mong_health_questionnair10

Annex 2: Pilot Questionnaire What follows is a Pilot Questionnaire based on the Mongolia experience to assess accountability in the health sector. This Questionnaire will be further adapted based on further testing in other countries.

The Health Sector Context a) Legal and policy frameworks - Is the provision of health care considered in the national constitution, in legislation, and in policy documents?

- Are existing legal and policy frameworks well implemented? Are there specific reasons for any non-implementation?

- Is there a separate set of regulatory policies and legislation on private sector service providers, including hospitals, health centers, pharmacies and traditional healers?

- How are these policies affecting service consumption, self-medication, and timely access to quality health services?

- Are there any specific policies to promote health service delivery in rural areas? b) Budgetary information - What percentage of GDP is allocated to the national health budget?

- What percentage of the national health budget comes from aid contributions?

- What percentage of the national health budget is allocated to pharmaceutical expenditures and drug procurement?

- What percentage of the budget is administered by local governments?

- What is the overall (public and private) per capita spending on health care?

- What is the government per capita spending in rural areas compared to urban areas?

- What part of total expenditures do fixed expenditures (especially salaries) take up? c) Integrity in the health sector - Are there any statistics on counterfeit drugs? What is the percentage of these drugs on the market?

- What is the percentage of absenteeism among health workers in hospitals and health centres?

- Are there any problems with ghost workers?

- Are there any reports on political influence, nepotism and favourism in the selection of candidates for: training opportunities; appointment; hiring; and promotion or licensing of health personnel?

- Is the selection of students for medical school open and transparent?

- Is there any monitoring system to ensure prices of medical services are effectively regulated?

- Are there any reports of pharmaceutical companies attempting to unduly influence physicians to prescribe their medicines?

- Are the decision-making processes related to budget allocations to local governments fair and transparent?

- Does the culture of gift-giving affect the delivery of health services?

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Are there any surveys on perception of integrity deficiencies within the health sector?

d) Financing of the Health Sector - What health insurance programs are in place? Which groups are covered (formal sector employees, public sector employees, large companies, rural communities, etc)?

- Has the Health Insurance system succeeded in improving service delivery performance through strengthened accountability and the introduction of market mechanisms in the health sector, for example by promoting value-for-money, better mechanisms for paying providers, clearer performance standards, etc?

- Has a competitive fund been created to encourage high performance among health service providers? If yes, how is performance being monitored and evaluated?

- Which types of services are currently being financed by the Ministry of Health?

- How much money does the Ministry of Health spend on each of these services/functions (break-down)?

- What are the norms and formulas for allocations from the national level to the local levels?

- Do funds flow directly from the national level to hospitals (or through intermediate government levels)?

- Do doctors receive special benefits for performing specific operations? Have these types of operations increased in recent years?

- What are the salaries in the health sector like? How do they compare with other professions and average per capita income?

- Is there public information available on salaries in the health sector (including physicians and civil servants)?

- Are there official user fees? For which kind of services (preventive/treatment)?

- What is the relationship between user fees and costs?

- Do local governments receive funds to pay for health service delivery? Is this funding adequate, predictable and transparent?

- How are local health budgets determined? What degree of autonomy do local governments have? How are the local needs assessed?

- Are budgets transparent?

- Which financing mechanisms are used at the local level for health service delivery?

Own resources (sale/rent of local government property, user-fees, charges or taxes), shared taxes, earmarked or categorical grants, or general grants?

- Are there reverse transfers of funds from the local to the central level in the health sector?

- Are there disparities between the rural areas due to norms or formulas of intergovernmental transfers or shared revenues?

- Do the fiscal transfer mechanisms encourage sound local budget prioritization or do delays or excessive tying undermine this?

- Do delays in actual transfer, or procurement restrictions, interfere with budget implementation? e) Roles and responsibilities in the Health Sector - At this stage, who is responsible for doing what in the health sector? Are the functions per administrative/territorial unit defined in a law?

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If not, how are the functions divided in practice?

Are all hospitals managed under the same administrative arrangements?

Which government level is responsible for hiring/firing/recruiting health personnel?

Is this different for different categories of personnel and different types of facilities?

At which levels are salaries of staff determined and administered?

Which government level is responsible for paying health worker salaries (out of what budget)?

