Implementing Health SWAp in Mongolia: From Aid Coordination to Sector Management

Master's Thesis , 2006 , 79 Pages , Grade: Distinction

Health - Public Health

This dissertation intends to contribute to improving sector-wide management and aid coordination in health. The dissertation objectives are: 1. To review the key issues related to sectoral management and aid coordination in the Mongolian health sector 2. To examine different frameworks and international experiences in implementing SWAp 3. To appraise likely options for implementing health SWAp in Mongolia 4. To propose a Road map to initiate the implementation of a SWAp in Mongolia

TABLE OF CONTENTS

Declaration

Dedication

Acknowledgements

List of figures

List of tables

List of boxes

List of annexes

Acronyms

Executive Summary

1. Chapter One: Introduction and Methodology
1.1. Introduction
1.2. Aim and objectives of the study
1.3. Expected outputs
1.4. Intended audiences
1.5. Methodology and study limitations
1.5.1. Study framework and techniques
1.5.2. Literature search methodology and criteria
1.5.3. Information sources
1.5.З.1. Search procedures
1.5.4. Limitations of the study
1.6. Structure of the dissertation
1.7. Conclusion

2. Chapter Two: Problem Analysis
2.1. Introduction
2.2. Country information
2.3. Structure and function of the health sector
2.4. Problem web
2.5. Situation analysis
2.5.1. Policy framework
2.5.1.1. Millennium development goals and Economic growth support and poverty reduction strategy
2.5.1.2. Health sector master plan 2006-2015
2.5.1.3. Decentralization
2.5.1.4. Main challenges for the policy framework
2.5.2. Expenditure framework
2.5.2.1. Medium term expenditure framework
2.5.2.2. Health sector financing and resource allocation 1З
2.5.2.3. Main challenges
2.5.3. Institutional framework
2.5.3.1. Organisational structure
2.5.3.2. Aid coordination mechanism
2.5.3.3. Main challenges
2.5.4. Capacity building in monitoring and evaluation
2.5.4.1. Main challenges
2.6. Conclusion

З. Chapter Three: International Experiences In SWAp
3.1. Introduction
3.2. SWAp definitions
3.2.1. Main elements of SWAps
3.3. History of SWAps
3.4. Different forms of SWAps
3.5. SWAps versus project aid
3.6. Government and donor perspectives
3.7. SWAps: key elements
3.7.1. Policy framework
3.7.2. Expenditure framework
3.7.3. Institutional development framework
3.7.4. Capacity development framework З
3.8. SWAps and З
З.8.1. PRSP and MDGs З
3.8.2. decentralisation
3.8.3. sector programme initiatives (GFATM AND GAVI etc)
3.9. Conclusion

4. Chapter Four: Feasibility Study And Option Appraisal To Implement SWAp In Mongolia
4.1. Introduction
4.2. SWAp stages: where are we now?
4.3. Feasibility assessment for SWAp implementation in mongolia
4.3.1. Feasibility analysis by a swap’s 4 elements
4.3.1.1. Policy framework
4.3.1.2. Expenditure framework
4.3.1.3. Institutional framework
4.3.1.4. Capacity building
4.4. Option appraisal for the type of SWAp and its management
4.5. Conclusion

5. Chapter Five: Recommended strategy to implement SWAps
5.1. Introduction
5.2. The objectives and rationale
5.2.1. Policy framework
5.2.2. Expenditure framework
5.2.3. Institutional framework
5.2.4. Capacity building
5.3. Road map for SWAps
5.4. Coordination mechanism
5.5. Conclusion

