Journal of Rehabilitation Medicine: Special Issue 50-4bokBW | Page 57

Disability and rehabilitation in Mongolia
of PwD); life-course approach (continuum of
care); universal health coverage; a culturally-
appropriate person-centred approach; multi-
sectoral, community-based rehabilitation (CBR);
and universal design (6).
The main objectives of the GDAP are shown
in Box 1.
MONGOLIA
Mongolia is a large central-Asian country, borde-
ring with the People’s Republic of China on the
south-east, Russia in the north and Kazakhstan
on the west. It occupies a total area of 1.56 mil-
lion km 2 (world’s 19 th -largest country) divided
into 21 provinces (aimags), which are further
divided into 329 districts (soums) (7). Mongolia
is sparsely populated, with only 3 million people
(2015), (population density 1.8 persons/km 2 ) (7).
The majority (> 71%) live in urban areas, with
almost half residing in Ulaanbaatar (8). There are
significant disparities amongst the aimags/soums
in terms of healthcare capacity, infrastructure and
level of governance. The population median age
is 27 years (approximately 27% are aged ≤ 15
years) and life expectancy at birth is 68.9 years
(9). In 2015, Mongolia had one of the highest
literacy rates (> 98%) in the world (for adults
aged > 15 years).
Mongolia has experienced positive economic
growth since its political tr ansition to democracy
(in the early 1990s), and since 2004 there has
been significant growth in gross domestic product
(GDP), with GDP per capita (PPP) of US$2,107
in 2007 (10). The World Bank income classi-
fication categorizes Mongolia as a low-middle
income country, rated 114 out of 182 on the
Human Development Index (HDI), according to
the UNDP Human Development Report (2007)
(11). Mongolia’s Human Development Index
(HDI) increased by 1.02% annually from 0.676
to 0.727 between 2000 and 2007 (11). Mining and
agriculture (mainly livestock husbandry) remain
the major economic resources. Despite positive
trends in economic growth, there is disparity bet-
ween rural and urban areas (7); many rural people
reside in traditional Mongolian tents (gers), and
27.4% of the population lives below the poverty
line (WHO 2012) (12). The Mongolian govern-
ment spends 6.3% of GDP on healthcare (total
expenditure on health per capita of US$345 in
2012) (10). Similar to other developing countries,
considerable effort has gone into improving the
acute-care sector, while post-acute care (including
rehabilitation) is a lesser priority at many levels.
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Overall, key determinants of poor health include:
illiteracy, unemployment, gender inequality, and
rapid urbanization (8, 13).
Despite the introduction of various disability-
inclusive policies in many developing countries,
PwD continue to have difficulty exercising their
civil and political rights, and accessing education
and employment (14). Mongolia is not an excep-
tion in this context. Although the GDAP is a step
forward in provision of rehabilitation services to
PwD, providing the opportunity to strengthen and
extend rehabilitation, it can be challenging for the
Physical Medicine and Rehabilitation (PM&R)
community, as it sets high standards and requires
evidence-based rehabilitative care (15). Previous
studies (14, 16) report challenges in successful
implementation of the GDAP and in setting prio-
rities based on the action plan in countries such
as Madagascar (14) and Pakistan (16).
This cross-sectional study provides an over-
view of the current PM&R effort in Mongolia
(based on literature review and interactive feed-
back from various service providers) compiled
during an organized workshop programme to
document the challenges and strengths within the
existing healthcare system, corresponding with
the established objectives listed in the GDAP.
METHODS
The visiting team (FK, BA, GA, MG) were in-
vited by the Mongolian National University of
Medical Sciences (MNUMS) and local PM&R
society as independent experts (June 2016) to
run an 6-day intensive teaching programme in
association with the University General Hospital,
Ulaanbaatar, Mongolia. Within the programme, a
1-day workshop concentrated solely on utilizing
the GDAP framework to identify barriers and
facilitators, and the remaining sessions focused
on educating participants, building workforce
capacity, and developing rehabilitation standards
and operational set-up for PM&R services within
Mongolia. This exercise was approved by the
MNUMS and the Royal Melbourne Hospital.
Participants and procedure
The training programme at the MNUMS was at-
tended by 77 healthcare professionals from various
medical rehabilitation centres across Mongolia
(including rural areas and private sector). These
included: 55 rehabilitation physicians, 6 neurolo-
gists, 6 physiotherapists, 5 nurses and 5 resident
medical doctors. Input was also obtained from 2
social workers and one clinical psychologist. All
J Rehabil Med 50, 2018