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Advancing the Roles of Local Health Volunteers in the Health Care Delivery

System of the Darkhan Health Department in Mongolia1

This paper narrates how a volunteer activity – understood under subject areas of
international volunteering and national volunteering – impacts on a more effective
health delivery system in Darkhan district in Mongolia. It describes the current
health situation in Mongolia and how VSO’s volunteering programme addresses
problems on effective health delivery. The potential impact of local volunteers’
engagement to challenge traditional health system and behaviours has been
examined. Finally, some general research questions are suggested as a basis for
looking at concrete impact of volunteering and volunteers towards meeting MDGs.

The Mongolian Health Situation

The population of Mongolia is approximately 2.5 million people, with
almost half of this population living in the capital city of
Ulaanbaatar. Rural residents have less access to education and
health care in comparison to city residents. This is partly because
education and health care facilities are concentrated in Ulaanbaatar
and the provincial capitals. This uneven distribution of services
across urban and rural areas has contributed to disparities in life
expectancy among the population (Mongolia’s Human Development
Report 2003).

Mongolia’s overall provision of health care is impressively high when
compared to other aid dependent countries, such as the Republic of
Congo or the Gambia, for example (with similar levels of aid
dependency, but much further down the Human Development
Index, partly due to poor health provision statistics). However the
level of care provided is far from being an international standard.
High incidence of tuberculosis amongst the poor continues and
despite relatively successful treatment, incidences have not
declined (270 cases per 100,000). Infant mortality is 58 per 1,000
live births, maternal mortality is 160 per 100,000-- worrying
statistics when one takes into consideration that 97% of births are
attended by trained health professionals. Undernourished people
make up 38% of the population and 25% of children are under-
height for their age. The number of people infected with sexually
transmitted infections is increasing rapidly, giving great cause for
concern in view of the HIV/AIDS pandemic, especially as infection
rates in Mongolia’s neighbouring countries, China and Russia, are
high and growing. According to one study, one third of women in
Mongolia have experienced some form of domestic violence and
more than one-tenth have been beaten by their partners. A large

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A paper written for the 5th ISTR Conference in Manila, Philippines by Marilou Pantua-
Juanito, Executive Director of VSO Bahaginan and Glenn Benablo, VSO volunteer working as
Health Management Adviser in Darkhan Health Department, Mongolia. VSO Bahaginan is a
member of VSO International Federation, a development charity that works to fight global
poverty and disadvantage through volunteering.
percentage of women patients at local health facilities and in
hospitals are receiving treatment as a direct result of this. (VSO
Mongolia CSP, May 2006)

Hospitals are mainly found in Ulaanbaatar, main cities and provincial
capitals, but the standard of care they provide is low. There are high
rates of infections, including serious ones such as Hepatitis B that
are acquired in hospitals, and post operative care is so poor that
more patients die as a result of post-operative complications than
from the causes of the operation. Health care accessibility for the
rural and peri-urban communities is limited. Even so, it is the poor
who use existing health facilities and available care whilst annually
more than 30,000 Mongolians who have enough money travel to
China for health care. Health policies are often good, but their
implementation is poor due to lack of expertise in the field, and
many preventable diseases are widespread due to a lack of good
health education programmes.

Like many other developing countries, Mongolia’s health system
suffers from poor equipment, low levels of quality care, health
personnel with low levels of motivation and acute differences in
access between the rural and urban populace. However, there are
some additional issues that are peculiar to Mongolia - a country in
transition from 70 years of Soviet rule. During the socialist period,
the health system was run on a medical model of care where
information and decision-making was controlled by the professionals
and treatment of the population’s illnesses was performed by
medical specialists in hospitals. Mongolia’s transition to a market
economy in the 1990s brought new issues that began to affect
society and in which the old health system was not equipped to deal
with effectively, such as increasing alcohol consumption, eating a
nomadic diet with a sedentary lifestyle, increasing levels of stress,
increasing pollution and increasing levels of injuries and accidents.
The current leading causes of death in Mongolia are cardio-vascular
diseases, cancer, respiratory illnesses, gastro- intestinal illnesses
and injuries (which sometimes cause disability both mental and
physical) and accidents (i.e. resulting from alcohol use, road
accidents, etc.).