References

Bibliography

Annexes

LIST OF FIGURES

Figure 1: Conceptual framework of the dissertation

Figure 2: Problem Web

Figure 3: Trends in Health Expenditure

Figure 4: Use of total health expenditure, 2002

Figure 5: Organizational model of Mongolian health sector

Figure 6: Elements of SWAps

Figure 7: Relationship of the SWAps elements to impacts

Figure 8:Linkage between expenditure framework and short-term budgets

Figure 9: Capacity pyramid

Figure 10: SWAp development stage

Figure 11: Organizational model of health sector for implementing SWAps

LIST OF TABLES

Table 1: Keywords by sub-area

Table 2: SWAP types and divergence in coordination in different settings

Table 3: Comparing SW Ap and the project approach

Table 4: Advantages and disadvantages of SW Aps

Table 5: Interaction between SWAps and Decentralisation components

Table 6: SWAP stages and characteristics

Table 7: Feasibility assessment of implementing health SWAp in Mongolia

Table 8: Option appraisal for SW Aps type and management arrangements

Table 9: Suggested framework for implementing a health-SWAp for Mongolia

Table 10: Objectives, Strategies and Activities for the next phase

LIST OF BOXES

Box 1: Schematic History of Development Co-operation

Box 2: Selected criteria

Box 3: Questions to guide moving to a SW Ap

LIST OF ANNEXES

Annex 1: Organizational structure of health sector

Annex 2: Financial Flows (Source: MoH, 2005b)

Annex 3: ODA partners to health sector (in million USD)

Annex 4: Macroeconomic main indicators for 2005-2008

Annex 5: Health and demographic indicators

TOTAL WORD COUNT -14520

ACRONYMS

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EXECUTIVE SUMMARY

Mongolia has experienced major social and economic changes since early 90s after collapse of the Soviet Union and has transitioned from a centrally planned communist country to a democratic one. Over the last 10 years, the country has embarked on a path of political transformation, liberalisation, and reform in all sectors supported by different donors. Consequently the country is highly aid dependent and the health sector is no exception. Most of the aid is in project form as determined by the donors, inadvertently fragmenting the health system. This fragmentation is further aggravated by a weak MoH that only recently is beginning to define its new role and responsibilities to adapt to new realities and needs.

Weak management capacity, ambiguity of roles and responsibilities, ineffectual donor coordination, inappropriate allocation and use of resources are the long-standing issues that contribute to poor sector management and inefficiency. Recognising these weaknesses, the MoH has initiated the development of a strategic plan using a wide-ranging consultative process, introduced health financing reform and improved dialogue with donors. Emerging central level capacity, increasing donor confidence and most importantly, awareness and willingness to move towards sector-wide management is now becoming more evident. These initiatives constitute the essential ground-work for starting a SWAp.

This dissertation intends to contribute to improving sector-wide management and aid coordination in health.

The dissertation objectives are:

1. To review the key issues related to sectoral management and aid coordination in the Mongolian health sector
2. To examine different frameworks and international experiences in implementing SWAp
3. To appraise likely options for implementing health SWAp in Mongolia
4. To propose a Road map to initiate the implementation of a SWAp in Mongolia

SWAps emerged in mid 90s with the intention of improving effectiveness of external aid in-line with host country priorities and through development of national plans in partnership with donors. The main elements of SWAps namely policy, expenditure, institutional development and capacity building were explicitly analysed to propose a suitable option for Mongolia.

The health sector reveals receptivity for implementing a SWAp, as the main elements such as sound strategic plan, expenditure framework, improved dialogue between MoH and donors and commitment to change are in place. Yet, much needs to be done.

The dissertation concludes by proposing a Road Map to implement a health SWAp as one contribution to improve the management of the sector. The option proposed is the most appropriate one based on the literature and author’s experience developing the Master Plan. While this option appears most applicable now, it should be allowed to evolve another type of SWAp as capacity develops and greater ownership is secured.

The country’s commitment to lead the process is in place, and this is the most encouraging factor. However, SWAps are not panaceas for all health sector ills, but it is one way of enabling the MoH to deal with these ills in a more coherent and system-wide manner. Continued effort is vital to sustain current achievements and to focus on flexibility, so that MoH and donors could share and work with a common set of principles, objectives and working arrangements.

1. CHAPTER ONE: INTRODUCTION AND METHODOLOGY

1.1. INTRODUCTION

Mongolia, like many developing countries, is highly dependent on external aid. The collapse in the early 90-s, following 70 years of Soviet support precipitated a severe economic crisis. Mongolia, with donor support, used that transition experience to start building the foundation of a modern, liberal democracy moving towards development. The Government of Mongolia (GoM) clearly recognises the need for further improving its capacity to coordinate and manage donor support through the ongoing involvement of the partners.

