo 12,245 45,168 3.69 452 114,534,100 FHC 1.00% 9,354 4.49 rd 3 khoroo FHC 14,157 49,596 3.50 372 0.75% 138,786,000 9,803 4.71 th 4 khoroo FHC 10,445 36,528 3.50 120 0,33% 110,300,300 10,560 5.07 th 5 khoroo FHC 6,233 21,342 3.42 640 3.00% 80,300,400 12,883 6.18 th 6 khoroo FHC 6,805 24,483 3.60 388 1.58% 84,526,600 12,421 5.96 th 7 khoroo FHC 5,328 16,263 3.05 168 1.03% 65,561,000 12,305 5.91 th 8 khoroo FHC 11,496 32,244 2.80 187 0.58% 144,268,800 12,549 6.02 th 9 khoroo FHC 9,772 31,387 3.21 623 1.98% 112,902,000 11,554 5.55 10th khoroo 10,595 34,845 3.29 2165 114,501,600 FHC 6.21% 10,807 5.19 11th khoroo 15,177 45,499 3.00 110 114,256,500 FHC 0.24% 7,528 3.61 12th khoroo 6,805 24,093 3.54 168 76,390,000 FHC 0.70% 11,226 5.39 1 Table 2 values in grey boxes represent potentially low performance indicators (number of patients below average, number of referrals above average). 2 OPD OPD Capitation Fee p.a. Khoroos and Catchment visits Patients % refer- visits FHCs population per referred rals Per cap- Per capita 2016 (MNT) capita ita (MNT) (USD) 14th khoroo 4,710 2,171 0.46 38 58,748,200 FHC 1.75% 12,473 5.99 15th khoroo 21,613 41,868 1.94 549 217,688,200 FHC 1.31% 10,072 4.83 16th khoroo 11,687 47,251 4.04 348 142,723,900 FHC 0.74% 12,212 5.86 Total 157,426 485,128 3.08 6,584 1.36% 1,691,604,400 10,745 5.34 Average 10,495 32,342 439 112,773,627 FHC = family health center, MNT = Mongolian Tugrik, USD = United States Dollar. Table 2: Chingeltei District, Subdistricts, and their Family Health Centers Key Data 20162 OPD Pa- Capitation Fee p.a. OPD Khoroos and Catchment visits tients % Per visits Per capita FHCs population per re- referrals (MNT) capita 2016 (MNT) capita ferred (USD) 1, 2, 3 khoroo 12.579 7.591 0,60 425 5,60% 162.612.000 12.927 FHC 6,20 4, 5 khoroo 9.633 23.952 2,49 59 0,25% 118.392.800 12.290 FHC 5,90 6 khoroo FHC 7.863 22.319 2,84 610 2,73% 86.528.200 11.004 5,28 7 khoroo FHC 12.827 16.442 1,28 900 5,47% 184.000.000 14.345 6,89 8 khoroo FHC 4.500 21.206 4,71 450 2,12% 81.000.000 18.000 8,64 9 khoroo FHC 9.459 4.850 0,51 19 0,39% 114.066.081 12.059 5,79 10 khoroo 8.892 24.766 2,79 135 0,55% 112.088.700 12.606 FHC 6,05 11 khoroo 5.941 21.336 3,59 337 1,58% 87.952.000 14.804 FHC 7,11 12 khoroo 16.186 57.357 3,54 165 0,29% 208.260.300 12.867 FHC 6,18 13 khoroo 8.744 24.592 2,81 132 0,54% 107.000.000 12.237 FHC 5,87 14 khoroo 9.308 5.382 0,58 32 0,59% 110.827.200 11.907 FHC 5,72 15 khoroo 9.431 4.037 0,43 288 7,13% 115.000.000 12.194 FHC 5,85 16 khoroo 12.717 47.052 3,70 118 0,25% 152.000.000 11.953 FHC 5,74 17 khoroo 15.192 7.841 0,52 214 2,73% 188.847.100 12.431 FHC 5,97 18 khoroo 10.299 6.053 0,59 61 1,01% 135.026.010 13.111 FHC 6,29 19 khoroo 11.851 39.514 3,33 135 0,34% 145.258.000 12.257 FHC 5,88 All 165.422 334.290 2,02 4.080 1,22% 2,108,858,391 12.748 6,21 Average / 10,339 20,893 225 131,803,649 FHC FHC = family health center, MNT = Mongolian Tugrik, USD = United States Dollar. Source: (Tables 1 and 2): Ulaanbaatar City Health Department. In 2015, funding for FHCs represented 19.2% of the Ulaanbaatar City budget allocated to health. The main drawback of the capitation system is that financial risks related to increasing 2 Values in grey boxes represent potentially low performance indicators (number of patients below average, number of referrals above average) 3 demand are with the service provider; i.e., capitation is an incentive to skimp on services and to refer patients to secondary care even if it is not necessary. And patients, being aware of the limited diagnostic and therapeutic capacity of FHCs, due to lack of equipment and experience of their rather young medical doctors, often bypass the PHC level and go directly to district health centers and hospitals. With an average annual capitation fee payment of 12,750 MNT (~6.21 USD) in the Chingeltei and MNT 10,745 (~5.34 USD) in the Khan Uul district covering an average of two to three visits per year, the first line of patient care is significantly underfunded.3 Considering the number of physicians working in FHCs, the average number of consultations per working day (220 / year) is 19 in the Chingeltei District (with variation ranging from 5 to 37) and 29 in the Khan Uul district (ranging from 3 - 41). Based on these figures the average consultation time would be 25 and 17 minutes, respectively, indicating a low level of utilization of FHC services. There is no significant difference in the number of (FHC) physicians per 1,000 population (0.47 in the Chingeltei, 0.48 in the Khan Uul District). The higher workload of doctors in Khan Uul is due to a significantly higher utilization rate. However, time available for patient care is eroded by excess of manual documentation and multiplicity of ICT modules that have bene introduced for different purposes. A comprehensive electronic data management and information system for PHC services is required that would include e.g. Electronic Medical Records (EMR) to help managing cases more effectively (including exchange of clinical data with secondary and even tertiary care facilities) and resources more efficiently with less time spent on manual documentation. The malfunctioning of the referral system is being demonstrated by the following figures: In 2016, the Chingeltei District Health Center (DHC) registered 787,144 outpatient visits - more than twice as many visits as all 16 FHCs in the district have seen during that same year (in a functional referral system the ratio should be inverse, at least). Only 0.52% of those cases were formally referred by one of the FHCs. The situation is similar, however less pronounced in the Khan Uul district: 778,441 OPD visits have been registered at the CDH, 1.6 times more than at all the 15 FHCs of the district; only 0.85% were formally referred. Once the scope and quality of services has been improved at FHCs, the MOH may think of introducing a fee for patients voluntarily bypassing the referral system in order to enforce a more rational use of resources in the health care system.
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