Are salaries paid regularly and on time?

Which government level is responsible for maintaining health care facilities?

Which government level is responsible for investment decisions concerning the building of new facilities or the improvement of existing systems?

In a case-based payment system, health service providers should be left to decide on the most efficient and appropriate way to meet patients’ needs. Have hospitals been empowered to make key decisions that influence cost and efficiency, for example to make adjustments to their workforce or other aspects of capacity?

Who owns which assets?

Who sets prices?

Who is responsible for public health services such as immunization?

Are sub-national governors responsible for appointing the health sector department heads?

f) Decentralization - How decentralized is the country? Are there any decentralization efforts under way?

- Are there any plans to devolve managerial and financial responsibility in specific sectors, notably in the health sector?

- Which types of services might reasonably be assigned to local governments?

- What regulatory authority should remain in the hands of which state agencies?

- How much money is being spent on investments in the sector now, and how much of this investment could be reasonably assigned to local governments?

- What is the capacity at the local level to deliver health services (financial management, budgeting systems, technical expertise, etc)?

- Do local khurals have technical expertise on health matters?

- Which should be the minimum standards in health service delivery in a decentralized system?

- What sectoral laws would have to be amended to assign local governments primary responsibility for health care management?

Horizontal accountability (the governance “supply� side) a) Political accountability - Have there been any Parliamentary inquiries into the running of the health sector?

- How many Parliamentary questions have been addressed to the Minister of Health in the last few years? On what subject matters?

- Does the Parliament control health budget spending?

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Are senior management in the Ministry of Health accountable to the ruling political parties?

Are sub-national governors held accountable by local assemblies?

Do the local assemblies check budgets and expenditures for the delivery of health services?

b) Organizational accountability - Is there hierarchical accountability and efficient management?

- Are civil servants’ performance monitored?

- Are there clear performance expectations, job descriptions, transparent and enforced rules and behaviour standards, as well as merit based promotion policies?

- Is the quality of services guaranteed through certification of health personnel?

- Is the quality of services guaranteed in terms of observance of international standards of care for mental health and HIV/AIDS services?

- Is there a list with essential medicines?

- In terms of medical supplies, are efficient record keeping, inventory systems, control procedures and security measures for central warehouses in place to prevent their embezzlement in the distribution process?

- Have any medical supplies been stolen from warehouses in recent years?

- Has there been any debate concerning signing up to Meta (Medicine Transparency Alliance)?

- Are cash registers in place for users revenues in hospitals and health clinics?

- Are the rules and procedures on procurement clearly defined and enforced? c) Administrative accountability - Which institution is responsible for auditing the delivery of health services?

- Are performance contracts for public expenditure in the health sector audited?

- Is there whistle-blowing in effect in the health sector?

- How many inspections are usually performed per year by the State Inspection in the health sector? What issues are usually inspected?

- How does the central government receive information on delivery costs, amounts actually delivered, etc?

- Are public expenditures in the health sector effectively controlled and monitored in an Electronic Treasury system?

- Does the Electronic Treasury system extend to the lowest level of government?

- Are donors and aid agencies held accountable for their financial contributions to the health sector?

- Have any Public Expenditure Reviews been undertaken? What are the findings? d) Professional accountability - Are codes of ethics in place for physicians (and pharmacists)? Are they enforced and taken into account for promotions?

- Are there rules in place in terms of conflicts of interest regarding the registration of medicines and pharmacies?

- Is there a professional body of oversight (ethics committee) in the health sector?

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Are there educational ethics programs in place for students in medicine, nursing or pharmacy?

Has training been delivered to civil servants in the ministries on new codes of conduct or ethical standards?

e) Legal accountability - Have there been any court cases against health workers for corruption?

- Does the judiciary have the necessary capacity/competence/independence to prosecute health workers for corruption offences?

- Have there been any administrative/civil/penal cases brought against health workers/institutions? What issues? Does corporate responsibility exist?

- Since its establishment, how many complaints has the independent anti-corruption authority received related to the health sector?

- How many were transferred to the Prosecutor?

- How many were pursued by the Prosecutor?

- Has the government been taken to court over health issues?

- Is the right to health a constitutional right? Can it be upheld by the courts, i.e. is this right considered justiciable?