This dissertation is a contribution to improving sector management, coordination capacity and effective aid management in the health sector. It has 5 chapters. This chapter describes the aim and objectives; expected outputs; study methodology and its limitations and the structure of the dissertation.

1.2. AIM AND OBJECTIVES OF THE STUDY

Aim: The dissertation aims to assess the feasibility of implementing a Sector-wide Approach (SWAp/SWAps) in the Mongolian health sector and propose a Road Map for its implementation. It will do so by achieving the objectives listed below. However, it should not be perceived as the only way to implement SWAps. It is proposed as the most a likely option given the present circumstances.

Objectives:

1. To review the key issues related to sector management and aid coordination in the Mongolian health sector
2. To examine different frameworks and international experiences in implementing SWAps
3. To appraise likely options for implementing health SWAps in Mongolia
4. To propose a Road map to initiate the implementation of a SWAp in Mongolia

1.3. EXPECTED OUTPUTS

The direct outputs of the dissertation would be the following:

- Identification of the root causes of poor sector-wide management and ineffective coordination of donor funding
- Review of the different forms and ways of implementing SWAps in health
- Feasibility study for implementing a health SWAp in Mongolia
- Proposing a roadmap for implementing a SWAp in Mongolia

1.4. INTENDED AUDIENCES

The study is intended to serve as a resource document and an instrument for improving sector management and aid coordination for the following audiences:

- Ministry of Health (MoH), Mongolia
- Government Implementing Agency for Health
- Health Development Partners
- All level planners and managers in health
- Key sector and line ministries

Others would include academics, international policy makers, students and researchers working in the same field.

1.5. METHODOLOGY AND STUDY LIMITATIONS

The study is based mainly on a review of the concepts and lessons derived from the literature, which describe international experiences in implementing SWAps in the health sector. A diversity of contexts for SW Aps

implementation will help to define the conceptual framework for examining the Mongolian health sector with regards to SWAps.

The work recently done by the MoH provides ample basis to undertake this study. Additionally, the author’s work experience with the MoH during the last 2 years, developing Health Sector Master Plan (HSMP), provided an opportunity to study the sector. This motivated the undertaking this study to contribute to improving better management and overall aid coordination in the sector.

1.5.1. Study framework and techniques

An in-depth type of study is used, employing an explanatory analytical approach based on a literature review.

The Literature review involved background reading, brainstorming, choosing database search strategies, doing database searches and obtaining necessary materials from various sources. The information analysis and presentation techniques used in the study included a problem web, the 7-S McKinsey organizational-analysis framework, a 2by 2 comparative table and a number of figures and boxes. The overall study framework is illustrated in Figure 1 below.

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The framework shows the consistency, flow and linkages between the chapters and in the criteria applied. This consistency is ensured by applying a the same criteria throughout the document.

1.5.2. Literature search methodology and criteria

The study used secondary information obtained from a variety of sources. The quality of the information sources was assessed against the following

criteria:

- Authority: Who is the author? Are they experts? (professional
background, membership in professional associations,
employed by research institutions, major development agencies, etc)
- Accuracy: Is the information reliable? (from well-known, reputable or official sources)
- Currency? Is information still valid?
- Relevance? Is information pertinent or the study?

The author also captured the different views and perspectives using various unpublished and official papers to avoid bias caused by a solely expert based view.

1.5.3. /nformar/on sources

The information sources used were divided into 2 main categories:

1. Information related to the Mongolian health sector
2. International experience implementing SWAps

The former information was obtained mainly through author’s personal contacts with colleagues from the MoH of Mongolia and from Mongolia’s “open government” websites.

