NCMCH
National Center for Maternal and Child Health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Mongolia is country with 3.0 million populations living sparsely over the 1.566 500 square kilometers, which makes it the least densely populated country, which means that 1.7 per square km. The sparse distribution of the population makes it challenging to deliver health care services to rural and remote areas and difficult to maintain quality specialist care facilities and qualified human resource in the countryside. Such discrepancy in the quality of health care aggravated by reduced income-generating opportunities in the countryside hinders the achievement of Mongolia’s national health targets and health Millennium Development Goals. Most provinces are distant from the capatial city, Ulaanbaatar with an average distance of 700 kilometers and poor infrastructure which makes air transport expensive for the population with GDP /per capita income of 3773 USD. In fact, the distance between cities poses a challenge in the delivery of health services to most of the nomadic people, 38% of the overall populatio

B. Strategic Approach

 2. What was the solution?
That’s where the Telemedicine Network comes in. The Network connects every provincial hospital in the country with experts at the National Centre of Maternal and Child Health in UB. Now, local physicians can consult with a team of national experts, in real time, without having to leave the examination room. The Project’s overall goal is to contribute to the reduction of maternal and peri/neonatal mortality rates in Mongolia through the introduction of innovative technologies in antenatal diagnostics, the provision of skills upgrading through comprehensive, continuous medical education, and improved case management using the tele-consultation network established between reference and provincial hospitals. The nationwide MCH-telemedicine network (based on Campus-Medicus software platform) is fully set up and functional at the national level. This system also offers distance consultations and distance learning opportunities for over 200 provincial doctors who are actively using it and a group of 39 experts has been arranged at the NCMCH.

 3. How did the initiative solve the problem and improve people’s lives?
Main strategies used in the project are as follow: 1. Set up fully functional tele-consultation network nationwide on the following areas: 1. High risk obstetrics case management based on patient e-files; 2. Prenatal US diagnostics image transfer; 3. Newborn consultation network and 4. Cervical pathology screening based on colposcopy and pap-smear imaging. 2. Staff development and knowledge transfer; 1. Facility upgrading with installation of high quality diagnostic and medical equipment; 2. Capacity development of service providers on new innovative technologies using updated clinical reference materials; and 3. On job skill-transfer training 3. Set up multidisciplinary expert team at the NCMCH; 1. Clinical decision support through tele-consultation network; 2. Introduction of Distance learning program as continuous medical education; 3. Updating national strategies and guidelines and 4. Promoting professional networking with international centers of excellence Technology used: Under the project, modern diagnostic and telemedicine equipment such as 2D&3D digital US machines with DICOM image processing, high–speed computer with audio visual accessories connected with internet and intra-partum CTGs monitoring with central station and digital colposcopes were provided. The software platform was Campus Medicos which is a collaborative platform for exchange of medical knowledge, distance consultations, forums and distant teaching in medicine. Images can be uploaded in series and shared video allow doctors to view the same live scenario, talk to each other, write chats and store images in a patient case. Expert doctors (Reference center) write their diagnosis (as the first or second opinion). Capacity development: Provincial hospitals have been equipped with high quality digital diagnostic machines, such as ultrasound and foetal monitors, as well as newborn incubators. They’ve also been given access to trained specialists on the management of high risk pregnancies, and maternal and newborn complications. The specialists from participating hospitals were trained on the management of high risk pregnancies, and childbirth and newborn complications. A large range of training activities have been carried out on emergency obstetrics skills, prenatal ultrasound diagnostics, early newborn resuscitation and screening, advanced surgical skills in gynaecology, and midwifery practices using different modalities (on-site training with simulators, short courses at the NCMCH, training abroad, distant learning and national scientific congress). A total of 1,081 health professionals in repeated numbers benefited from in-country trainings, and 44 health professionals participated in overseas trainings. The technical capacity of the NCMCH is strengthened through the introduction of the new services such as the maternal-fetal medicine programme with modern prenatal diagnostics, minimally invasive gynecological surgery and advanced services in Reproductive medicine. In order to support the access to continuous medical education, the project developed an e-learning platform (http://elearning.obgyn-telemedicine.mn/). To ensure the government ownership and sustainability of capacity development interventions, four-weeks training modules are integrated into the Continuous Medical Education (CME) programme of the Center for Health Development and are offered on a regular basis to specialists as two CME credit hour courses. To date, a total of 249 specialists successfully registered as active users and come of them received on-line credits while completing all modules. To support professional networking between specialists from various national and international institutions, the national event “National Congress “Improving Practice by Exchanging” was introduced as a national Congress. As a part of collaborative project, Maternal Fetal Medicine program was introduced at the NCMCH and the first 8 professionals were certified. As a result capacity development, the quality of diagnostics of rural hospitals were improved as 88.3% of all consulted cases were managed locally according to advise provided by the experts. Based on the last content analysis done in 2015, the Proportion of agreement in the diagnosis between the provincial specialist and NCMCH expert1 is reached to 85.4% as compared to baseline of 62.3%