Vertical accountability (the governance “demand� side – inclusive participation) a) Elections - Are national/local elections organized regularly and considered free and fair?

- Has corruption in the health sector ever been a theme during an election campaign?

- Are local assemblies and governors democratically elected? Do they have a say in health matters at the local level? b) Civic engagement - Are there any local health boards or committees? How are they composed? What are their functions, roles and responsibilities?

- Are there feedback mechanisms in place to influence policy makers or service providers?

- Are periodic household surveys being conducted to monitor patterns of health service utilization and out-of-pocket payments by vulnerable groups?

- Has a consultation process been conducted to debate hospital rationalization, notably hospital consolidation and workforce restructuring?

- Has participatory budgeting been institutionalized at the national/local levels of government?

- Has public expenditure tracking taken place at the national/local levels?

- Has citizen monitoring of health service delivery taken place at the national/local levels?

- Have community score cards been used for health service delivery at the local levels?

Are there any lessons learned from these experiences?

- Have citizen report cards been used to evaluate health service delivery?

- Is there any citizen engagement in local budgeting?

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How many NGOs are active at the local level (in the health sector)? Are there any patients’ associations?

Have culture practices (for example, nomadism) impeded the development of community based NGOs in the health sector?

Has any non-profit law been enacted in recent years?

Which kind of challenges do CSOs face at the local level (capacity, financial, political pressure, etc)?

Do CSOs make their accounts public?

Do NGOs generally represent a constituency or are they Non-Governmental Individuals (NGIs)?

Have women, youth and elderly associations been able to influence public policies related to the health sector?

Have vulnerable and marginalized groups been engaged in health service delivery/policy setting? (girls, adolescents, older women, migrants, ethnic minorities, sex workers, people with disabilities, people living with HIV/AIDS, incarcerated men/women, etc)

c) E-governance, Access to Information and Media - What does the national e-government plan say about access to public information in the health sector?

- Is there an online Government Portal? Does it constitute a mechanism for transparency and accountability of the Government?

- Does the Ministry of Health make public information available on the MoH website?

- Is information available and accessible online at the provincial and district level?

- Have any E-Governance solutions been introduced to reduce corruption in the health sector?

- Has any law on Access to Information been adopted in recent years?

- Is there a law on State secrets? Has it been discussed, amended or revoked in recent years?

- Is there public reporting on health budgets/expenditures (at different government levels)?

- Are Audit reports/State Inspection reports of the health sector publicly available?

- Is information available on the Mongolian legislative process in terms of the health sector?

- Are any public officials/civil servants/health workers subject to publishing asset declarations under the new Anti-Corruption law? Have these provisions been implemented?

- Are patients informed about user fees, drug prices, availability of services, etc?

- Is information on grant transfers from the national level to the local level available or displayed for the public?

- How transparent is local decision making related to the health sector?

- Which methods are used by local NGOs to disseminate information on the health sector?

- Is information available about causes of death for children and adults, disaggregated for women and men, rural and urban areas?

- Is information available on the health status of women?

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Is information available on the health status of children?

Is information available on laws, regulations, policy goals in the health sector (related to primary health care, maternal and reproductive health care, health care for people living with HIV/AIDS, immunization against major infectious diseases, measures to prevent, treat and control epidemic and endemic diseases, a national public health strategy and plan of action, etc)?

Where do citizens generally get their information from on health issues?

Are there any challenges in terms of press freedom in Mongolia? Do they affect reporting on health issues?

Is journalism and local level media functioning as a mechanism for government accountability? What are the key challenges?

Are difficulties in the delivery of health services addressed by the media?

Do community radios report on health issues?

Are there any specialized publications on health matters?

Who owns/funds the different media (TV, radio, newspaper, digital news)?

Do new media need a recommendation letter from the local governor to obtain a broadcasting license?

d) Other accountability mechanisms - Are there any efficient complaint mechanisms in place which provide opportunities to report and prosecute abuse and restore the public trust in institutions?

- Have any public protests taken place related to health sector service delivery? If yes, have they led to policy change?

- Have any public advocacy campaigns been organized related to the health sector service delivery? If yes, have they led to policy change?

- Has any investigative journalism brought malpractices in the delivery of health services to light? If yes, has this led to policy change?

- Are there any traditional meetings/mechanisms through which local governors/health service providers can be held accountable?