4 main sources were used for information about Mongolia:

- Government and Health Sector Policy, Planning and Regulatory documents
- Reviews of the health sector and reports from health reform projects
- Reviews and mission reports on health policy and aid coordination
- Various donor agency: Country Assistance Strategy papers

The information related to international experiences on SWAps was obtained from the following sources:

- Leeds Univercity Library; The LUL was searched for books on the subject. As, the topic is rather new, no books on the subject were found. However, books on general health reform were used. BMJ, Lancet and Health Policy and Planning journals were manually scanned to retrieve updated information.
- Specialized online databases: Web of Science, Pubmed, Medline etc. were accessed using a database search methodology described below in 1.5.З.1.
- Browsing specialized websites on SWAps: websites of the Swiss Tropical Institute (STI), Canadian International Development Agency (CIDA), Royal Tropical Institute, Netherlands, Eldis and Official Development Institute (ODI), Institution for Health Sector Development (IHSD) were browsed. These provided good, up-to-date sources of information. The author also obtained and used the CD­ROM based learning materials on aid effectiveness by ordering through IHSD website (recently renamed as HLSP).
- Use of subscription facilities: CIDA-owned website was used for information updates and during the period of May-July, 2006 more than З0 e-mail alerts were received.
- Related lecture handouts and notes: Nuffield lectures on health sector reform, governance and health planning were used.

1.5.3.1. Search procedures

The database/website search used the key words strategy described in Table 1.

Table 1: Key words by sub-area

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The author did not attempt to limit the information by entering “date limits” for the search as the topic itself is rather new and not much very outdated information was expected.

Web of Science searches using separate keywords resulted in 15 to 18665 documents with varied relevance to the topic. Use of “and” between key words narrowed down the results from 6 to 36. Most of the information was downloadable; however, information that could not be downloaded was obtained from different sources such as the LUL archive, WHO, Eldis, STI websites. Selection of the documents was done using the criteria mentioned in section 1.5.2.

1.5.4. Limitations of the study

The study has the following limitations and potential bias that need to be borne in mind to help readers appreciate the study from a diversity of perspectives.

- SWAps were implemented mainly in Africa and in a few Asian countries. However, there was no information available on post­Soviet countries and SWAps. This limited, to some extent, the comparative analysis exercise.
- SWAps are still at the learning stage. Their long-term impacts are not yet fully apparent.

1.6.STRUCTURE OF THE DISSERTATION

The Dissertation is arranged in 5 chapters.

The current chapter (chapter 1) introduces the dissertation presenting the overall aim, objectives, expected outputs, intended audience, methodology its limitations and the structure of the dissertation.

Chapter Two: “Prob/em Analysis” examines the current Mongolian health sector with a focus on the government expenditure, resource allocation system, aid coordination mechanisms, policies and SWAp prerequisites.

Chapter Three: “/nternationa/ Experience in SWAps” is a review of SWAp definitions, types, development history and comparison with project aid, donor and government perspectives about SWAps and the lessons learned from SWAps.

Chapter Four; “Feasibility study and option appraisal to implement a SWAp” in Mongolia provides an analysis of the preparedness of the MoH for SWAps and explores the options of implementing SW Aps in Mongolia.

Lastly, Chapter Five: “Recommended Strategy to Implement a SWAp in Mongolia” presents key process elements to implement a health SWAp, a Road Map and implementation coordination mechanisms.

1.7. CONCLUSION

This chapter introduced the study aim and objectives; expected outputs; intended audiences; methodology and study limitations. Sources of the information used were presented along with the search procedures. The conceptual framework of the dissertation is provided to guide the reader through the document. The chapter concludes by introducing the structure of the dissertation.

2. CHAPTER TWO: PROBLEM ANALYSIS

2.1. INTRODUCTION

The previous chapter provided an introduction and overview of the dissertation. The current chapter will briefly analyse the local context focusing on relevant functions and structure of the Mongolian health sector. The Problem analysis is presented in a problem-web format. The current context is analysed with emphasis on areas of policy/sector reform, health expenditure, institutional framework and capacity-building.

2.2. COUNTRY INFORMATION

Mongolia is a vast (1.6 million square kilometres) landlocked country, located in Central Asia. The country borders with Russia to the north and China to the south. In the last 12-15 years, Mongolia has experienced dramatic changes and development challenges, as 70 years of a one-party state with its centrally planned economy and support from the former Soviet Union collapsed in the early 90s. Since then, the country has embarked on a path of liberalisation, reform and political transformation that has influenced all aspects of social and economic life (WHO, 2005).

