2010年-世界发展银行全球_Rapid_Assessment_of_the_Effect_of_the_Economic_Crisis_on_Health_Spending_in_Mongolia_56页_3mb

Summary of the Rapid Assessment of the Effect of the Economic Crisis on Health Spending in Mongolia

Core Content

This document presents a rapid assessment of the impact of the global economic crisis on health spending in Mongolia, conducted by Caryn Bredenkamp, Geir Sølve Sande Lie, and Logan Brenzel in 2010. It is part of a broader study examining four countries, including Jamaica, Kenya, Mongolia, and Tajikistan. The study focuses on changes in health expenditure between 2007/2008 (pre-crisis) and 2009/2010 (post-crisis), analyzing the effects on government health budgets, household out-of-pocket spending, and donor commitments.

Main Views and Key Information

Economic Crisis in Mongolia

• The economic crisis in Mongolia, which lasted from mid-2008 to the first quarter of 2010, was severe and multifaceted.
• Real GDP growth dropped from over 8.9% in 2008 to less than -1% in 2009.
• National revenues fell to 31% of GDP in 2009 from 41% in 2007, leading to a significant fiscal deficit.
• The crisis was exacerbated by the collapse of copper prices and a natural disaster known as a dzud, which devastated the livestock sector.
• Mongolia's economy is highly dependent on copper exports, making it vulnerable to global price fluctuations.

Government Health Budgeting and Spending

• The 2009 national health budget was significantly lower than the previous year, with a further 10% reduction in a subsequent budget amendment.
• Budget cuts were concentrated in investment line items, while recurrent expenditures, particularly salaries, were largely preserved.
• The share of health in the total government budget increased after the budget amendment, indicating some level of prioritization.
• At the sub-national level, hospital budgets were affected due to central allocations, while primary care facilities, funded on a capitation basis, were less impacted.

Household Health Spending

• Household out-of-pocket spending remained high, accounting for a significant portion of total health expenditure.
• The government implemented specific policy measures to expand health insurance coverage to vulnerable groups, aiming to protect households from increased financial burden.
• Informal payments and drug costs were reported to be rising, indicating potential strain on households.

Health Financing

• The health system is primarily financed through the state budget and the Health Insurance Fund (HIF).
• The HIF covers variable costs and is funded through payroll contributions, informal sector contributions, and state budget support for vulnerable groups.
• Primary care is fully tax-financed with no user fees, while secondary and tertiary care involve user fees of 10% and 15%, respectively.
• The referral system remains underdeveloped, leading to inefficiencies and overuse of higher-level facilities.

Donor Support

• Donor commitments to the health sector during the crisis largely tracked previously planned commitments.
• The government's response to the crisis included efforts to maintain health spending despite economic constraints.

Key Findings

• Government Budget:

  • The health budget was cut significantly in 2009 and further reduced by 10% in a subsequent amendment.
  • The health sector was relatively protected compared to other sectors.
  • The share of health in the total government budget increased post-crisis.

• Health Expenditure Trends:

  • Per capita health expenditure in 2008 was US $76, with US $60 covered by the government.
  • Total health expenditure as a share of GDP declined from 6% in 2000/01 to 3.8% in 2008.
  • The share of external resources for health varied significantly over the years, with a peak of 27.5% in 2000 and a decline to 7.2% in 2008.

• Health Service Delivery:

  • The system is organized by administrative divisions, with primary care delivered through family group practices (FGPs), soum doctors, and bagh feldshers.
  • The referral system is not functioning effectively, leading to inefficiencies in care delivery.

• Provider Payment Mechanisms:

  • Prior to 2006, payment systems for secondary and tertiary hospitals were based on fixed per-case payments and detailed line item allocations.
  • In 2006, a shift to a fully case-based payment system was introduced, with differentiated tariffs based on service type, institution, and level.
  • Primary care providers are now paid on a capitation basis, promoting cost control and efficiency but also raising concerns about reduced service delivery.

• Household Impact:

  • Out-of-pocket expenditure remains high, with over 84% of private health expenditure being paid directly by households.
  • The government introduced health insurance to protect vulnerable groups, but the system remains underdeveloped.

• Donor Response:

  • Donor support for health was largely consistent with pre-crisis plans.
  • The crisis did not significantly alter donor commitments, suggesting that development aid was not immediately affected.

Recommendations

• Strengthen the referral system to improve efficiency and reduce overuse of higher-level facilities.
• Enhance the capacity of the health insurance system to provide broader protection to vulnerable groups.
• Improve data collection and reporting mechanisms for health expenditure to better monitor and respond to future crises.
• Explore alternative financing mechanisms to ensure continued investment in health, especially in the context of economic volatility.

Conclusion

The economic crisis had a substantial impact on Mongolia's health budget and expenditure, with significant reductions in investment spending and increased reliance on health insurance and other protective mechanisms. Despite these challenges, the health sector remained relatively protected compared to other sectors. The study highlights the need for improved financial management and policy responses to ensure the sustainability and equity of health services in the face of economic uncertainty.