| 4. In which ways is the initiative creative and innovative?
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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.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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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.
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| 6. How was the strategy implemented and what resources were mobilized?
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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.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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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.
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| 8. What were the most successful outputs and why was the initiative effective?
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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).
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| 9. What were the main obstacles encountered and how were they overcome?
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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.
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