The potential of the RED strategy to address inequity and social disadvantage
The application of the RED strategy in Mongolia is an example of active social management (through the health sector) in order to correct social disadvantage. The observations by health managers and providers in this assessment capture the challenge of responding adequately to the health needs of the population without also addressing their social problems. Interviewees in this assessment underlined the notion that the transition to the market economy and related patterns of internal migration had loosened social bonds, weakened traditional community leadership and strained extended family ties, thereby negatively impacting on health for many vulnerable groups.
This isolation presents itself in a number of ways. These include being "outside the health system" in terms of lack of financial capacity or knowledge to access health services, being "outside the administrative system", as measured by lack of civil registration, being "outside the economy" as measured by unemployment or low-income status, and, most importantly, being "outside of any social network" as measured by lack of any "carer" status (single mothers, orphans or elderly without care-takers, school drop-outs). Ill health in the Mongolian urban setting is therefore more than a consequence of being low-income, but reflects a "compound effect" [
52] of poverty, unhealthy daily living environments, social vulnerability and isolation.
This RED strategy assessment has underlined the extent to which individuals and families in the lowest socio-economic groups lack the social and behavioral pathways of social influence, engagement and social support that characterize "networked" healthy societies [
53]. It is conceivable that the RED strategy, as a method of "instrumental" social support for access to health and some social services, is able to assist with the tangible needs of the population by linking them better to mainstream social agencies (including NGOs, local authorities and government services).
National context - service delivery models, partnerships and health care access
The establishment of the Family Group Practice system in Mongolia, along with development of health insurance mechanisms and a capitation-based model of funding have provided a solid foundation for the development of the national health system [
54]. However, based on the outcomes of the RED strategy in Bayanzurkh district, it is quite clear that this solid foundation, though a necessary condition, is currently insufficient to meet the needs of the most vulnerable groups in society. These groups have in some cases fallen "outside the system," with high levels of social isolation amongst them. Furthermore, based on the case studies of health access barriers, there is convincing evidence that significant minorities of the population are not accessing health and social services at all.
The service delivery model of the Family Group Practice in many ways is built around the concept of primary medical care, and less perhaps on the concept of primary health care. Although mandated by Ministerial Order #154 to service the health needs of the registered and non-registered elderly, children and pregnant women, some Family Group Practices are simply not funded or organized to reach such groups, providing little motivation to actively search for them. Even with clear Government orders, it is all too easy for the poor and powerless to fall outside the scope of mainstream service provision. The awareness raised among health workers in Bayanzurkh, that after house-to-house search, an "unexpected number" of vulnerable clients were identified seems to confirm this tendency. This realization has important implications for the financing and organization of health care service delivery for the very poor.
The Family Group Practice is of course a "Family" Group Practice and not a "Facility" Group Practice, so additional community participation mechanisms will ensure that families remain the focus of the health care system. In practice, this means stimulating more community-focus in daily operations which partly target wider social issues that affect access to health services (school attendance, social isolation, unemployment, disability care, substance abuse, nutrition). For this reorientation to take place in practice, local area mechanisms for participation by all stakeholders will need to be modeled in order to formalize the networks and develop procedures for resolution of community health problems. The nurses of Bayanzurkh demonstrated that this reorientation must come from a range of organizational and social actors, and not only from the health sector itself.
On the other hand, as participants in this assessment indicated, there are limits to the Family Group Practice's capacity and function to adequately respond to the social determinants of health. Nevertheless, the Family Group Practice still has the potential to develop and strengthen social networks for health. In order to re-engage vulnerable families with the health and social system and have long-term impact, the structure supporting the Family Group Practices has to change and broaden to include other responsible civic actors including district health authorities, Khoroo Governors Offices and section leaders, NGOs and volunteer networks and the families themselves. Some ideas from this RED strategy assessment of how these partnership mechanisms could work are detailed in the additional file attached to this paper.
The complex array of social determinants that contribute to social isolation and related poor health, are clear arguments for integrated approaches to service delivery. The cases of social exclusion outlined in this paper would respond best to participatory or "partnership" methods of health governance that are more inclusive and expressive of the health rights of disadvantaged social groups.
Looking to solutions - improving health and social services access through the RED strategy
The experience of the RED strategy in Mongolia raises one of the perennial questions of primary health care practice. Should health services promote demand for fixed facilities or should health workers "outreach" to these communities? The difficulty with unique emphasis on a fixed-facility approach is that health issues become contextualized in terms of clinical health responses only. There is less opportunity for community networking to stimulate improved health, and a tendency of health care providers to "personalize" what are in fact social health issues. The fact that many of the health managers and providers in this assessment easily identified the underlying social causes of poor health access for their catchments gives testimony to the fact that a more networked health strategy will be required to make a sustainable positive impact on health outcomes.