Prevalent behaviour is more curative than preventative such as
living a healthy lifestyle. Mongolians will often bypass primary
health facilities and go straight to hospitals for medication (and will
expect to be medicated on arrival). In addition, there is a plethora of
local pharmacies from where one can access both prescription and
non-prescription drugs over the counter. Self- diagnosis and
treatment are common and some are at risk of being dependent on
medicines including antibiotics.
The Mongolian Government acknowledges that the present health
service model is not meeting the needs of the population. The
Ministry of Health has, thus developed a ten-year plan (2005-2010)
that aims to reduce the disparities between urban and rural health
services, reduce the incidence of disease, improve access to quality
health services and improve health promotion among the
population. The primary method for achievement is a change in the
focus of the health service from treatment to prevention.

A causal map analysis of the situation was done by VSO with the
Ministry of Health (VSO Mongolia Health Programme Area Plan
2006). As a result of this analysis, the health programme area will
address the following problem statement, “Poor quality of health
service delivery in Mongolia, with a focus on treatment rather than
prevention, negatively affects the health of the population”. The
main causes identified as leading to this problem include:

1. The paternalistic approach of the health service creates a
culture of dependence and lack of knowledge among the
population.
2. The current style of education in schools and in medical
colleges does not generally teach the skills people need to
take control of their own health choices and exercise
responsibility.
3. There is a lack of resources and capacity in the service to
meet the needs of the population.

The Mongolia HDR 2003 concludes “balanced development does not
only mean equitable investments in urban and rural areas, but also
the empowerment of people in urban and rural areas to decide their
development path. Greater decentralization, devolution and
participation are key to balanced development."

VSO’s global strategic plan defines development as ‘…a complex
and continuous process that empowers people and communities to
fight disadvantage.’ (Focus for Change, VSO)

In 2004, VSO Mongolia adopted a participatory approach to assess
the developmental needs of the country in relation to this global
aim, as well as VSO Mongolia’s skills areas and capacity. As a result,
VSO Mongolia has decided to focus on health as one of its three
development goals, which include education and secure livelihoods
in its 2005-2010 Country Strategic Plan (VSO Mongolia Country
Strategic Plan, 2006)

VSO Mongolia gathered specific health area information through
workshops and meetings with partners and stakeholders. Together,
the programme area aim, objectives, indicators, activities and
ongoing monitoring and evaluation system were developed to suit
the Mongolian context and capacity of VSO.

As a result of the consultation process, disadvantaged groups within
the country were identified. The root causes of their disadvantage
were highlighted and VSO Mongolia’s health activities have been
focused towards achieving the following objectives:

1. Reduced incidence of disease by improving service delivery in
hospitals and health clinics in two (2) peri-urban districts of
Ulaanbaatar and in up to three (3) provinces. Healthy lifestyles will
also be promoted in the targeted geographical areas where partners
will have developed and implemented a Healthy Lifestyles
Programme focussed on illness prevention and community health.

The main interventions proposed to address this objective will
include the training of health professionals in the philosophy and
method of health promotion. This will also involve collaboration in
the development of health promotion materials.

2. Improved quality of health management and capacity of health
services in a sustainable manner. These will be done in collaboration
with both government and health departments in the selected
geographical clusters. It aims to develop a long-term partnership
with the Ovorkhangai Regional Health Diagnostic and Treatment
Centre (ORHDTC), Dornod Regional Health Diagnostic and Treatment
Centre (DRHDTC), Darkhan Health Department (DHD), and Chingelti
District Health Unit (CDHU) of Ulaanbaatar.