Mongolia has a population of 2,504,000 (GoM, 2004), with nearly half of the population living in rural areas. The fertility rate has decreased in the last decade, while the population continues to age. As of 2003, 35.8% of the population is between the ages of 0 and 14, and people over 65 constitute 3.5% (GoM, 2004).

Administratively, the country is divided into 21 aimags (provinces), and one autonomous municipality, Ulaanbaatar. The aimags are sub-divided into soums (districts), and the soums are subdivided into baghs (sub-districts).

Mongolia’s transition to a democratic society and a market economy since 1992, was beset by many problems and setbacks. Yet it compares favourably with most transition countries. Between 1990 and 1994, however, the country suffered an economic depression of considerable magnitude. The economy began to rebound in 1995 and has continued to improve since then with minor fluctuations during 1999-2001 because of severe winters.

With average per-capita income of $590 (in 2004), Mongolians earn more than the average East Asian low-income countries (average $510). However, one third of the population lives below the poverty line (Borowitz er а/ 2005). Human Development Index (HDI, 2005) ranks Mongolia 114th among 177 countries (UNDP, 2005).

Health expenditure as a share of GDP is 4.7%, higher than the former Soviet Union country averages of 2.91% (MoH, 2005b). Donor funding plays a significant role in health sector as it amounts to 11.5 % of total public health expenditure (MoH, 2005b). Consequently, there is an urgent need to improve management and efficiency of donor funding for sustainable development of the sector.

2.3.STRUCTURE AND FUNCTION OF THE HEALTH SECTOR

Mongolia inherited a health care system based on the Semashko model. However, during the last decade, the system has begun shifting from a centralized to a devolved system, with numerous public sector reforms being undertaken.

The current structure of the sector seeks to separate responsibility for health policy, funding and delivery of health services. The Government’s role is shared among (WHO, 2005):

- Ministry of Health: responsible for overall planning, policy formulation, regulation and monitoring of health status and service delivery
- Health Insurance Fund: Collects income-related fund from employers, wage earners and also, receives subsidies from MoF to cover vulnerable groups, then makes prospective payments to hospitals.
- Aimag and soum (peripheral administrative units) and the city governor’s office: Managing public hospital services at the local level

The sector has 3 levels of care managed by respective departments in MoH and National Center for Health Development (NCHD) (Annex 1). More than 70 years of a centralized, socialist system has resulted in:

- Curative oriented services
- Overproduction of specialist doctors
- Ineffective large overstaffed hospitals
- Poor managerial and organizational capacity
- Inefficient use of resources

Notwithstanding, over the last decade the situation has been changing gradually through sector reforms such as decentralisation, health insurance, user charges, a PHC approach and developing a Health Sector Master Plan.

2.4. PROBLEM WEB

The main interacting factors contributing to poor sector management and inefficient aid coordination are illustrated in Figure 2.

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The problem web shows that the main problems are grouped around the core problem and these link to the other problems. Weak capacity to manage the sector, ambiguity of roles and responsibilities of managers, absence of a donor coordination mechanism, inappropriate use and allocation of scarce resources are the long-standing issues that are causing poor sector management in Mongolia. Lack of transparency and accountability caused by poor accounting and financial management is hindering better use of resources and donor support. One can conclude that the main issues coalesce around policy-development, financial- management, institutional-development and capacity-building, hence these issues would be further analysed in 2.5.

2.5. SITUATION ANALYSIS

There has been some progress made in health sector especially the commitment to development and strategic planning that reflects the needs of the population. However, the sector is facing a number of challenges related to poor management capacity, lack of coordination, including aid and a piece-meal approach to planning. The WB mission report (Borowitz et al 2005 p12) reveals that the “...Mongolia’s health system is in disarray, but not for lack of money..” Thus the traditional approach to solving problems by increasing funding, will not significantly improve the health system in Mongolia as it is already absorbing almost 6% of GDP, a figure higher than most transition countries. Therefore, it is more logical to improve the operating efficiency and management capacity of the system, so better outcomes could be achieved with same or even smaller expenditures. The local context is analysed in terms of the following 4 areas.

