Health on the steppes

Helping to optimize the healthcare system in a country in the throes of epidemiological transition: this is the aim of the work carried out by Montpellier-based economist Marlène Guillon, who has made Mongolia her distant research ground.

It's a territory three times the size of France, with a population of just 3 million, half of whom live in the capital, Ulaanbaatar. With barely 2 inhabitants per square kilometer, this country boasts the lowest population density in the world. Welcome to Mongolia, between mountains, steppes and deserts, where almost one in three inhabitants is nomadic or semi-nomadic.

Marlène Guillon has had the chance to survey these steppes on several occasions. Since 2018, the researcher from the Montpellier recherche en économie (MRE) laboratory has been leading a project on the efficiency of health centers in rural areas. " They're called Soum health centers, they're primary care centers scattered over this vast territory, so that people in rural areas can all have access to care ". For curative visits, prevention, childbirth, vaccination, screening, even light hospitalization or minor surgery, these Soum health centers are small structures with an average of less than 3 doctors, 6 nurses, midwives and paramedical staff for around ten hospital beds.

A country in epidemiological transition

But how did our economist come to work in this faraway country? My post-doctoral supervisor had been working with Mongolia for a long time, but on macroeconomic stability issues," explains Marlène Guillon. But given the context in the country, we thought it would be interesting to look specifically at the allocation of healthcare resources . The context? A budgetary situation that is clearly unfavorable to increasing public spending on healthcare, despite the government's determination to extend universal healthcare coverage. " Per-capita healthcare spending is 10 times lower than in France, with no possibility of increasing the budget allocated to healthcare in the coming years. In these circumstances, improving the efficiency of the healthcare system becomes a top priority ", stresses the specialist.

This is a real necessity in a country where maternal and infant mortality is still high, " and where chronic diseases such as diabetes and cardiovascular disease are also on the rise ", explains Marlène Guillon. In this context of " epidemiological transition ", every tugrik invested in the healthcare system must be well spent. This is the mission our researchers have set themselves by examining the efficiency of Soum health centers. " We're trying to assess whether these centers could offer care that's as effective as it is now, but with fewer resources - that's what we call efficiency ", explains the researcher.

To measure this efficiency, researchers analyzed data from 260 Soum health centers across the country in 2017 and 2018. In particular, they looked at what economists call "inputs" and "outputs". " Inputs are all the resources invested in the center, such as personnel or equipment. Outputs are all the care provided to patients ," explains Marlène Guillon. The economist went out into the field to collect data from the Mongolian Ministry of Health, before returning to process them in her Montpellier laboratory. " We also trained local doctors and public health professionals to carry out these efficiency analyses ", explains the researcher.

Facilitating access to care

In particular, these measures enable us to identify the centers that are not working very well. " We found, for example, that the Soum health centers in the poorest regions were the least efficient, because despite free care, patients still have to pay for medicines, for example". The researcher also testifies to the difficulty of access to care for nomadic herders in these regions: " if a herder has to go for treatment to a center that may be a day's walk away, he has to leave his herd behind for several days, and many can't afford that ", she laments.

This is one of the major challenges of these efficiency studies: to optimize the healthcare system as a whole, so that everyone benefits as much as possible. If we realize that a Soum health center could provide the same care, with the same quality, but with fewer resources, we can make savings on its operation," emphasizes Marlène Guillon. This is money that could be reinvested elsewhere in the healthcare system, for example by covering the cost of transport for farmers who live too far away, or by compensating for the loss of income due to time spent away from their herds . Or by covering the cost of medication when it is too high.

Minimize waste of resources

" The idea is not to reduce healthcare spending at the risk of lowering the quality of care," reassures the economist. Quite the contrary: " the aim of our research is to propose a system better adapted to the reality on the ground. By minimizing the waste of resources, we can reallocate this budget to other healthcare projects ".

An approach that the researcher would also like to extend to health centers located in urban areas. " We call them Family Health Centers, which are private health care centers under contract to the Ministry of Health ". This new project, financed by the Asian Development Bank, saw its launch postponed due to the pandemic. " I haven't been able to set foot in Mongolia since February 2020", regrets Marlène Guillon, who makes no secret of her eagerness to return and hopes that the vaccine will reopen the country's borders to her. " Maybe in July or August "...