Interventions proposed to address this objective will include training
of health managers and collaborative development of management
and administration systems. Activities will extend to training and
sharing of professional skills and information with health
professionals of all disciplines. This will include ‘soft skills’ areas of
patient care, for example communication and ethics, to further
develop the quality of service offered to the Mongolian population.

The Volunteer as Catalyst of Change

As part of the programme intervention, VSO volunteer Glenn
Benablo, a community nurse trainer recruited from Philippines
through VSO Bahaginan, started working with Darkhan Health
Department (DHD) in October 2005. Glenn’s role focuses on
capacity building of nurses in DHD, which currently supports a city-
based central hospital, 3 soum (district) hospitals and 6 city-based
Family Group Practices (FGP), with 38 volunteers, 4 of whom are
male.
Glenn started his work in DHD by undertaking a thorough social
investigation. This research was important in deciding the most
appropriate approach to employ. The study revealed that there are
patients in the community who use the free services of the FGP
brought by the cultural habit of going straight to city hospitals.
However, the illness would already be in the advanced stage. Or
even if they go to the nearest medical facility, not all of them are
physically able to travel to the FGP. This then has the knock-on
effect that doctors and nurses spend extensive amounts of time in
the community visiting the sick, which takes them away from
spending time at the clinics.

Strategies to deal with some of the issues noted above include:
• Intensification and strengthening of Primary Health Care
services at FGP level
• Installation of local health volunteers at FGP level
• Healthy Lifestyle promotion training
• Increasing community awareness on healthy lifestyles through
health professionals and local volunteers

Based on the social research, it was also determined that in order to
support the community nurses in the most effective way it would be
of benefit to start focusing on the community health volunteers as a
way of lightening some of the nurses’ workload. Historically,
volunteers have existed in Mongolia, but they have not been used in
the most effective way. To date the majority of Glenn’s time has
been spent on supporting the reactivation of national volunteers.

The Process towards Involving local volunteers

Seeing the potentials of involving local volunteers, a pilot project
entitled “Advancing the Roles of Local Health Volunteers in the
Health Care Service Delivery System of the Darkhan Health
Department” was crafted. Prior to the conceptualization of the
project, the VSO Volunteer Nurse Specialist facilitated the following
processes:
1. Consultative Meetings. Aiming to identify and define
the developmental needs of the health department, a
series of consultative meetings were conducted with the
department’s directors;
2. Focus Group Discussion. In support of the
developmental needs expressed by the directors, a
series of FGDs were conducted with 8 Family Clinics,
Central Hospital and Soum Hospitals participated by the
hospital and clinic directors and staff;
3. Strategic Planning. The data gathered from the
consultative meetings and focus group discussions were
used during the strategic planning conducted with the
few directors. The planning was based on the 15-year
development plan of the department and linked it to
VSO’s country strategic plan. A 2-year implementation
plan was developed for the Family Clinics and a
development plan was also developed for the whole
health department;
4. Project Development. After the developmental
strategies were planned, projects were identified
according to priorities. The most realistic and achievable
one was the revival and strengthening of the local
health volunteering system. And it was in this stage
where the conceptualisation of the health-volunteering
project was initiated. A project proposal was crafted,
finalized and submitted to VSO for assistance in
sourcing out funds.
5. Advocacy. While the project is ongoing, the
department’s implementation plan and health
volunteering project were presented to government
legislators. Director of City Social Policy, Governors and
Member Parliament were met to gain support in terms of
legislation, possible government funding, and
endorsement to international funding agencies.
6. Partnerships. Collaboration and linkage with other
stakeholders and partner agencies continue while the
project is being implemented.

The Darkhan Project: Improving health delivery

Since October 2005 doctors and nurses of the FGP have been
trained on how best to manage volunteers, with a formal training
workshop held in June 9-10, 2006. Particular training for the
community volunteers has focused on prevention rather than cure
as well as basic nursing skills and First Aid.