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
1. The ultimate purpose of this project is not to develop fancy and expensive Telemedicine service in Mongolia but to use it as a simple tool to improve access to specialist care and professional information. The network created under the project is not a classic Telemedicine and it was designed as a professional network between service providers to promote a team spirit over the patient care. Telemedicine never replace local health care and it only serves as a support and educational device. 2. The capacity development is a heart of the project in local settings to support equitable access to quality MCH/ RH care. 3. The telemedicine approach is very much relevant and effective strategy for Mongolian context of huge geographical areas with sparse population and huge disparities in quality and access to health services. Through this initiative, it was possible to strengthen the capacity of service providers to provide timely and appropriate care, especially to mothers with pregnancy and childbirth complications. 4. Regarding the training methodology, the project replaced classroom teaching with skills based hands-on training using simulations in various clinical settings in emergency obstetrics care and advanced surgical skills. 5. Introduced high quality equipment in prenatal diagnostics (US machine with Doppler) with vascular study and fetal growth screening which in turn greatly contributed in improving the diagnostic capacity of rural doctors. The diagnostic images also supported by on-line confirmation if needed. 6. The creation of an online learning platform gives health professionals easy access to information and support from national experts. This improved access to knowledge and professional expertise has been instrumental in the reduction of maternal mortality in Mongolia's rural communities. 7. Also in 2015, the project helped to introduce the first Reproductive Medicine Unit with minimal invasive surgeries at a public hospital, marking an important first step to the availability of quality reproductive health care in Mongolia.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Implementing partners are: • Ministry of Health- responsible for the overall coordination and oversight of the project • National Center for Maternal and Child health is responsible for: (1) mobilizing expert teams from NCMCH to provide tele-consultations and guidance to provincial service providers; (2) developing clinical guidelines and protocols; and (3) conducting training sessions. • 21 provincial hospitals are responsible for (1) ensuring active participation of provincial health specialists to project activities; and (2) providing workspaces equipped with 24-hour access to a high speed internet connection, which are essential to project implementation Project beneficiaries are; The health institutions covered by the project, i.e. 21province hospitals, six rural general hospitals (inter-Soum level) and the NCMCH (departments of gynecological surgery, maternity including antenatal diagnostic, high risk pregnancy care, delivery, neonatology, and the center for infertility) the health professionals working in these facilities (basically gynecologist-obstetricians) the pregnant mothers, women with reproductive age and newborns. Annually around 70-80 000 women gave birth and all of them were benefitted from the services supported by the project at the central as well as peripheral levels.
 6. How was the strategy implemented and what resources were mobilized?
The project has been implemented in two phases (2007-2011& 2012-2016) and co-financed and implemented by UNFPA Mongolia as an integral part of its core operations in Mongolia as denoted within its Fourth and Fifth Country Programmes (2007-2016). Total budget for the second phase – EUR 2.144.925.26 • Government of Luxembourg – EUR 1 400 098.49 • UNFPA – EUR 744 826.77 Since the NCMCH is main implementing partner, AWPs were developed annual basis based on overall project expected outcomes and outputs. Key activities are: • Provision of specialized equipment and supplies • Setting up additional facilities for prenatal diagnostics and tele-consultation units at a new sites • Upgrade and develop clinical reference materials • Organization of capacity development trainings on quality maternal and newborn health care; • Introduction of new services such as maternal and fetal medicine, minimal invasive surgery, advanced treatment in reproductive medicine at the reference center. • Project visibility in broader settings. Project Monitoring and evaluations Project monitoring was undertaken in accordance with UNFPA and LuxDev monitoring and reporting procedures and guidelines. As indicated in the agreement between UNFPA and Lux Dev, project implementation status was reported quarterly and annually by UNFPA to Lux Dev along with other MON/005 project component results. In addition to regular communication with IPs, field monitoring visits including spot-checks for Harmonized Cash Transfer modalities (HACT), were conducted jointly with IPs. Recommendations from these monitoring visits were provided to partners at national and local levels to strengthen project progress towards the intended results and quality of interventions. The regular audit conducts every year based on overall amount of budget expenditure by IPs. The audits conducted at the NCMCH by an independent auditor “Moore Stephens International Limited” in the past three years, including 2015 have yielded “unqualified” opinions, speaking of a robust financial management system at the partner institutions.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Stakeholders included the Ministry of Health, NCMCH, CHD, and representatives from local, provincial and national health care institutions, professional associations (MFOG), the Mongolian National Medical University, and national and international development partners like WHO and UNICEF. During the consultations, a log-frame with indicators and targets was developed, and key challenges and the way forward for the project were agreed with main stakeholders. The final draft of the project document was reviewed and approved by the Government of Luxembourg and MOH, Mongolia and the co-financing agreement between donors were signed in December 2011 for the second phase. The annual progress reports usually shares with MoH and also with main stakeholders who contributed in the implementation of the project.

