U N F PA / M O N G O L I A

UNFPA Country Office/Mongolia, UN House, 12 United Nations Street, Ulaanbaatar

Tel: + (976) 11-323365, + (976) 11-353501

J O I N T U N F PA / W H O M I S S O N I N C O L L A B O R A T I O N W I T H T H E M I N I S T RY O F
H E A LT H T O R E V I E W T H E C U R R E N T S T A T U S O F A C C E S S T O A C O R E S E T O F

C R I T I C A L , L I F E - S AV I N G M A T E R N A L / R E P R O D U C T I V E H E A LT H M E D I C I N E S
IN MONGOLIA

1 8 J UN E– 03 J ULY 2 00 9
 TA B L E O F C O N T E N T S

Page

Acknowledgements 3

Executive Summary 4

Chapter 1. Context and Background 9

Chapter 2. Key Findings and Action Recommendations

1. Need and Demand 10

2. Essential Medicine List 11
3. Availability of Critical RH Medicines 12
4. Standard Treatment Guidelines/Protocols 15
5. Rational Use of Critical RH Medicines 17
6. Quality Assurance 17
7. Storage 19
8. Procurement and Supply Chain Management 20
9. Costs 22
10. Coordination/Integration 24

Chapter 3. Conclusion and Recommendations 27

Annexes

A. Terms of Reference 28
B. Mission Schedule 31
C. List of People Met 35
D. Key Documents Reviewed 39
E. Checklists (Health Facility; Medical Stores/Pharmacies;
Product Specific; Procurement) 40
F. List of Acronyms 49
G. Map of Mongolia 51
H. Organizational Structure of MOH 52
I. List of People Attended/Participated in Final Debriefing Session 53

2 

 
 ACKNOWLEDGEMENTS

The Mission Team would like to express its gratitude to Dr. J. Tsolmon, Vice Minister of Health, Ms. Ch.
Munkhdelger, Head of Division for Medicine and Medical Devices, Dr. Ts. Sodnompil, Director of Department
of Health, GIA of MOH, Mr. Gunibazar, Vice Director, the State General Inspection Agency and Heads of
Departments of Health of Ulaanbaatar, Bulgan, Khentii, Orkhon aimags.

Also our gratitude to all those dedicated staff members serving the peoples in Mongolia in the hospitals, other
health facilities, pharmacies and stores, private sector representatives, professional associations and the
communities that we have visited during this mission

The team would also like to acknowledge the assistance of other developmental partners, especially WHO
Geneva and Country Office in Mongolia; UNICEF, Mongolia office, JICWELS, ADB, MSI, MFWA and other
civil society organizations in Mongolia whose ideas; experience, inputs and reports were valuable to this mission
(Detailed lists in Annex: C).

Special thanks are also extended to the UNFPA Mongolia Country Office Representative Mr. Jose Ferraris and
other staff for the assistance in organizing this mission; colleagues from the UNFPA Asia Pacific Regional
Office in Bangkok and Commodity Security Branch (CSB) in New York for their technical support and
encouragement.

Without the support and contribution of the aforementioned groups, agencies, and individuals, this report would
not have been possible.

Team Members:
Dr. Kabir U Ahmed, UNFPA, New York
Dr.Buyanjargal Ya, MOH, Mongolia
Dr. Govind Salik, WHO, Mongolia
Dr.Enkhjargal Kh, UNFPA, Mongolia
Dr. Altantuya D, State Inspectorate Agency
Dr.Yanjinsuren D, Lecturer, HSUM
Ms. Enkhmaa Ts, UNFPA, Mongolia
Dr. Anna Ridge, WHO, Geneva
Ms. Amarjargal Ch, MOH, Mongolia
Dr. Tsevelmaa B, UNFPA, Mongolia
Mr. Kang Nam Il, Population Centre, DPRK
Dr. Kim Kwang Jin, Population Centre, DPRK
Dr. Daariimaa Kh, Lecturer, HSUM
Dr. Bold A, National Consultant, UNFPA

3 

 
 Executive Summary

In an effort to improve access to quality essential Reproductive Health (RH) medicines and medical devices,
WHO, UNFPA and partners in the Reproductive Health Supply Coalition (RHSC) are engaged in a series of
activities aimed at promoting harmonized global standards and technical assistance. These include developing
guidance on sourcing good quality suppliers and products, building procurement capacity in resource-limited
countries, and removing barriers to the appropriate use of these products.