Historically, within Darkhan there were between 10-30 volunteers
linked to each of the previously 8 FGPs. Many of these were
volunteers in name only and were not demonstrating commitment
or giving time to this role. In order to place the emphasis on the
volunteers, a process of streamlining was initiated resulting in the
selection of five of the best volunteers at each clinic. These five
most committed volunteers were then re-branded as Family Clinic
Health Workers (FCHWs). This was a deliberate step and sent
messages to staff at the FGP as well as to the wider community
regarding the value and respect that belonged to the ‘improved’
work of a smaller number of committed volunteers.

In May 2006, four staff from DHD and three FCHWs undertook a
study tour to the Philippines to further their understanding (in a very
practical way) of how local community volunteers are used in the
Philippine context. The study tour was clearly strategically planned,
with local organizations carefully considered on how appropriate
they would be in ensuring replicable learning. Glenn used a lot of his
knowledge of the area and tapped former colleagues to customise
the Darkhan team visit. As a result, the study tour was a huge
success. The learning from the Philippines very successfully argued
the case for mobilising and strengthening support to community
volunteers towards enabling them to undertake a vital role.

As a result of this study tour, the director of the Darkhan Health
Department Dr. L. Zolboot has significantly changed his views of the
value of community volunteers, from one of slight indifference to
complete commitment. This real and not token commitment can be
seen in the way the Director has ensured the provision of an
allowance that each FCHW will be given (Tugrig 5000, i.e. approx.
US$ 5) per month in recognition of the work they do. There is
currently no law in Mongolia that would support this, so this has
been on the director’s own initiative. It is important to recognize
however, that the Director has the mandate and budget
responsibility to make these kinds of changes (this is not the case
for other VSO partners such as the District Health Centres in the
peri-urban districts of Ulaanbaatar). He is now keen that this will
form a basis for a national scheme and therefore shared throughout
the country!

To ensure that the FCHWs value their own contribution as well as a
way of highlighting recognition to the surrounding communities,
they have now been given official identification, training certificates,
vests and utility bags with essential equipment and instruments,
which clearly mark the volunteers out as FCHWs. It is sometimes
difficult to illustrate how these small changes can make a significant
difference to how a person is able to operate and how they are
regarded. The FCHWs we met clearly stated that these visual aids,
which marked them out as professionals, and the resources they
had been given to do their work had made a substantial
improvement to how they were seen in the community. One could
also tell how proud these FCHWs were of their achievements and
how these had been recognized.

Using puppetry as a medium for communicating important and
sensitive health promotion lessons was also one particular
technique that was shared and taken back to Mongolia from the
Philippines. Only a few weeks on, the Mongolian delegates have
already created their own puppets and made a health promotion
video about the need for vaccinations. This has been shown on local
television and they are anticipating that it will also be televised
nationwide. The Darkhan group now regard themselves as actors
with an ability to diversify their roles to suit the health promotion
roles, not to mention the artistic ability that has emerged in the
making of the puppets!

Deciding on who should attend the study tour to the Philippines
proved also to be a factor contributing to the success of the project.
Participants included the director of the DHD and FCHWs. This
provided an opportunity to break down some of the existing
hierarchies within the system. On the one hand, it provided the
director, the person with the most decision making power, to better
understand the challenges of nurses and community volunteers
(and in the process convinced him of their value). However it has
also enabled the FCHWs to enter into dialogue with the director both
during the trip but also after. Previous to this study tour, FCHWs
would not have come to the director’s office or to the office of the
head of nursing to discuss issues. Now, this is becoming increasingly
acceptable. An example of this is the upcoming press briefing to the
public on this project and its successes. The director was adamant
that it will not be him taking centre stage, but he was very
enthusiastic about supporting the FCHWs to directly speak about the
change they have been through and its impact on them. He is keen
that it is the FCHWs who are seen in Darkhan (and potentially
nationwide), so they can receive increased recognition and respect
for their work.