 8. What were the most successful outputs and why was the initiative effective?
1. Nationwide tele-consultation network is available and functional in MCH care. Over 1800 mothers and newborns’ lives saved through the network (2012-2015). A distance communication of specialists between the reference and local hospitals via – consultation cases has obviously improved and resulted in increased strategic clinical judgment of local service providers for patient management. 2. Improved human resource capacity in Maternal and newborn care A total of 1165 service providers’ knowledge and skills in high risk obstetrics and emergency obstetrics management were upgraded throughout the project implementation which resulted in Quality changes in case management: 1. Local case management with compliance of newly introduced guidelines now 67.5% of the cases ; 2. Agreement between experts and rural specialists increased to 84.5% compared to a baseline of 62.3% in 2011, indicating significant improvement in quality of care provided in provincial hospitals. 3. Strengthened services at the tertiary level The NCMCH is now able to provide the following new services: Advanced diagnosis in pregnancy with interventional sonography and prenatal screening for fetal abnormality Minimal invasive surgery and women’s reproductive health services including subfertility treatment Advanced services for premature newborn care Maternal and newborn surveillance system with responses 4. Reduced MMR and Mongolia achieved MDGs. As the Millennium Development Goals (MDGs) came to a closing in 2015, Mongolia was recognized as one of the only 9 countries in the world to have achieved the 5th MDG on maternal health, having successfully reduced the maternal mortality ratio (MMR) by more than ¾ since 1990. The project investment have resulted in significant gains in maternal and newborn health care in Mongolia, and significantly contributed to the achievement of Millennium Development Goal (MDG) 5 by improved early detection and timely management of pregnancy complications at the provincial level through the nationwide tele-consultation network; regular consultations among participating hospitals on maternal and neonatal near-miss cases facilitated by the Maternal and Child Health Surveillance System; introduction of competency-based Emergency Obstetric Care (EmOC) and on-the-job surgical skill trainings; and development of an eLearning platform at NCMCH with continuous medical education (CME) modules (4th NRHP and project final evaluation report). 5. Reduced perinatal and neonatal mortality rates in Mongolia. As a result of continued support through the network and quality in-service training for early newborn care in local hospitals, rates of perinatal and early newborn mortalities dropped from 15.4 and 7.8 to 12.8 and 6.8 per 1000 live births, respectively, between 2011 and 2016 (MNSS).