A well-functioning supply chain capable of selecting, forecasting, quantifying, financing, procuring, and
delivering the medicines and related medical devices and consumables needed is a critical element in all efforts to
improve the health and well-being of mothers and children in developing countries. Delivering goods alone is
not sufficient to ensure better outcomes for those who benefit from RH programmes. RH Commodity Security
(RHCS) is essential to meeting the target of universal access to reproductive health by 2015, as called for by the
International Conference on Population and Development and the Millennium Development Goals.

The purpose of this mission was to present a “snapshot” of the current status of access to medicines for
Maternal and Newborn Health Care and Reproductive Health, which are not routinely monitored. The findings
of this mission are intended to supplement the findings of other on-going studies and studies planned for the
very near future. The six critical RH medicines chosen for the study were Oxytocin injection, Ergometrine
injection, Magnesium Sulphate injection and three antibiotics, Ampicillin injection, Gentamicin injection and
Metronidazole injection. These medicines were chosen because they are the WHO recommended medicines for
the prevention and management of three major causes of Maternal Mortality:

• Haemorrhage (Oxytocin, Ergometrine injections)

• Eclampsia, pre-eclampsia (Magnesium Sulphate injection)
• Maternal/Neonatal Sepsis (Ampicillin, Gentamicin and Metronidazole injections)

The main objectives of the mission were to conduct a pragmatic exploratory study to:

1. Obtain a snapshot of the current status of access, supply and rational use of selected life saving
maternal/RH medicines
2. To guide Institutional support and capacity building in the areas RH commodities security.
3. Suggest action recommendations for consideration by MOH and Key Stakeholders for improving
accessibility, availability, procurement, rational use and quality issues of selected life saving maternal/RH
medicines

Information required for the study was obtained through document reviews, key informant interviews, and
selected site visits for the purposes of tracking the need, demand and supply of the six products (tracer
medicines) through the supply system to the point of use. Field visits were conducted in Ulaanbaatar, Bulgan,
Khentii, and Orkhon aimags (and selected soums).

LIMITATIONS and STRENGTHS OF THE STUDY

This is a rapid assessment exercise which aims to provide a snapshot of the current situation in Mongolia
regarding the availability and use of the selected sample of life saving RH medicines in a pragmatic sample of
health facilities and pharmacies in a number of provinces in Mongolia. The aimags were selected purposively
considering transport, human capacity and the time constraints of the assessment and also because they have not
been included in recent/previous RH assessments. Therefore, a limitation of the assessment is that the findings
may not be generalizable to health facilities and pharmacies throughout Mongolia.

However, the strengths of the assessment are that it can be completed in a short time frame; it is relatively
inexpensive; the findings can supplement and/or validate other similar on-going or planned studies; it can enable
wider stakeholder involvement in collaboration with the MoH and the findings can be used for further raising
awareness among key stakeholders.

4 

 
The full terms of reference for this assessment exercise can be found in Annex A.

Key Issues Identified and Suggested Action Recommendations

Issues Identified with the EML:

• Ergometrine not currently listed in EML

• Metronidazole injection listed in Section 6.4 Antiprotozoal Drugs and not in Section 6.2.2 Other
antibacterials
• Hydralazine is not included in the Mongolian EML
• Salbutamol injection 50 mcg is listed in Section 22.2 Antioxytocics

Action recommendations for EML:

The MoH through its Department of Pharmacy and the Department of Health establish a working
group/focal point to:
• Consult with Obstetric and Gynaecology experts and professional organizations to review need to add
Ergometrine to the EML at the next meeting to revise and up-date the EML
• Take the necessary actions to add Metronidazole injection to Section 6.2.2 Other antibacterials during
the current ongoing revision of the EML and obtain the required official approval and disseminate the
revised EML through approved channels
• Consult with Obstetric and Gynaecology experts and professional organizations to determine whether
there is a need to include hydralazine on the EML and then prepare the necessary documentation and
authorizations for implementing the recommendation.
• Take the necessary actions to replace Salbutamol injection with Nifedipine 10mg immediate release
capsules in the next revision of the EML

Issues Identified with the Availability:

• Overstocks of ergometrine in some visited sites

• Occasional stock outs of some selected medicines (from 1 week to 2 months) such as oxytocin, (mainly
in UB City) metronidazole (in rural areas because of high cost), and ampicillin ( because of excessive
demand and poor forecasting) were observed in some visited sites.
• There was no standardised guidelines for estimation of medicines

Action recommendations for increasing availability:

• Capacity building on estimation/forecasting at all levels through the development and application of
standardised estimation and forecasting tools and relevant training and supervision
• MoH should systematically scale up the LMIS that had been initiated and supported by UNFPA by
establishing a clear mechanism for its institutionalisation using an official working group approach.