2.5.1. Policy framework

The recent wider public-sector policy reforms and sector strategy development have resulted in number of challenges, despite their achievement and commitment to development. Each policy reform being undertaken is presented in terms of the current situation, recent progress followed by the main challenges.

2.5.1.1. Millennium Development Goals(MDGs) and Economic Growth Support and Poverty Reduction Strategy(EGSPRS)

The GoM adapted and approved Mongolia specific MDG targets and defined responsibilities to be achieved by 2015. These MDGs provided the overall policy-framework within which sectors identified their priorities and developed achievable strategies.

The PRSP was developed in August 2003 and was named EGSPRS. The Government is committed to reducing poverty through higher economic growth focusing on education, health and social welfare sectors. The EGSPRS principles (GoM, 2003), that guide sector planning include:

- country-led planning and monitoring, involving broad-based
participation by civil society and the private sector in all operational steps
- results-oriented management focused on outcomes that would benefit the poor
- partnership-oriented, involving coordinated participation of development partners
- employment of a long-term perspective for poverty reduction

Health sector reform, hospital optimization, improving financial management efficiency, access to health services by poor and quality of health care are on the EGSPRS health agenda. These are reflected in the sector plan.

The continuous reduction of infant and maternal mortality over the last few years may have been the result of strong political commitment and support as many donors have already committed their support for the MDGs and EGSPRS.

2.5.1.2. Health sector Master Plan 2006-2015ÍHSMP)

The HSMP was developed as a response to various public sector reforms and this is reflected in its objectives and strategies. The development process used a “learning-by-doing” approach and wide- ranging consultation.

The HSMP provides the direction and scope of work for the health sector for the period 2006-2015. The HSMP is supported by its Implementation Framework and companion documents namely Medium Term Expenditure Framework (MTEF), Monitoring and Evaluation Framework (M&EF) and Planning and Budgeting Framework (PBF) to ensure smooth implementation. Overall, a sector-wide management perspective was constantly maintained and reinforced during the development of the HSMP.

The HSMP outlines how stakeholders would contribute to improving and sustaining the health of the people and links priority strategic actions and matching resources to a changing environment (MoH, 2005a).

2.5.1.3. Decentralization

Decentralization was initiated in the mid 1990s and was a response to the reduction in central level subsidies. It transferred authority and responsibilities in the area of financing and planning that were previously held at the central level, to the local governments. However, because of inadequate procedures and unprepared, under-qualified local management staff, decentralization has not produced meaningful results so far.

The recent Public Sector Financial Management Law (PSFML) introduced additional dimensions into the decentralisation process and highlighted the need for sector-wide reform and the development of a comprehensive, medium to long term sector-wide strategic plan to make this reform process more coherent and systematic.

While the essential legal framework for decentralisation and sectoral reform are in place, the implementation of these provisions leaves much to be desired in terms of the policies, guidelines and procedures and the reconciliation of the conflicts between the various laws underpinning these reforms (MoH, 2004).

2.5.1.4. Main challenges for the policy framework

- Institutional weaknesses and lack of capacity undermine the implementation of EGSPRS and MDGs
- Poor alignment and unclear linkages between the strategy, planning, and budgeting processes (i.e., between the EGSPRS and GoM-MTEF)
- Planning that is ad-hoc and reactive instead of strategic and proactive
- Absence of clear guidelines and procedures for systematically implementing decentralisation and the related application of the PSFML at all levels
- Lack of planning and financial management capacity at the peripheral level

2.5.2. Expenditure framework

In 2005, MoH developed its own MTEF for the HSMP within the government’s fiscal framework. The MTEF is expected to play an important role to improve sector efficiency and effectiveness by acting as resource allocation tool. However, the associated financial management capacity is inadequate and needs appropriate training.

2.5.2.1. Medium term expenditure framework (MTEF)

The MTEF describes the resource envelope and provides direction for the allocation of resources within the sector’s priorities. Although the MTEF tried to capture all sources of funding for the public health sector for 4 years, including donors and other stakeholders investing in health, in-line with the government’s fiscal expenditure framework, there are inaccuracies due to unwillingness of some donors to reveal their spending. That might have been caused by insufficient trust on part of the donors to sign up for sector support. The MTEF also considered the funds required for the implementation of the HSMP.