The lack of "connectedness" between health administrations and local authority was recently noted in an international review of health inequity studies. Over a 20 year time frame, it has been demonstrated that only 17% of the studies and interventions described roles for municipal government in the reduction of local health inequities, and that studies and interventions demonstrate a "pervasiveness of 'behavioral' and 'biomedical' perspectives [
55]. One other review has highlighted the fact that local governments often lack the financial and expert capacity to address urban problems, resulting in the lack of representation of the needs of the poor in local urban governance and planning [
56].
The constraints of Mongolia's health system and local government organization raises real questions about the efficacy of such a heavy emphasis on "contractual" models of health care delivery, certainly in a society marked by high levels of income inequality and mobility. The "chaos" described by one of the respondents to characterise the level of community disorder, combined with the comments by a central planner of things seemingly "being out of control" highlights the need for both stronger central resource commitment and decentralized "steering" of the sector to ensure that health service delivery is more inclusive of the needs of the very poor in local areas. The fact that large numbers are falling "outside the system" indicates the need for putting in place practical procedures for mapping, tracking and registering populations and for strengthening systems of community partnerships to effectively reach these populations and respond to their needs. Table
2 illustrates the contrasting approaches of contractual models of management with models of governance informed by a social accountability approach.
Table 2
Enhanced Contractual Models of Health Service Governance through Lens of Social Accountability, Mongolia RED Assessment 2010
Capitation-based funding | Capitation Based Funding (funding per capita) in addition to "Special Funds" Arrangements for Marginalized Populations |
Outcomes-based funding | Both Process and Outcomes Based Funding (for example financing of community participation and partnership building in addition to activities supporting achievement of coverage targets) |
Planning and financing for officially registered populations | Financing for officially registered populations as well as financing of the unregistered based on population estimates provided through micro-planning data |
Processing health entitlements through facility-based operations | Promoting population entitlements to health and social service access through active participation and networking in vulnerable sections of the community |
Provision of primary medical care | Promotion of primary health care through community partnering and networking with municipal authorities, NGOs and community leaders (in addition to delivery of standard package of medical benefits) |
Facility-based operations | Facility-based operations combined with active community search and engagement of the vulnerable for equity of access to health and social services |
This strengthening of partnerships in a decentralized context as outlined above and in the section above is reflected in Ministerial Order #154 on national scale-up of the RED strategy. This order is highly illustrative in terms of new approaches to health system strengthening being adopted in Mongolia.
Firstly, the transition of management of the RED strategy from the National Immunization Program to the Department of Planning is in recognition of the fact that, in order to address persistent inequities that have a basis in the social determinants of health, a health system strengthening approach that embraces a wider package of health and social services will be required.
Secondly, RED in Mongolia is now driven by stronger partnerships between system planners (local government, health planning and finance) and program planners (immunization and maternal and child health). The value of the partnerships between system and program planners is that the former have the capacity to mobilize resources and encompass a wider health and social services agenda, and the latter (particularly from immunization as demonstrated by the success of the RED strategy internationally) have the capacity to build upon successful operational strategies at community level.
Finally, the new policy on RED in Mongolia also illustrates the developing role of local authorities and social welfare agencies in partnering with the health sector to address inequities in access to health and social services. In fact it is local authorities, with social welfare and health sector participation, who will oversee the strategy at the local level [
57].
The RED scale-up, facilitated under the national directives of the Ministry of Health and supported through UNICEF and the Global Alliance for Vaccines and Immunization, is bolstered by a wider set of evolving partnerships across local government, NGO and social welfare agencies. This indicates much better prospects for sustaining the strategy in the longer term.
However, despite the health access improvements and structural gains achieved under the RED strategy, some important limitations of the strategy need to be noted, particularly with respect to its capacity to quantify the increase in health service access coverage for the urban poor. As has been observed in earlier sections of this article, the particular characteristics of urban poor populations include their mobility (on a seasonal or daily basis) and lack of registration status. Notwithstanding these methodological difficulties, this assessment establishes the limitations of qualitative methods, as well as the constraints of effectively capturing the quantitative outcomes of the RED intervention. This indicates the need for a more "mixed-methods" approach in future assessments, with consideration being given to conducting cross-sectional household surveys in targeted areas to balance the case study findings.