Issues Identified with the availability and use of STGs/Algorithms/Protocols :

• Guidelines currently available in health facilities date from 2000-2003. May be out of date when
compared with the current evidence based practice recommended by WHO
• No nationally endorsed standardized treatment algorithms displayed in or near delivery room because of
lack of these officially approved algorithms. There was evidence that several vertical initiatives had been
undertaken by health professionals for making treatment algorithms available in or near the delivery
ward, but there was no consistency in the type and source of the information displayed. Examples
included photocopies of pages from an obstetric textbook describing the use of Oxytocin for induction
of labour and a A4 size poster detailing the different dosage regimens for Magnesium Sulphate,
depending on the strength of solution (50% or 25%), for the treatment of pre-eclampsia/eclampsia,
which had been provided by the Maternal and Child Health Research Centre. However, this was only
found in one Soum Hospital.
5 

 
 • WHO guidelines were not adapted to reflect the locally available strengths of magnesium sulphate

Action recommendations for STGs/Protocols:

• Review, revise and adapt the current handbooks and guidelines approved for Mongolia to be in-line the
latest WHO materials and update the Mongolian versions accordingly
• Develop standardized nationally endorsed posters of the treatment algorithms for prevention and
treatment of PPH; treatment of pre-eclampsia and eclampsia and management of maternal sepsis and
neonatal sepsis for display in facilities which provide delivery services and set up a mechanism for these
posters to be widely distributed in sufficient numbers to the facilities at all levels
• Set up a mechanisms for regular future revisions of guidelines that should include treatment regimens
based on the use of 25% solution of magnesium sulphate in line with revised treatment algorithms

Issues Identified with the Rational Use:

• Critical knowledge practice gap exists regarding the appropriate use of oxytocin and magnesium sulphate
in some selected sites visited, but was not generalised.
• These selected tracer medicines can be bought from private pharmacies without prescriptions
• Magnesium sulphate injection is being sold to outpatients for the treatment of hypertension. Magnesium
sulphate is an anticonvulsant, not an antihypertensive medication. Irrational use of this medicine. Need
to investigate why it is being used as an outpatient treatment for hypertension.

Action recommendations for Rational Use:

• Provision of in-service training to practitioners to effectively use the guidelines and standards for the use
of Oxytocin 10 IU as a routine and essential part of AMTSL
• Ensure the application of the guidelines and recommended standard dose of continuous MgSO4
solution in accordance with the approved treatment algorithms and supportive in-service training.
• Good prescription and dispensing practice should be strengthened with the support of the Department
of Health and the Hospital Drug and Therapeutic Committees (DTC) through the provision of on-
going in-service training

Issues Identified with the Registration and Quality Assurance:

• One unregistered brand of calcium gluconate (Novosibchem Pharma, Russia) was found to be in use in
3 of the surveyed health facilities that included an aimag general hospital (1) and FGPs (2)
• One unregistered brand of magnesium sulphate (Vero Pharm, Russia) was found to be in use at one of
the surveyed Soum Hospital

Action recommendations for Registration and Quality Assurance:

• The State General Inspection Agency in collaboration with the Department of Health should investigate
the unregistered calcium gluconate and magnesium sulphate products and take appropriate measures
and develop a framework approach for dealing with counterfeit and unregistered drugs

Issues Identified with the Storage:

• There was widespread inappropriate storage of Oxytocin in most of the visited Facilities/pharmacies.
• It was also found at the same survey sites the manufacturer’s instructions for all these tracer medicines
were only in English or in Russian.

6 

 
Action recommendations for Storage:

• MoH to demand that all procurement contracts include storage instructions and drug inserts in
Mongolian as an essential condition for selection during the tendering process. MoH should also
demand that approval of the registration of the drugs be conditional on commitment by the drug
manufacturer/supplier to provide storage instructions and drug inserts in Mongolian.
• MoH review the current storage facilities and conditions at the central and local level facilities and then
revise and update the standards for storage of drugs and other medical supplies.

