SOCIAL ISSUES. A. Poverty and Gender Analysis

Transcription

1 Appendix SOCIAL ISSUES A. Poverty and Gender Analysis 1. The Second Health Sector Development Project (HSDP2) has a poverty and gender focus and addresses health concerns of the rural poor and women, such as infectious and communicable diseases and reproductive health. HSDP2 will cover five rural aimags with higher poverty incidence and worse health outcomes than others: Bayanhongor, Dzavhan, Dornod, Hentiy, and Ovorhangay. Poverty, health, and gender considerations justify the selection of HSDP2 sites. This section provides an overview of absolute and relative poverty and health conditions over time. 2. Poverty incidence increased from 15% in to 36% in Absolute poverty has stabilized overall since 1995, except in the aimag centers (not including Ulaanbaatar), where poverty incidence increased due to internal migration and growing unemployment. The population living in extreme poverty increased from 1995 to Poverty is growing. Urs aimag has the largest population living below poverty, and Dzavhan, the largest population living in extreme poverty. More female- than male-headed households live in poverty. Ovorhangay aimag has the largest proportion of herdsmen. 3. The increasing differential in income translates into an increasing differential in the population s ability to afford health care. Per capita monthly health expenditure is seven times greater among wealthier than poorer households. The share of household expenditure for health among the poor (2.3%) is substantially larger than that of the wealthier households (1.5%). Several other indirect costs of health are unmeasurable, such as travel cost to health facilities, opportunity cost of time, and drug costs. Many rural health facilities are perceived to offer relatively poor quality of care and so patients travel as far as aimag centers and sometimes to Ulaanbaatar to attend hospitals. Health insurance subsidies are offered to those defined as vulnerable, but the income- or food-poor and the unemployed are less likely to be categorized as vulnerable under the current definition. 4. The infant mortality rate (IMR) was 64 per 1,000 live births in 2000 (MICS 2000). MOH data suggest that IMR declined from 64 in 1990 to 35 by 2000, but almost 50% of infant deaths are suspected to have been missed through incomplete demographic registration. Rural IMR is 1.5 times higher than urban IMR, and Dornod aimag has an IMR double that of Dundgobi (which has the lowest IMR). IMR for boys is higher than for girls. 5. MMR increased to 161 per 100,000 live births in from 119 in 1990 (Maternal Mortality Survey). In the past decade, MMR increased overall, with rural levels twice those of urban areas. Dzavhan, with the largest proportion of extreme poor, has the worst MMR four times higher than in Bulgan. Women from herder families are at a higher risk than others, representing almost 50% of all maternal deaths. Diseases not related to pregnancy are the primary cause of mortality, followed by pregnancy complications. 3 Abortion is a growing concern. At least 60% of deliveries with complications at aimag hospitals were referred from soum health centers, primarily due to eclampsia. 1 National statistics organization. 2 Living Standard Measurement Survey, 1995, UNFPA and Reproductive Health in Mongolia.

2 48 Appendix Nutrition of children and adults is extremely poor. Malnutrition and anemia are high among children and pregnant women. At least 40% of pregnant women suffered from chronic anemia. Poorer households had a higher prevalence of anemia. Poor maternal nutrition leads to high maternal mortality as well as a growing number of low-weight babies. With promotion of breast-feeding, undernutrition among infants decreased. However, inadequate household feeding practices have led to relatively poor nutrition among children of 2 5 years: 12% of under-5 children were underweight in 1990, and this rate remains the same today. 7. Tuberculosis, associated with poverty and crowded living conditions, is increasing, with the highest rates reported by Darvhan-uul, Selenge, and Dornod aimags. Respiratory diseases are still among the top five diseases. The health system continues to require resources to address communicable disease concerns. 8. Health service utilization remains high. Vaccination coverage is almost universal among children and pregnant women, and most deliveries are under the care of skilled health personnel. On average, at least five outpatient visits per person per year are reported by public sector facilities, with utilization rates at Orkhon aimag at least three times higher than in Ovorhangay aimag (lowest use). 9. Health service utilization among the poor is far lower than among wealthier households 4. The poor are more likely to visit soum health centers, primarily because of access and costs of care, whereas the wealthier are more likely to use aimag and private hospitals 5. B. Summary Poverty Reduction and Social Strategy 1. Linkages to the Country Poverty Analysis Sector identified as a national priority in country poverty analysis? Yes Sector identified as a national priority in country poverty partnership agreement? Yes Investment in the health sector will help reduce diseases among the poor and help them live a healthy life through provision of medical services, public health, and health promotion programs. Improved health will increase opportunities and capacity of the poor to participate in economic activities, care for their families, and pursue educational opportunities. 2. Poverty Analysis: Proposed Classification HSDP2 will target poor aimags. Under the integrated improvement of rural health services component, about 400,000 people in five rural aimags, representing 18% of the country s total population, will benefit directly from improved availability and quality of rural health services. About 48.5% of the population in these aimags is poor, compared to the national average of 36%. The targeted aimags are not only poorer but also have high endemic disease and infant mortality rates, which are composite proxies for poverty incidence, indicating that most of the population in the aimags faces multiple deprivations. 4 Kainyam, Tungalag Protection of Vulnerable Groups with a focus on criteria for identification of vulnerability and its implication for health insurance reform, HMIEC, MOH, Mongolia. 5 World Bank Mongolia Poverty Assessment in a Transition Economy.

