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Promoting Private Sector Engagement in Health in Mongolia
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Promoting Private SectorEngagement in Health
Mongolia
Eglantine Germain
Intern for EASS Health Sector
Supervisors:
Claude Bodart
Altantuya Jigjidsuren
28th November 2013
The views expressed in this paper are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank
(ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and
accepts no responsibility for any consequence of their use. The countries listed in this paper do not imply any view on ADB's part as to sovereignty
or independent status or necessarily conform to ADB's terminology.
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1. OBJECTIVES : UNDERSTANDING THE PRIVATE HOSPITAL SECTOR
PRIVATE HOSPITALS’ ROLE – INSTITUTIONAL, LEGAL & BUSINESS ENVIRONMENT – PPPS
Private
Public
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STUDY DEFINITION:1. Owned by a profit company or non-profit organization2. Privately funded by out-of-pocket payments, & government health
insurance3. Provide out & in patient care
2. A PRIVATE HOSPITAL OVERVIEW: UNREGULATED AND GROWING
36% 16% 15%
851 PRIVATE CLINICS IN UB
~100 PRIVATE HOSPITALS IN UB
NO DEFINITION OF PRIVATE HOSPITALS IN THE HEALTH LAW
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Problems:
-Concentration of private hospitals beds-Erratic variations
Reasons:
- Legal and regulatory loop holes
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Facility 2004 2005 2006 2007 2008 2009 2010 2011 2012
1 Private hospitals 143 160 168 159 159 160 166 171 179
growth rate - 12% 5% -5% 0% 1% 4% 3% 5%
2 Private clinics 434 523 612 698 904 922 947 1013 851
growth rate 21% 17% 14% 30% 2% 3% 7% -16%
Table: Number of private clinics, hospitals and patients in Mongolia, 2004-2012
Source: Health development centre, 2012
2. A PRIVATE HOSPITAL OVERVIEW: UNREGULATED AND GROWING
District No. of private beds/10 000
population
No. of public
beds/10000
population
No. of total
beds/ 10000
population Chingeltei 1.3 22.7 24 Songinokhairkhan 27.3 10.6 37.9 Nalaikh 4.6 42.9 47.7 Baganuur 3.7 50.2 53.9 Khan Uul 32 26.6 56.6 Bayanzurkh 19.7 76.7 95.4 Sukhbaatar 30.2 88.7 118.9 Bayangol 65.4 92.0 157.4
1] Statistics Department of UB, 2011 – population / district[2] Ministry of Health, 2011 – number of private beds/ district
Table. Public and Private Hospital Bed Density per District, 2012
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7Promoting Private Sector Engagement in HealthMon olia
Entities that license private hospitals
Entities that accredit private hospitals
3. THE INSTITUTIONAL FRAMEWORK : KEEN & UNSETTLED
Figure: Health system’s organizational hierarchy
Source: Developed from MOH website
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Area Public PrivateDefinition of role Health Law 2011 No definition
Licensing Standards Six standards for the publichospitals
No standards
Training HR 2 programs No trainings
Importing Equipment Government provides Technology is very difficult toimport & high import taxes
Tax No taxes No tax privileges
Financing Composition of all the publichospitals’ income:76% State budget20.9% HIF3% Other revenue
Composition of all the privatehospitals’ income:0% State budget7.9% HIF92.1% OOP
HIF rates are much higher half the amount reimbursed to
government hospitals.
MOH approved user chargedservices
No regulations to set ceilings orlimit OOP.
OOP : Out of Pocket Payments
4. THE LEGAL AND BUSINESS ENVIRONMENT
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Table: Discrepancies between public and private regulations and business environment
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Complaints
Problems
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5. PUBLIC PRIVATE PARTNERSHIPS Graph IX.1: Problems faced by public and private providers and the problems in public health.
“ institutional relationships between the state and the private for-profit and/or the
private not for-profit sector, where the different public and private actors jointly participatein defining the objectives, the methods and the implementation of an agreement of
cooperation” .