 9. What were the main obstacles encountered and how were they overcome?
Two examples. There was no sufficient technical capacity in the country in developing technical specifications for procuring quality medical equipment. During the first phase 2007-2011, the project provided essential medical equipment to the project sites. Nevertheless, the quality of equipment was questioned. The suppliers did not have adequate capacity to repair and troubleshoot. Thus, in the second phase 2012-2016, the technical specifications were defined with assistance from an international biomedical engineer from the Swiss Centre for International Health (June 2012) hired by project, and at least two year follow up plans were included in the competitive bid requirements. The project had much better value for money on equipment which were highly appreciated by the end users. As project was scaled up during the second phase to cover all provinces, it become increasingly necessary to monitor the maternal and newborn morbidity and mortality data from aimags. The information on maternal deaths and “near misses” were not analysed systematically and were compiled only twice a year for discussion. Through joint advocacy with UNFPA to the MOH and Ministry of Finance, Maternal and Child Health Surveillance Unit was created and 8 positions for epidemiologists, ICT technicians and researchers with salaries coming from state budget were approved. The project conducted trainings for the recruited staff, including the training on International Classification of Diseases 10 in Bangkok. Currently the unit have up to date data on maternal and newborn deaths within 24 hours and severe complications within a week, develops annual reports and reviews such as confidential enquiries into maternal deaths “Why mothers died?”. The most recent review is published in February 2017 and covers maternal deaths during 2012-2016. The findings served for development and approval of clinical guidelines and policy documents. The unit is now an integral part of the NCMCH.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The telemedicine approach, which the application of information and communication technology in medicine, allows exchanging patient’s information over the internet, including ultrasound scans, fetal heart rate charts, laboratory results and other digital images between the rural doctors and experts in the capital city of Ulaanbaatar, to better diagnose and treat maternal and newborn conditions. In other words, it provides the access of remote and vulnerable population to better quality specialized care. The patient satisfaction levels are also high. Now, with more than 1800 cases of maternal and newborn complications consulted over the telemedicine network since the October 2008, it has become a new commodity that increases access to specialized health services for rural population, which helps saving women’s and newborns’ lives, as well as saves time and money of poor families living in remote areas, who now often can avoid expensive trips to Ulaanbaatar to resolve their health needs. It has to be noted that mothers do not travel alone, but accompanied by family members, which adds to the cost. It also has become a tool for increasing knowledge and skills of rural health care providers. The project has been continuously developing the skills of the rural specialists in operating the equipment, diagnostic approaches and clinical procedures. With the gained competencies, the rural doctors are increasingly able to manage the complications locally with advice. This significantly reduces the number of costly referrals, while only those with very severe conditions are referred. The direct beneficiaries are women and newborn, and their families. Poorer and less educated women and girls are more likely to have preconditions for complications such as high fertility, teen pregnancy, malnutrition, anemia, obesity or domestic violence which increases the risks for complications during pregnancy, childbirth and postpartum periods. Therefore, the project contributes to reducing the risks of impoverishment because of illness, and to gender equality.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Not applicable

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
No specific measures were undertaken to ensure vulnerable groups to get the benefits. But by design, the project covers poorer, rural and less educated women and girls who are more likely to present the complications as explained above. Project contributed for better access to quality specialist services to vulnerable (distance) and for saving the lives of mothers and newborns through innovations.

Contact Information

Institution Name:   National Center for Maternal and Child Health
Institution Type:   Academia  
Contact Person:   Enkhtur Shonkhuuz
Title:   Dr.  
Telephone/ Fax:   +97699059825
Institution's / Project's Website:  
E-mail:   enkhtur_mgl@yahoo.com  
Address:   BGD, Huvisgalchiin street
Postal Code:   16060
City:   ULAANBAATAR
State/Province:  
Country:  

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