Issues Identified with the Procurement and Supply Chain Management:

• Most of the oxytocin and all of the ergometrine is currently provided and funded by UNFPA
• A variety of approaches (all within the procurement law) were employed by the various surveyed
facilities. These were 1) bulk procurement through an aimag tendering process, 2) direct procurement
from the wholesalers or 3) through the Revolving Drug Fund mechanisms.
• Inadequate capacity for estimation/forecasting RH essential medicines in terms of estimation and
forecasting methods used, knowledge and skills of the staff doing the forecasting/estimation,
unavailability of standardised forms/checklists with their associated guidelines and procedures for doing
estimations and forecasting requirements and weak or non functioning DTCs.

Action recommendations for Procurement and Supply Chain Management:

• The government should also examine a variety of sustainable mechanisms for procurement, storage and
distribution of all RH essential medicines, with special emphasis on oxytocin and ergometrine and select
the one suitable for implementation in Mongolia using the findings of the in-depth study referred to
earlier that is integrated with an expanded national LMIS also mentioned above.
• Further in-depth study of different supply methods for Soum Hospital for all essential medicines to
identify the essential components that would constitute a most efficient and cost-effective supply
system.
• Forecasting capability should be strengthened and integrated with the institutionalised LMIS, as
mentioned earlier.

Issues Identified with the Costs:

• Health Facilities have to contend with very wide variation in cost when procuring these tracer and other
medicines
• Metronidazole injection is very expensive especially in the rural areas (950-2500 tugrik; US $ 0.679-
1.786).
• The Drug Registration Process does not include a price ceiling conditionality

Action recommendations for the Costs:

• Government to obtain a commitment by drug manufacturers, importers, wholesalers and, where

applicable, retailers to adhere to a price ceiling and drug pricing policies and lists of the government as
an essential conditionality and prerequisite for the registration of all RH essential drugs and all
medicines on the EML
• Government (MoH and MoF) should establish a permanent mechanism for developing, periodically
reviewing and revising and enforcing, with adequate sanctions, a price list for all medicines on the EML
that is integrated with the national.

7 

 
Issues Identified with the Coordination/Integration:

• Co-ordination and harmonisation of project activities in the country related to LMIS and the regulation,
inspection, provision and use of essential RH and other medicines along with MCH and RH activities
between different organizations and partners is currently quite weak.
• Inadequate participation of private sector and domestic NGO partners in initiatives/projects
undertaken by the MoH in the area of reproductive health, such as training workshops, seminars and
capacity development activities

Action recommendations for Coordination/Integration:

• Promote a more integrated approach for planning, implementation and monitoring of RH interventions
through the use of the established MoH aid coordination mechanisms including setting up of working
group and/or focal point n the MoH
• Increase participation of private and domestic NGO partners in future initiatives/projects by MoH in
the area of reproductive health, including training activities and capacity building by mandating
representation on the strengthened coordination mechanisms mentioned earlier and through mandatory
participation of selected partner staff and stakeholder representatives, using mutually accepted selection
criteria.

8 

 
Chapter 1. Context and Background

With a population of 2.6 million people on an area of 1,566,460 square kilometers, Mongolia has a vast, sparsely
populated territory and four seasons alternate with a harsh continental climate. 60.6% of population lives in
urban areas and 39.4% lives in rural areas.

Population of Mongolia is continuing to rapidly change both in terms of its geographical distribution and
urbanization. 8 provinces of the country have their population actually decreased over period of 15 years from
1990 to 2005; while on overall, population of the country grew from 2.1 million to 2.5 million over the same
period. In 2008, Mongolia’s population reached 2.684 million.

At the same time, population of Ulaanbaatar doubled from 586 thousands to 994 thousands in 2006. This
number doesn’t include a large number of migrants who seldom register (unofficially the capital’s population is
estimated to be near 1.2-1.5 million people).
Exactly, 32.6 percent of the population are children under the age of 15, and 28.3 percent are women of 15-49
years of age. Average life expectancy is 66.5 years of age for Mongolians, where women’s average life expectancy
is 70.2, and men’s 63.1. (NSO, Annual report, 2008)

Mongolia is divided into 21 aimags, 338 soums and UB city divided into 9 districts and 132 khoroos. Urban
migration has resulted in the growth of Ulaanbaatar City’s population. While high-risk pregnancies are
increasingly being referred from the soum to the aimag and from the aimag to the capital city, childbirths have
risen in the aimags and the capital city, and aimag joint hospitals and maternity hospitals in Ulaanbaatar are
unable to sustain the load. For instance, the number of women giving birth in Ulaanbaatar rose by 23.0 percent
compared to 10 years ago, while the number of beds in maternity units decreased by 22 percent.