Private hospital
Unregulated growth
Disparity of quality ofservices offered
Inaccessible to the poor
Lack of financial assistance
Lack government support
Unfair competition
Public hospital
Over burdened facilities
Under equipped and staffed
Inefficiency
insufficient funds
Line-item budget restrictions
No autonomy
PPP- Long Term Risk Sharing
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5. PUBLIC PRIVATE PARTNERSHIPS: TYPE
Infrastructural
PPP
Integrated
PPPs
Facility based
hospital PPP
Lease contract
Servicesprovided by
private sector
Infrastructure +non clinical
services
Infrastructure +clinical and non
clinical services
Diagnostic +clinical services
Diagnostic
Type of
contracts
DBFM DBFO BOT or BOO or
franchises
BLT
Initial situation No hospital No hospital In pre-existing
public hospital
Out of the
public hospital
Best countries Developed Developing Developing Developing
Examples Canada, UK,Australia
Lesotho andBrazil
India India
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National PPPlegal
framework
State Policy onPPP
2009
Concession Law2010
amended in2012
PPP potential projects:
•Center for burnt victims•Research center•Hemodialysis centers•General tertiary hospital
Tripartite PPP
Medical waste management:
•US$240,000 investments•792 hospitals
5. PUBLIC PRIVATE PARTNERSHIPS : LAWS
Health specificPPP legal
framework
GovernmentResolution #198
2010
Health PPPpolicy
2011
MinisterialOrder
#305/320, 2011
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6. PRIVATE HOSPITAL QUALITATIVE ANALYSIS
Selection:15 hospitals in UB
3 hospitals in Khovd and Arkhangai
4 clinics
Criteria:Good reputation
More than 50 beds or a special license from MOH
Accreditation and receives Health insurance fund
Opened less than 14
years
Opened for more than
14yrs
Number of hospitals
8 7
Average number of inpatients 4208 3625
Average number of outpatients 24 375 13 429
Average number of beds 108 90
Average price of a room for 1 person For one person 51 000 27 000
Most popular specialties offered Internal medicine,
general surgery and
obstetrics
Internal, emergency,
neurology and traditional
Number of hospitals with CT and MRI 3 CT and 1 MRI 2 CT
Number of hospitals with Laboratories 5 5
Number of hospitals that own theirbuilding
7 6
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6. PRIVATE HOSPITAL QUALITATIVE ANALYSIS
Business climate & Government relations
Number of private hospitals thathave borrowed
86%
Willingness to pay increased
50%
Lack of income & competent staff
80%
Offer & demand of health services
increased
100%
Agreed to work withgovernment
86%
Bad relations with government
60%
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7. R ECOMMENDATIONS
GENERAL ORGANIZATIONAL RECOMMENDATIONS
• Build institutionalmemory
• Data collection andtransmission
• Reassessment of tasksand workload
• Plan the Health Market – Certificate of Need
GOAL 1 :ESTABLISH LEGAL ENVIRONMENT FOR FREE MARKET CONDITIONS
• Defining the private
sector
• Drafting licensingstandards
• Insitu accreditation andcommunication
GOAL 2: INCREASE EFFICIENT INVESTMENT IN HEALTH
• Fairer financing of
private facilities: HIF +credit loans
• Increasing HIFefficiency: software,HR, tariffs
GOAL 3: ESTABLISH A LONG TERM RELATIONSHIP WITH PRIVATE SECTOR
• Organize seminarsincluding private andpublic sector
• Jointly define potentialprojects & discuss withprivate companies
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7. R ECOMMENDATIONS: PUBLIC PRIVATE PARTNERSHIPS
Primary health care franchises- Facility based PPP-- South Africa
- Cambodia
Improving technology- Facility based PPP or Lease contracts-- Radiology in Andhra Pradesh
- Hemodyalisis in Andhra Pradesh
A general or specialized tertiary hospital - Integrated PPP- Mamohato Memorial Hospital Lesotho
- Hospital do Suborbio Brazil
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Thank you
16
1031 private
health facilities
in UB
Erratic growth
patterns
POORLY
REGULATED
Business
Opportunities
Political
Will
BETTER
MEDICALCARE
Establish Legal
Environment for free
market conditions
Increase efficient
investment in Health
Establish a long term
relationship with private sector
+
+
=
=
3 THINGS TO R EMEMBER FROM THIS PRESENTATION
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THANK YOU
QUESTIONS?