Feedback on the Project

At two FGPs that were visited, discussions with staff highlighted how
successful this project has been in both valuing and refocusing the
work of the volunteers and thereby releasing time for the clinic
doctors and nurses. Both doctors and nurses reported that the work
of the FCHW now allows them to remain at the clinic for more hours
as the highly capable volunteers can often do community visits. Now
that the FCHWs have been supported around how to plan their work,
much less supervision is required on the part of the doctors and
nurses, as they know and are confident that the FCHWs will get on
with the priorities for the moment. The FCHWs are part of the
communities. They are aware of arrivals and departures, of people
who are sick or not living healthily. They are able to relay that
information to the clinics and use this knowledge to promote health-
seeking behaviour of the community people or, if necessary,
encourage them to visit the clinics instead of remaining at home or
going straight to the hospital.
Doctors in one FGP in particular spoke very highly of the FCHWs and
their real commitment to their current role. It was very much felt
that the doctors, nurses and FCHWs were a tight team who work
together, celebrate together and support each other. One FCHW
who was previously a housewife and has now taken on this
volunteering role (at the doctors’ recommendation) is currently
considering (and is being supported by the doctors) going to
medical school to become a doctor. This is a significant achievement
in Mongolia where the health system has historically been extremely
hierarchical.

Furthermore the community is also recognizing this good work. In
some areas, particularly in some ger 2districts, the areas are large
and it takes time for the FCHWs to get around and visit patients. The
community, in recognition of the positive support the FCHWs give,
have come together and bought a bicycle for one FCHW who has to
travel large distances. From a community that is one of the most
disadvantaged in Darkhan with extremely high levels of poverty,
this is a substantial tribute to the good work of the FCHWs.

Ways forward

The Darkhan team is keen to ensure that momentum is not lost on
the project and are looking at ways to keep the impetus going. In
June, a press briefing will be organized to share the project and what
the outcomes have been. The director is keen to support a roll out of
this methodology nationwide.

Already another one of VSO’s partners, the Chingeltei Health Unit in
the peri-urban district of Ulaanbaatar have travelled to Darkhan to
learn from their experiences. A meeting with Chingeltei staff after
this event illustrated how keen they were to implement some of the
learning from Darkhan while recognizing that their situation (e.g.
budget and size of constituency) is somewhat different.

The VSO volunteer will be continuing to work on this project with his
colleagues including
• Facilitating volunteer management training for doctors and
nurses at the FGPs
• Value formation and gender development training (i.e. looking
at the Mongolian context and analysing the team’s values
around local practices)
• Salesmanship and interpersonal relationship support and
training (e.g., how can the clinics and FCHWs promote
themselves and their work more
• Popular Education using Puppetry skills
• Roll out of this methodology nation wide. Already three
of DHD and VSO partners, the Chingeltei, Uvurkhangai
and Nalaikh Health Districts have travelled to Darkhan
to learn from their experiences. VSO volunteers were

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Gers are traditional round felt tents. They are quite roomy (about 4
metres across the middle), easy to heat with the wood stove in the centre,
and provide a comfortable, practical and attractive living space.
also placed in these areas to ensure proper replication of
this project
• Developing and managing small-scale health-related
businesses
• Conduct training sessions for local volunteers on:
• Basic Computer Training;
• Community approaches in the management of
common illnesses;
• Functional English Literacy Program; and
• Project expansion to include 3 soums
(municipalities) of Darkhan-Uul Aimag (province).

VSO will also continue to support this project and will focus on
providing opportunities for replication within Mongolia, particularly
in areas where there are capacity and resource constraints.
Discussions are underway around funding possibilities to support
this innovative and very exciting project.

References:

Glenn Benablo (2007), Local health initiatives in Mongolia: An article written for
WHO Mongolia Newsletter. Ulaanbaatar, Mongolia.

Mongolia’s Human Development Report (2003). New York: UNDP

VSO Mongolia (2005), VSO Mongolia Health Programme Area Plan, unpublished
report to VSO.

VSO Mongolia Annual Review Report (2006), Case Study: Dharkhan Local Health
Volunteering, unpublished report to VSO.

VSO (2003). Focus for Change. London: VSO