Better reproductive health saves lives of women and kids in Mongolia

Pamposh Dhar, ADB Consultant

A health project drastically reduces maternal and child mortality in rural Mongolia An ADB-financed health project in Mongolia has helped halve the maternal mortality rate and substantially reduce infant and child mortality, improving the lives of Mongolian women. In five provinces where ADB more intensively supported the health sector, the change has been even more impressive. This was partly achieved through the training of 7,850 rural health workers, the majority of whom were women, including community-based nurses, doctors, and medical and administrative staff at provincial health centers. When ADB approved the Second Health Sector Development Project (HSDP2) in 2003, Mongolia had unacceptably high rates of maternal and child mortality, both of which could be appreciably reduced by providing accessible basic healthcare facilities. In 2001, as many as 169 women and 30 infants lost their lives for every 100,000 live births. Another 40 children died before the age of 5. By 2008, the ADB project added to other development efforts, and helped bring down the numbers drastically. The maternal mortality rate (MMR) declined to 85, the infant mortality rate (IMR) to 24, and the under-5 mortality rate to 32. In the five target provinces, the rates were even lower, with an MMR of 44 nearly half the national average; an IMR of 21.2; and an under-5 mortality rate of 25.3. The project covered the five rural aimags (provinces) of Bayanhongor, Dornod, Dzavhan, Ovorhangay and Hentiy. These aimags were chosen because 48.5% of the population was poor, much higher than the national average of 36%, and because they are largely rural provinces with extremely remote villages. Mongolias vast distances had made provincial and even district-level health facilities hard to access, making it difficult for women to seek health care services. To overcome this problem, the project focused on primary healthcare provided by community nurses, district healthcare centers, and provincial hospitals. The project also strengthened public health education initiatives started during an earlier ADB-supported program to encourage villagers to seek both preventive and curative medical attention. Staff were trained at all levels of the healthcare system to improve service delivery. The project strengthened an evolving trend away from a reliance on hospital-based curative care to placing more emphasis on a primary health care system based largely on preventive services. The Project had three specific objectives: improve the quality of health services in the remote rural areas of the five aimags covered by the project; encourage people to make better use of the available health facilities in these aimags; and strengthen Mongolias health sector, extending the reforms in sector efficiency, effectiveness, and sustainability, and institutional development that were introduced under the earlier ADB-supported program.

A Gender Action Plan to Maximize Benefits to Women A Gender Action Plan (GAP) was built into the design of the project to ensure the project was gender-inclusive and maximized benefits for women. The GAP addressed the need to improve womens reproductive health by improving health services, making them more accessible, and at the same time encouraging women to make full use of the available services. Mongolias mostly-female community health workers were trained to provide better care at public health centers and attend to women in the countrys vast rural areas through outreach services. This training support to community workers was a crucial part of the project. These workers have their work cut out for them in Mongolias harsh environment. One nurse described a typical working week, during which she traveled by horse for more than 150 kilometers in bitter winter weather to visit a pregnant woman, encouraged her to attend antenatal clinics, and discussed the health of her older children. After this, she traveled to another herder campsite to provide palliative care to a man dying from cancer. She remained there for several days helping the family care for the man. She and other nurses highlighted the usefulness of the project training for their work. These nurses play a vital role in rural areas, linking remote communities with the health system by referring high-risk patients to hospitals, encouraging preventive health care practices such as visits to antenatal clinics, and conveying important public health messages to the communities. Empowering Community Nurses to be Agents of Change Several community-based nurses said they are now more confident in their work. They have been empowered to be agents of change in their communities and are more effective in their work. Training primary health care workers, improvements to health infrastructure and equipment, and new patient-focused approaches to delivering services improved key maternal and child health indicators in project areas. Access to antenatal care is now equal to or above the national average, and the proportion of women experiencing pregnancy-related complications decreased from 50.0% to 34.5%. Attention to gender issues and the achievement of gender equality results directly contributed to overall project outcomes and effectiveness. A combination of gender-responsive strategies helped address some of the constraints faced by women when accessing health services, including non-medical barriers. For example, an accompanying grant from the Japan Fund for Poverty Reduction (JFPR) provided subsidies to cover transport costs to clinics and helped register citizens so that they would be eligible for services provided by the government. A Focus on Women and a Holistic Approach The project had three major strengths leading to its beneficial impact on the life of women: (i) it incorporated and implemented a Gender Action Plan; (ii) it explicitly identified women as among its major beneficiaries; and (ii) even though it was a health project, it also addressed nonmedical barriers that women faced in accessing healthcare. The fact that the project addressed non-medical barriers points to a practical and holistic approach centered on the needs of women. This approach, and the strategies of the Gender Plan, increased womens access to health services, particularly to antenatal care. The training of health care workers upgraded their skills and increased their understanding of health needs. Together with an upgrading of health facilities, this led to better quality of care in the five project 2

aimags. This, in turn, led to women having more confidence in the health care system and therefore making better use of the facilities it offers. The project has appreciably improved the health of poor women and children in the five rural provinces that received intensive support. It has brought many practical improvements, including lower maternal and child mortality, greater access to preventive health through antenatal clinics, outreach programs, and public information campaigns. Further, the project has helped make the health sector throughout Mongolia more responsive and more relevant to peoples needs. Through its emphasis on training to upgrade the skills of doctors, nurses, and health workers at all levels, the project has helped institutionalize a patientfocused approach and a holistic view designed to improve both the access and the attractiveness of quality health care.

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.