3 Appendix HSDP2 will focus its support on PHC, which is an internationally proven best practice to meet the needs of the poor and vulnerable groups, especially women and children. HSDP2 will also facilitate access to PHC services among the poor. To reduce financial barriers and providers discriminatory attitudes, HSDP2 plans to introduce incentives for service providers to see the poor through capitation payment mechanisms weighted by the poverty rate and performance-based contracts as for family group practices (FGPs) in urban areas. Subsidies and outreach services for the poor and vulnerable groups are stipulated in the contract. HSDP2 is classified as a core poverty intervention. 3. Participation Process International and local consultants recruited under the project preparatory technical assistance carried out a multilevel consultation process with a wide range of stakeholders. Four stakeholder groups were identified and consulted across a range of issues. Primary stakeholders included service users and providers at the bag, soum, and aimag levels. Secondary stakeholders consisted of national and local policy and decision makers. The analysis of response showed a high degree of concurrence among stakeholders on the causes and effects of problems in delivering good-quality and affordable health services, especially to the poor and vulnerable. The main divergence was in perceptions of how the poorest groups are treated, with staff having a much better opinion of their interventions than the recipients, who clearly feel discriminated against by individuals and the system. The differences among stakeholder groups required a wide range of participation strategies. For service users and service providers, the participatory appraisal and planning method was used. For local and national policy- and decision makers, one-on-one interviews, group interviews, and regional workshops were conducted. To deepen participation, project component design was done through counterpart groups in MOH and a multidisciplinary steering committee (MOH, Ministry of Education, Ministry of Finance and Economy, Parliament, State Social Insurance General Office, university and aimag representatives). Widespread participatory discussions took place, particularly to identify needs and demands for capacitybuilding activities to implement reform. Participation input proved to be useful and important to project design, not only because of the information provided but also because of the resulting awareness of the value of participation and consultation. The consultation loop set up with stakeholders will be maintained. 4. Social Issues Significant/ nsignificant/ ne Strategy to Address Issues Resettlement ne resettlement is expected in HSDP2 as all civil works take place in existing locations. Gender Significant HSDP2 focuses resources on PHC at the bag and soum levels to best respond to the needs of women and children, particularly in promoting reproductive health. The first-referral function of aimag hospitals Output Prepared Gender action plan

4 50 Appendix 13 will be strengthened to provide quality services to referred cases of pregnant women and children. HSDP2 has a gender focus not only for service users but also for service providers. HSDP2 will improve women s working conditions. More than 98% of bag feldshers, soum doctors and nurses, and aimag nurses are women. About 95% of aimag doctors are women. In urban areas, 95% of FGPs are also women. HSDP2 supports PHC and directly benefits women workers. Affordability ne HSDP2 will not initiate any user fees or cofinancing of services that have risks of negative impact on poor s affordability. HSDP2 will help the health insurance system increase efficiency, poverty focus, and sustainability. To ensure the poor s access to services, HSDP2 will organize surveys and strengthen monitoring mechanisms on service utilization by the poor and their problems. Labor ne HSDP2 will develop career development support (CDS) for those who wish to move to rural areas as well as for those who wish to leave the health sector. CDS is expected to have a positive impact on labor productivity by making available qualified doctors and nurses in rural areas where such qualified personnel do not exist, and by providing pre-service Indigenous People Other Risks/ Vulnerabilities t significant training. HSDP2 will use languages familiar to ethnic minorities, especially in health information campaigns to communities and at bag-level training. HSDP2 is in environment category B. Medical waste management will be improved when HSDP2 rehabilitates and rebuilds health centers and aimag hospitals. In designing civil works, the environment management plan, including the medical waste management plan will be developed. Summary of Initial Environmental Examination C. Gender Plan 10. Women in Mongolia live longer and are healthier than men. Life expectancy at birth in 2001 is 61.2 years for men and 68.3 years for women. In terms of healthy life expectancy, which takes into consideration disability in addition to length of life, women have 58.0 years of healthy life, compared to 49.9 years for men. 11. However, these better indicators do not necessarily mean that women receive better social and health attention. Maternal mortality, which is largely preventable by the application of available medical knowledge and basic technologies, is unacceptably high and does not show any improvement over years. It may even be worsening. Women suffer from an unnecessary disease burden. Reproductive health conditions are the cumulative result of poverty;