Natural disasters and harsh weather conditions cause herders to migrate to different areas miss the obligation to
register with the local government, and, among them, many poor and disadvantaged people are not able to
receive reproductive health services. About 83.3 percent of maternal mortality cases are herders and unemployed
women, and the average distance between their home and the hospital was 61.8 km. (Why did women die? ADB,
MCHRC, 2006)

Health services in Mongolia from primary to tertiary level are organized as follows: bagh, soum or family clinic,
aimag or district, and specialized hospitals or centers. Out of the 2,100 health institutions operating nationwide,
there are 15 specialized hospitals and centers, 3 regional diagnosis and treatment centers, 27 aimag and district
general hospitals, 6 rural hospitals, 321 inter-soum and soum hospitals, 228 family practitioner units, and 299
maternity waiting homes, as well as 1063 private clinics. (Health statistics, 2008)

Maternal Service Delivery: Management of the maternal and newborn health services

At primary level or family, village and soum clinics, general practitioners are responsible for the health of
reproductive age women, antenatal care for low risk pregnant women and postpartum care after uncomplicated
deliveries, family planning services, and for identifying and referral of women with high risk pregnancies and
complications. The primary care providers should also care and treat patients according to specialist instructions
and provide home visits to postpartum women and newborn. During these home visits, family or soum doctors
check women and newborn health and provide necessary management.

Secondary level health services include district health centers and hospitals, and aimag and city general
hospitals. Aimag and Ulaanbaatar city health departments provide policy development, planning and
management of local health services. They are responsible for the structure of services, coordination and
distribution of the resources, and monitoring and supervision of the general hospitals, soum, village and family
clinics, bagh service delivery points on its administrative territory.

Tertiary level health services include national centers and hospitals provide specialized medical care in UB and
referral services for rural populations. They also responsible for research and some of them act as teaching
hospitals under Ministry of Health.

9 

 
Chapter 2. Key Findings and Recommendations

1. Need and Demand

Need in this context refers to a patient’s capacity to benefit from an intervention. Based on this rationale the
particular medicines chosen for this assessment were those that are the internationally recognized, evidence-
based recommended treatments for the management of three of the major causes of maternal mortality in
Mongolia:

• Post Partum Haemorrhage (Oxytocin injection and Ergometrine Injection)

• Severe Pre-eclampsia/Eclampsia (Magnesium sulphate injection)
• Maternal infection/sepsis (Ampicillin injection, Gentamicin injection, Metronidazole injection)

The most recent health indicators available for maternal and child health in Mongolia are those published by the
Implementing Agency of the Government of Mongolia in their 2008 yearbook. Of the 31 maternal mortality
cases reported in 2008, 48% occurred in Ulaanbaatar, 26% at Aimag hospitals, 19% at Soum and inter-soum
hospitals and 7% at Regional diagnostic and treatment centres. Post-partum haemorrhage (PPH) was responsible
for 32 % of maternal deaths, with pre-eclampsia and eclampsia accounting for 19% and sepsis 16%. Preventing
and managing cases of PPH, pre-eclampsia/eclampsia and maternal sepsis are dependent on the utilization of
antenatal care services (ANC) and assistance at delivery by health professionals who have undergone specific
training in obstetric care.

