Mongolia: crafting essential country-specific tools to tackle NCDs – World Health Organization

Facing up to NCDs

Mongolia has one of the highest mortality rates due to noncommunicable diseases (NCDs) across the Western Pacific. Home to over three million people, Mongolia is facing a rising tide of NCDs. In 2018, around six in ten deaths were attributed to either cardiovascular disease (CVD, 34.4%) or cancer (24.6%) in 2018.

Smoking prevalence remains high, with more than four in ten adult men being daily smokers, while trends in child and adult obesity have significantly increased over the last two decades, driven in part by the increasing ubiquity of ultra-processed foods and beverages.

Recognising the critical importance of preventing and managing heart disease to health and development, the Government of Mongolia has approved a national Sustainable Development Vision 2030, setting a goal to reduce CVD mortality to 17.4 per 10,000 people by the end of 2020.

Primary care is an important entry point to reach this goal. In Mongolia, primary health facilities include family, soum and village health centres, designed to respond to the unique geographic conditions of the country.

However, it is widely recognised that existing resources will need more help to improve heart health. Stronger health system action is needed, but is held back by limited resources. As such, accelerating NCD responses that are community-based, patient-centred, long-term and sustainable is vital.

Credit: WHO

To address the devastating impact of NCDs in Mongolia, in June 2019, the Mongolian Government Ministry of Health, supported by WHO and the Korea Centers for Disease Control and Prevention, launched 'MongPEN'. The name comes from a Mongolian version of WHOs Package of Essential NCD interventions, commonly known as PEN. It also features information on improving heart health (from WHOs HEARTS technical package), such as guidance on how to identify patients at high risk of CVD, and making use of an ePrescription service to gather data.

Using MongPEN, the Ministry of Health hopes to strengthen its health system to prevent and manage NCDs, by:

Credit:Ministry of Health Mongolia

Dr B.Usukhbayar, Physician at the Family Health Centre of 10th khoroo, Songinokhairkhan District, explains to us why having MongPEN has been so important.

I see many benefits of MongPEN in primary health care. First, we have received systematic training on NCD interventions, followed by supportive supervision and refresher training. This has been very empowering.

MongPEN makes our work easier in several ways. It assists with clinical decision-making by providing guidance to conduct risk assessments for cardiovascular disease. It supports us to follow up with our patients with hypertension and diabetes, enabling physicians, nurses and social workers to work as a team. Finally, it empowers both care providers and patients to act on unhealthy lifestyle behaviours.

In short, MongPEN has provided all the necessary tools for us to make a positive change in CVD prevention and management, and to make our community healthier."

Initially piloted in two demonstration sites - Darkhan-uul province, and the Songinokhairkhan district in Ulaanbaatar City - a recent evaluation has found several challenges to using MongPEN more widely. These included a lack of capacity to provide necessary care, inconsistent follow-up that made it hard to understand if conditions were under control, and disparate paper-based health information systems, putting strain on staff and undermining effective data collection.

Credit: Ministry of Health Mongolia

As identified by Ms D. Sarangerel, the former Mongolian Minister of Health (October 2017 - July 2020), MongPEN offers lots of opportunities for the future:

"In Mongolia, cardiovascular diseases have been the single biggest cause of mortality, accounting for 34.4% of all deaths in 2018. Tertiary health facilities are overwhelmed with heart disease patients, whereas primary health centers lack the capacities - and sometimes simple yet necessary tools - to provide preventive care for conditions like hypertension and diabetes.

With WHOs full technical support, we launched MongPEN at selected primary health centers in 2019. By implementing this comprehensive package at the primary health care level, we see great potential to reduce morbidity and mortality from cardiovascular diseases, and to strengthen the primary health care system in the country."

Over a three-month period, the funds granted by the Government of Denmark were used in two key ways.

First, recognising the need to shift away from paper-based records, to a high-quality way to collect data on NCDs, this project sought to procure a new server for Mongolias ePrescription system. While a computer may sound an unusual choice, it is absolutely crucial. Building the capacity to collect electronic data on NCDs not only lays the groundwork for improving Mongolias health system, but also aims to gather the best quality information to improve patient care.

Second, responding to the challenge of COVID-19 quickly became an urgent concern. Countries globally have had their NCD services disrupted, with health efforts instead pushed towards tackling the pandemic. To maintain NCD services during the pandemic, funding was used to procure additional reagents for glucose and cholesterol testing, and face masks, allowing those on the NCD frontline to deliver essential services to high-risk patients.

Patient Mrs J. Jargal doing exercise at home. Credit: Ministry of Health Mongolia

Mrs J Jargal, a resident of 10th khoroo, Songinokhairkhan District in Ulaanbaatar city for over twenty years, explains why discussing NCDs has helped her:

"In previous years, I do not recall if our Family Health Centre was proactively identifying people with high blood pressure and high blood sugar.

One day in January, I received a phone call and my husband and I were invited to have our blood pressure and blood sugar checked. After this check, we were advised to reduce body weight, take control of diet, do regular exercise and avoid smoking and drinking.

Back then, my weight was 92 kilos and my blood pressure was 150/110 mm Hg. After a half year of close consultations with my doctor and exercising at home, I have lost 7 kilograms. As prescribed by the doctor, I have also been taking my medicine and my blood pressure is reduced and well under control. As well as feeling a lot better, I have become friends with my doctor at the Family Health Centre!"

In just three months, the Mongolian Government Ministry of Health has made considerable progress towards its two goals.

In a short period of time, investments in a server have helped scale up the ability to collect data on NCDs. It is hoped these tools can be scaled up across Mongolia, including possibilities to create automated processes, allowing patient follow-up to be done automatically, rather than risk being missed when only using paper records.

Alongside this investment, further support was provided for wider dissemination of previously translated technical packages for training and education, enabling better resonance with the local community.

Responding rapidly to the COVID-19 pandemic, the Ministry of Health was able to procure equipment, medical devices and disposable items for 16 health centres. This equipment was supported by continued supervisory visits by the Ministry to demonstration sites.

And while face-to-face staff gatherings cannot happen just yet, a national workshop for training has also been organised for September 2020, building on momentum generated by the investment.

Despite the uncertainties of COVID-19, this work has supported the Mongolian Government Ministry of Health to not only upskill health centres to treat and manage NCDs now, but also provide the building blocks for a revolutionary new way to collect national NCD data. In the midst of a global pandemic, that is one positive to look forward to.

As Dr T. Munkhsaikhan, the current Minister of Health reflects, there are several opportunities to boost the role of NCDs in primary care across the country:

"It is great to see the MongPEN initiative has been implemented at 16 family and soum health centers of Darkhan-Uul province and Songinokhairkhan district of Ulaanbaatar city for over a year. It has already been showing its initial results, such as improved hypertension control rate at primary level and reduction in referral of uncomplicated cases of hypertension and diabetes to the secondary level of health care.

I would like to acknowledge the WHO support and collaboration on piloting this important initiative in Mongolia. We will continuously collaborate with WHO and will scale up MongPEN to all primary health centers in the country step by step".

Across the Global Week for Action on NCDs (7-13 September), we are sharing stories from the field about why acting on NCDs is so important. These stories have emerged from a recent project funded by the Government of Denmark.Today's story was written byDr Warrick Junsuk Kim, Dr Bolormaa Sukhbaatar, Ms Bernice Castro and Mr Daniel Hunt.

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Mongolia: crafting essential country-specific tools to tackle NCDs - World Health Organization