5 Appendix educational, social, and cultural behavior; and health care factors. This indicates that measures to improve reproductive heath must be carefully planned and targeted. 12. HSDP2 is classified under gender and development because of the significant benefits that women receive. HSDP2 pursues health system reform and health service improvement that will equally benefit men and women but includes specific actions to improve women s health. This gender plan delineates specific approaches to ensure positive impact on women s health. This gender plan is also expected to help the Government to achieve Millennium Development Goals (MDGs) for women. 13. The following scope of the gender plan will be implemented as part of HSDP2: (i) Integrated improvement of rural health services a. HSDP2 will focus on PHC; strengthen bag feldshers (community nurses), whose major responsibility is reproductive health and soum health centers, where more than 30% of patients are women of reproductive age and another 40% are children. Support to the bags and soum levels will benefit women greatly. Aimag hospitals will be strengthened to provide quality services to referral cases of pregnant women and children. b. Through civil works and equipment provision, HSDP2 will improve working conditions in rural facilities, where most health workers are women. c. HSDP2 will train PHC rural health workers, most of whom are women, to provide efficient outreach services to achieve MDGs. (ii) Institutional capacity development a. HSDP2 will provide a refresher course to all FGPs and a basic course to new FGPs. Training will include provision of efficient outreach services to achieve MDGs. b. HSDP2 will provide basic equipment and train FGPs, most of whom are women. c. The FGP monitoring system will be strengthened to assess the satisfaction level of the poor and women. d. HSDP2 will increase MOH and local government capacity in planning a health system, and services that are efficient, effective, sustainable, and responsive to diverse needs of different client groups, including the poor, women, men at health risk, and children. (iii) Project management Data for project performance monitoring and evaluation system will be gender disaggregated.

6 52 Appendix Through the gender plan, HSDP2 aims to accomplish the following: (i) (ii) Approximately 120,000 women of reproductive age, living in five HSDP2 rural aimags, will have improved access to quality reproductive health services. Approximately 200,000 women living in five HSDP2 rural aimags will be encouraged to promote their health and adopt health-seeking behavior for themselves and their families. (iii) More than 7,000 urban and rural women PHC workers will be trained. (iv) Working conditions will improve in rural facilities in five HSDP2 rural aimags, where most health workers are women. 15. ADB will work with the Government to ensure that the gender plan is implemented and will contribute to achieving the MDGs. Progress of the gender plan will be included in quarterly progress reports. D. Ethnic Minority Assessment 16. Most Mongolians are Khalkh (81.5%). More than 30 ethnic and minority groups account for 18.2% of the population. Ethnic minority groups are concentrated in three aimags Bayanolgiy, Urs, and Khovd. 17. Table A13.1 shows ethnic minority groups in HSDP2 aimags. Substantial ethnic minority populations exist in Dornod and Hentiy, while in other HSDP2 aimags, minority group populations are very small. 18. data are available on health status by ethnic minority group. However, information is available on literacy and education (Table A13.2). significant difference is noticed among ethnic minorities in education opportunities. The Constitution indicates that no person will be discriminated against based on ethnic origin, and guarantees equal access to education among ethnic minorities. Ethnic minorities may thus be assumed not to be disadvantaged in access to health services, and health status. 19. specific information is collected on occupation by ethnic group. In 2000, 47% of the population depended on agriculture for their livelihood. Ethnic groups have lived in the same place for centuries highly concentrated in Bayanolgiy, Urs, and Hovd with no significant changes in their lifestyle. Ethnic groups participate in community activities with equal rights as the rest of the population. All the population speaks Mongolian, but in Khazakh the ethnic minority speaks its own language and, in accordance with article 8 of the Constitution, this national minority is allowed to use its native language in education, communication, and the pursuit of cultural artistic and scientific activities. 20. Given the equal levels of social indicators among ethnic minorities, no indigenous people s development plan or special actions in favor of any particular group are needed.

7 Appendix Table A13.1. Ethnic Groups in Second Health Sector Development Project Aimags Out of which Aimags Total Kalkhs Other Ethnic Groups Ethnic Minority Main Ethnic Groups Bayanhongor 74,574 74, Uuld, Durud Dornod 73,855 49,588 24, Buriads Dzavhan 88,518 88, Durud, Bayad, Kazak,Tuva Ovorhangay 96,472 96, Uuld,Duvud, Kazak, Buriad Hentiy 70,103 57,391 12, Buriad, Kazak, Urianhai Source: National Statistical Office, and Housing Census 2000 by aimag Ethnic Group Table A13.2. Literacy and Education by Ethnic Group Literate Illiterate Educated n- Educated Secondary Education Khalkh Kazakh Dorvod Bayad Buriad Dariganga Zakhchin Uriankhai Darkhad Uuld Torguud Khoton Khotgoid Myangadd Tuva Others Total Source: National Statistical Office, and Housing Census 2000.