After the transition, Mongolia introduced local authority and privatization, reflecting similar directions to the reforms in other former socialist countries such as the Czech Republic and Poland . These reforms affected the input level by impacting the governance authority and financing of the medical schools. On the process level, effects appeared in the learning environment and human resources. Effects on the output level appeared in the professional values and development of health professionals (Table 3). In the following sections, we discuss changes in these concepts by comparing the socialist and market eras.
Table 3. Effects of the transition
Effects of transition
Academic authority without proper regulation
Tuition fee-based revenue of medical schools
Varying quality of the learning environment
Poor environment for faculty development
Poor quality of professional development
Lack of motivation due to financial pressure
The socialist system had centralized planning of human resources for health, based on a governmental assessment of the country’s situation. The Ministry of Health (MoH) set the admission quota for medical school and assigned workplaces for medical graduates based on the social needs of the population . Moreover, the system fostered close cooperation between MNUMS and hospitals under the MoH, as hospitals provided large clinical bases to MNUMS . The government fully funded MNUMS, so it faced no financial pressure. However, the expenditures on HPE were low due to the economic situation, and cooperation with non-socialist countries and availability of other financial sources were limited due to the political situation in Mongolia.
“Human resources for health planning in the socialist era was based on social needs” (F1)
“The medical school rigidly followed the rules to carry out planning without financial pressure” (DM1)
After the transition, the government divided authority over human resources for health planning between the MoH and Ministry of Education, Culture, Sciences and Sport (MECSS). The MoH became responsible for health policies and hospitals , while the MECSS became responsible for educational policies and medical schools . The absence of government regulation due to fragmented policies and weak management between ministries has resulted in quantitative imbalances of health professions . For instance, hospitals received the authority to organize specialized training programs, which has resulted in an increasing number of specialists. Concurrently, the number of private medical schools dramatically increased without proper government regulation . The licensure for private institutions based on the collection of documents rather than the social needs of the population . In 1999, the government established the Department of Accreditation and Licensing Exams to ensure the quality of medical schools . Tensions have existed regarding the quality of both the accreditation process and licensing exams . Local stakeholders heavily criticized the increasing number of unqualified private medical schools, even though the accreditation system has existed for decades.
“Private medical schools are similar to business companies; conflicts of interest exist” (DM2)
“The accreditation process has not resulted in quality improvement so far” (F2)
In 1997, the government decided to cover only the expenses of electricity and heating systems of higher education institutions . Financial support from other countries has increased due to the new political structure, with the United States of America, South Korea, Japan, China, Great Britain, and Germany being the main providers . However, most of these programs exclusively finance health improvements, rather than HPE as a part of the health system . The absence of university hospitals limits the revenue of medical schools, and tuition fees are the only source of financial support of many medical schools. However, the amount of tuition fees continues to be assigned by the government; so that medical schools attempt to enroll more students in order to adapt in the market economy. Local stakeholders stated that the government should increase the authority of medical schools to regulate their finances and support them in efforts to find additional resources to improve their academic goals.
“Medical schools are completely dependent on tuition fees” (DM3)
“Government support, such as building university hospitals and supporting international projects, is needed for medical schools” (F3)
Because of the close cooperation between MNUMS and hospitals in the socialist era, the learning environment for clinical practice was sufficient . However, all aspects of the HPE system were dependent on political doctrine, to the point that half of the content of the medical curriculum was dedicated to the history of the Communist Party and the theory of communism . Furthermore, the strong curative orientation of the health system and medical curriculum became non-responsive to social needs in the later years of socialism . Medical graduates with higher scores were assigned to work as faculty members at MNUMS . The government evaluated whether MNUMS fulfilled its annual plan, as well as individual whether individual faculty members completed their assigned tasks. The government provided performance-based incentives such as international training in different countries, vouchers for nursing camps, and opportunities for public housing.
“In the socialist era, cooperation between hospitals and MNUMS was strong” (DM4)
“Human resources were fully mobilized in accordance with planning” (Do1)
After the transition, the quality of educational services varied across institutions . The absence of a core curriculum resulted in varying quality of medical graduates from public and private medical schools. Moreover, the quality of specialized training programs varies across hospitals and medical schools; both programs have advantages and disadvantages. For instance, students trained at hospitals have more opportunities for clinical practice and are guaranteed employment at hospitals; however, the contents of these program do not correspond to global standards. In contrast, students at medical schools follow a standardized program, but, the environment is not supportive and opportunities for clinical practice are limited due to the absence of university hospitals. Factors such as enrollment number and educational services have not been unified across both types of programs .
“The development of a core curriculum through the cooperation of stakeholders is urgently needed” (F4)
“The involvement of hospitals in specialized training is increasing; it leads to conflicts between hospitals and medical schools” (DM1)
The rapid expansion of curricula and programs has led to increasing demands for faculty development . International training and revolutions in information technology have provided opportunities; however, faculty members are struggling to keep pace with these challenges due to the insufficiently supportive environment . For instance, clinical faculty members do not have opportunity to engage in clinical care due to the absence of university hospitals. Simultaneously, the supervisors of specialized training programs at hospitals are clinical physicians, most of whom do not have experience with educational strategies. Moreover, new aspects of the socio-economic environment have placed financial pressures on faculty members , who receive no financial compensation for research or extracurricular activities.
“Some clinical faculty prefer to work as clinicians due to the poor supportive environment of medical schools” (F1)
“Without proper assessments, it is difficult to pursue research as a primary goal” (F2)
Because of the strong orientation towards curative services in the socialist era, MNUMS prepared graduates to be general doctors, pediatricians, dentists, and hygienists . Medical graduates were highly experienced in clinical skills and could provide specialized healthcare services after graduation . Health coverage was universal, even though services were not well resourced and equipped . Furthermore, health professionals were motivated by factors such as guaranteed employment and public housing. The health professions were among the few high-class occupations at the time , and they retained considerable prestige in society.
“Final-year medical students used to work as clinicians in hospitals” (DM2)
“Patients and the public respected even medical students in the socialist era.” (Do2)
After the transition, the numbers of unqualified medical graduates increased, and health professions faced difficulties in maintaining professional development. All medical graduates should pass the licensing exam and obtain a 5-year license. In order to extend the license, health professionals must take the exam again or collect sufficient continuing education credits within 5 years . However, Mongolia has still faced mismatches of competencies and insufficient capacity of health professionals . Therefore, it is thought that licensing system has not been effectively implemented. First, the test-based structure of licensing exam conflict with the need to assess core competencies . Second, collecting credits is more likely to be a system of control than to be a system aiming at improving the quality of health professionals.
“The test-based licensing exam assesses only the knowledge of health professionals” (F3)
“Collecting credits are not helpful for quality improvement” (Do3)
Another issue is that the fixed salary established by the government and the absence of incentives have undermined the motivation of health professionals. Concurrently, public trust in the healthcare system and health professionals is rapidly falling in Mongolia. Compared to the 1990s, the rising incomes of the population have resulted in increasing expectations for higher-quality healthcare services . The lack of supplies and outdated equipment have impaired the diagnostic capacity of health professionals . Local stakeholders mentioned that the health professions have not completely lost their perceived value due to the financial situation; therefore, a proper payment system and a supportive environment are needed.
“A performance-based payment system is crucial for motivation and professional development” (DM3)
“The government should prioritize the health sector and health professions in national policy” (Do4)