Table 1: Current situation in Mongolia

Utilization of ANC (RH survey 2008) Place of Delivery (RH survey 2008)

• 74% of pregnant women attended ANC in • Approximately 98,3% of births took place
first trimester in a hospital or clinic
• On average, the percentage of ANC and • 0,8% born at home
early ANC coverage in Ulaanbaatar city • 0,9 % born elsewhere
was lower than in the Aimags

Assistance at delivery (RH survey 2008) Maternal mortality by social status (2007-2008)1

• 47 % attended by Ob&Gyn specialist • 30.9% herdswomen

• 23,4 % attended by general practitioner • 35.8% unemployment
doctor • 18.5% blue collar
• 28,3 % attended professional midwives • 9.9% student
• 0,4 % attended by feldsher • 4.9% white collar
• 0.3 % attended by nurse
• 0.4 % attended by others

1. MCHRC 2008. Current situation of Maternal Mortality in Mongolia, 2007-2008, Ulaanbaatar

Over the last 5-10 years there has been strong political commitment in Mongolia for the development of specific
Reproductive Health (RH) strategies to create an enabling environment for achieving the Millennium
Developing Goals which were set by Mongolia to reduce maternal and child mortality and morbidity. These
strategies are outlined in the Health Sector Master Plan (2006-2015)1, the Third National Reproductive Health
Programme of Mongolia (2007-2011)2 and the Maternal Mortality Reduction Strategy (2005-2010)3. On-going
implementation of these national strategies will continue to drive demand for essential RH medicines.

1
 Ministry of Health. 2005. Health Sector Strategic Master Plan 2006‐2015.  Government of Mongolia 
2
 Ministry of Health. 2007. The Third National Reproductive Health Programme of Mongolia 2007‐2011. Government of Mongolia 
3
 Ministry of Health. 2005. Maternal Mortality Reduction Strategy 2005‐2010. Government of Mongolia 
10 

 
Key strategies which directly impact on the demand for essential RH medicines in Mongolia are:

• To improve quality and accessibility to RH services by hastening the introduction of international

standards and evidence-based practices
• To increased accessibility, equity and availability of RH and safe motherhood services for the remote,
migrant and disadvantaged groups of women
• To create conditions necessary for providing emergency care to mothers and children in remote,
peripheral areas

Demand is also being driven by the implementation of guidelines for the management of pregnancy related
complications. In 2001, the Ministry of Health translated and printed 2000 copies of the Integrated Management
of Pregnancy and Childbirth (IMPAC)4 guideline, which were disseminated nationwide. Between 2001 and
2004 specific training for all Obstetric and Gynaecology Soum doctors in 16 provinces was provided (there are
still 5 provinces which have yet to receive training) and in 2003-2004 the guidelines were included in the revised
undergraduate and residency training curriculum. The Pregnancy, Childbirth, Postpartum and Neonatal Care5
(PCPNC) guideline was first introduced in 2003 for midwives. In 2007 the Mongolian version was up-dated
following the publication of a second edition of the WHO PCPNC guidelines. At this time training on PCPNC
for Soum midwives in selected provinces was organized. At the same time the midwife curriculum was revised
to include the PCPNC guideline.
Mongolia follows pro-natalist policies and as a result the birth rate is increasing. The following social benefits
included in the number of policy documents including Law of Mongolian Development Fund, Law on Subsidies
for Mother and Child and Monetary Allowances for Child, Mother and Family. These include:
• Newborn child payment 100,000 tugrik (one off payment)
• Child Money Program 3000 tugrik/month, plus 25,000 tugrik/quarter
• Maternity leave benefit 70% salary if employed; 20,000 tugrik/month if unemployed for 4 months
• Mother’s Medal One off payments of 50, 000 tugrik for having 4 children and 100,000 tugrik for having
≥ 8 children

In the last two years, the number of births increased, from 47,376 in 2006 to 63,087 in 2008. This was an
increase of 33%. An increasing birth rate will naturally lead to an increase demand for essential RH medicines.

2. Essential Medicines List (EML)

The National Essential Drug List provides an indication of which medicines should be available at the different
levels of healthcare facilities in Mongolian. MoH facilities are encouraged to use the EML to inform purchasing
decisions. However, purchase is not restricted to medicines on the EML.