ANNEXES
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ANNEXESname institution domain of interest
1 Ms. B Purevdav MOH - Department of Policy Implementation andCoordination- Division of diagnostic, treatment technology private hospital standards
2 Ms. Oyuntsegtseg G. MOH Department of Public Administration and Management
- Division of health care organization, management and
development accreditation
3 Ms. N. Gerelmaa MOH-Policy planning department HIF regulation
4 Ms. Ts Tsolomongerel MOH- Policy and planning department Health PPP policy; new Health insurance law;
5 Mr. B. Batarsukh MOH-Policy planning department Public Private Partnership
6 Ms. B. Soninkhu MOH-Policy planning department Public Private Partnership
7 Ms. G. Lkhomsuren UB city Health Department Statistics on private hospitals and licensing
procedures
8 Ms. Kh Zendmaa UB city Health Department Statistics on private hospitals
9 Mr. B. Bayarbold GASI- Health, Education, Culture and Science Department in charge of hospital inspections for quality of
medical care, epidemiology and pharmacology
10 Mr A. Bold Fourth Health Sector Development Project Health service planning and private sector role in
service provision
11 Ms Davaajargal Health Development Center Private hospital statistics
12 Ms. Aruntuya Health Development Center Private hospital statistics
13 Dr. Tumurtogoo GIZ Citizen Health Insurance Law specifications
14 Ms. T. Gantuya SIGO- Health insurance fund Division Statistics of HIF reimbursement to private
hospitals
15 Ms. G. Byambsuren United Association of Private Sectors Health Organization Understanding private hospitals’ perspective
ANNEXESName of the
beds according to beds according to beds according to
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ANNEXES№ Name of the
Hospital beds according to
MOH beds according to
HDC beds according to
UBHD
1 Avitsena - - 43
2 Аchetan Elite - 286 100
3 Bayangol 40 40
4 Bayanzurkh
District Hospital - 250 310
5 Bolor Melmii 28
6 Gurun Gal - 100 - 7 Mamba Datsan 14
8 Mangut 158 140 140
9 Mong-Em - - 22 10 Nomin 65 - 115
11 Tani Tulu bid 70 50 50 12 Songdo - 60 - 13 Elec - - 7 14 EMJJ - - 35 15 Enk Undra 75 - 45
ANNEXESCharacteristics
Indicators Private hospitals Private
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ANNEXESCharacteristics Indicators Private hospitalsin UB
Private
clinics in
UB
Initial investment of the
private facilities Personal investment 8 2
Commercial loans 4 0
Multiple owner's
contribution 4 0
Father company 2 1
Foreign investment 1 0 Loan from commercial
institutions Yes 13 0
No 2 3
Purpose of the Loan Investment 13 0
Equipments 5 0 Own building 3 0
Expansion 2 0
ANNEXESCharacteristics
Indicators Private hospitals in Private clinics
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ANNEXESCharacteristics Indicators Private hospitals inUB
Private clinics
in UB Intentions for the hospital for the
next 2 years Investing in innovative equipment 4 2
Having big surgery department 4 0
Expansion of the hospital 3 0 Investing in human resource 2 0
Making hospital more comfortableand luxurious
2 0
Expanding specialization/service 1 2
Building 2 subsidiaries: pediatrics
centre and adult centre 1 0
Building a sanatorium 1 0
Collaborating with foreign highquality and more experienced
hospital, exchanging experience.
1 0
Plan of the investment Equipment 7 2 Both infrastructure and equipment 4 1
Infrastructure 3 0 Training of doctors 2 0 Human resource 1 0
Redoing or rethinking investment
in aspects of the hospital
The building 4 0 The clientele 4 0 The size 3 1 The location 1 1 The specialties 1 1