2.5.2.2. Health sector financing and resource allocation

Mongolia’s expenditure on health is relatively high when compared with the transition countries with similar levels of income. Although Figure 3 shows an increasing trend in funding for the health sector, anticipated health outcomes are not forthcoming. There is an urgent need to improve financial management and eliminate related inefficiencies, through prioritizing the activities, improving resource allocation and improving fiscal and policy accountability.

Figure 3: Trends in Health Expenditure

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Currently, the government health budget is planned in such way that after estimating the available funds from the Health Insurance Fund (HIF) based on hospital bed numbers, the remaining gap is covered from the state budget. However, the unit cost for health service delivery is not taken into account thus the current ratio of funds from these sources cannot realistically reflect the actual costs (MoH,2005b). Recent establishment of the NHA was a major step towards ensuring realistic budgeting. Costing of essential services and unit cost at the aimag level was done and will be applied for the budgeting starting 2006 (Personal communication, MoH officer in-charge of finance, Mongolia, 2006).

The MoF norms and standards are used for the allocation of funds to various line-items throughout the public sector. This leads to allocating almost identical funding to the aimags irrespective of the variability in their poverty and health indicators (MoH, 2005a). Therefore, current resources allocation mechanisms are weak and there is irrational allocation of resources across levels of care.

Allocation of funds is uneven; with very limited allocations to public health and primary care activities despite emphatic policies. Strengthening the financial management system will be vital if the government, supported by the international partners, plans to move towards implementing SWAps.

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Source: Borowitz M et al (2005)

According to the figure 4, most of the funding is directed to hospital services. It is noteworthy that, because of underestimation, the expenditure share for primary care and public health may not be accurate estimates, as many public health related functions are delivered through hospitals (Borowitz M et al 2005). The higher hospital costs may be explained by the unclear roles and responsibilities at the higher levels of care and inappropriate referrals.

2.5.2.3. Main challenges

- Fragmented and inefficient financial management
- Lack of financial management and policy analysis capacity
- Inability to allocate scarce resources according to the priorities
- Lack of coordination and unclear regulations to enforce the policy- budget link
- Failure to set out resource implications of proposed strategies in terms of their being affordable and sustainable
- Lack of ability to translate strategies into operational plans

2.5.3. Institutional Framework

Development of the HSMP re-emphasized the challenge to improve sector management and coordination capacity, as successful implementation of HSMP would require far-reaching organisational changes that would trigger high resistance.

2.5.3.1. Organisational structure

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Figure 5 present a descriptive overview of the sector’s Organizational Structure using the McKinsey 7-S problem-analysis format.

From figure 5 one can see that the system is still learning and changing from its traditional centralized, hierarchical system to a more flexible and responsive population needs-oriented system.

The present organizational and management structure is inefficient and ineffective and is subject to frequent, politically driven, re-organisations and structural changes. Although, last few years, various re-organizations and structural changes have occurred, these were politically driven and did not consider effectiveness, efficiency and better performance (HSMP, 2005).

A major challenge, now, is to shift management thinking from input to outputs and from planning on an ad-hoc basis to planning strategically and sector-wide. A results-based management system needs to be sustainably institutionalized. HSMP strategies under the area of Institutional Development and Sector-wide Management promote

[...]

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¹ Most of the papers on SWAps were written by experts, researchers and officers from or supported by donor agencies. This may have excessively emphasized a donor perspective, introducing a donor bias.

¹ Some public health expenditures may be “buried” in some line-item hospital costs. Weaknesses in the accounting system and the chart of accounts structure preclude adequate analysis

• College: University of Leeds (Nuffield)
• Grade: Distinction
• Author: Anar Ulikpan (Author)
• Publication Year: 2006
• Pages: 79
• Catalog Number: V182226
• ISBN (eBook): 9783656057086
• ISBN (Book): 9783656056867
• Language: English
• Tags: implementing, health, swap, mongolia, from, coordination, sector, management