The current version of the Mongolian EML was last revised in 2005. There are plans to revise the EDL later
this year. Currently Oxytocin, Magnesium Sulphate and Gentamicin are listed in the EML for use in Soum
hospitals and above. Calcium gluconate and Ampicillin are listed for use at all levels of health care including the
Feldsher posts. Metronidazole injection is currently listed in section 6.4 Antiprozoal Drugs for use at Aimag
Hospitals, Clinical Hospitals and Specialized Centres. Only Metronidazole tablets are listed in Section 6.2.2
Other antibacterials. Ergometrine is not currently listed in the EML. Whilst reviewing the current Mongolian
National EML it was noted that there are some WHO recommended essential medicines for Reproductive
Health that are not listed. It was noted that hydralazine is not included in the Mongolian EML 2005. In the
WHO Model List of Essential Medicines hydralazine is listed for the acute management of severe pregnancy

4
 World Health Organization. 2000. Integrated Management of Pregnancy and Childbirth. Managing Complications in Pregnancy 
and Childbirth. A guide for midwives and doctors. Geneva: World Health Organization 
5 nd
 World Health Organization. 2006. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. 2  ed. 
Geneva: World Health Organization 
 
 
11 

 
induced hypertension. Another discrepancy with the WHO Model List is the inclusion of Salbutamol Injection
50 mcg in Section 22.2 Antioxytocics. Salbutamol has been replaced by Nifedipine 10mg immediate-release
capsule for the prevention of pre-term labour in the WHO Model List of Essential Medicines.

Table 2: Listing of critical RH medicines in the EML

Level of care Feldsher Family Soum Inter- Aimag Clinical

Post Hospital Hospital soum and Hospital,
Hospital District Specialized
Hospital Hospital
Ampicillin inj. 9 9 9 9 9 9
Calcium 9 9 9 9 9 9
Gluconate inj.
Oxytocin x x 9 9 9 9
Magnesium x x 9 9 9 9
Sulphate inj.
Gentamicin inj. x x 9 9 9 9
Metronidazole x x x X 9 9
inj.

Issues Identified with the EML:

• Ergometrine not currently listed in EML

• Metronidazole injection listed in Section 6.4 Antiprotozoal Drugs and not in Section 6.2.2 Other
antibacterials
• Hydralazine is not included in the Mongolian EML
• Salbutamol injection 50 mcg is listed in Section 22.2 Antioxytocics

Action recommendations for EML:

The MoH through its Division of Pharmacy and Medical Devices and the Department of Health
establish a working group/focal point to:
• Consult with Obstetric and Gynaecology experts and professional organizations to review need to add
Ergometrine to the EML at the next meeting to revise and up-date the EML
• Take the necessary actions to add Metronidazole injection to Section 6.2.2 Other antibacterials during
the current ongoing revision of the EML and obtain the required official approval and disseminate the
revised EML through approved channels
• Consult with Obstetric and Gynaecology experts and professional organizations to determine whether
there is a need to include hydralazine on the EML and then prepare the necessary documentation and
authorizations for implementing the recommendation.
• Take the necessary actions to replace Salbutamol injection with Nifedipine 10mg immediate release
capsules in the next revision of the EML

3. Availability of Critical RH Medicines

Generally the availability of the tracer medicines at the health facilities/pharmacies was good and stock outs were
reported to be rare and ranged from a few days to a period of 2 months. The Maternity Hospitals in UB reported
more stock outs than the health facilities outside of UB. There were reports from referral hospitals and
specialized hospitals in Ulaanbaatar that due to the increased delivery rate in the last year they had experience
some periods of shortages and had to ask patients to purchase medicines, such as oxytocin from local
pharmacies. Small stocks of Magnesium Sulphate and Oxytocin were found at the Family Group Practices and
Clinics. According to the EML, these medicines are not recommended for this level of care. In some health

12 

 
facilities there were overstocks of ergometrine. Health professionals reported that they no longer use it as
Oxytocin is now the first line treatment for AMTSL and treatment of PPH.

Table 3: Availability at health facilities (In Labour/Obstetrics/Maternity/Delivery Ward/ Family

Group Practice)
Health Facility/Type Oxytocin Mag Calcium Ergo- Ampi- Genta- Metron-
Injection Sulphate gluconat metrine cillin micin idazole
injection e Injection Injection Injection Injection
Injection
Government/Public
Maternal Child Health √ √ X X √ √ √
Research Center (24 hrs)
Specialized

Family Group Practice X √ √ X X X X

(FGP), UB
Barong Buren Soum √ √ X X √ X X
Hosp
Orkhon Provincial √ √ X √ √ √ X
General Hospital
Mend Polka Family √ √ √ X √ √ X
Group Practice (FGP),
Orkhon
Bulgan Prov.General √ √ √ √ √ √ √
Hospital
Emiin Tsetseglen Family X √ √ X X X X
Clinic, Bolgun
Khishig-Ondur Inter- √ √ √ √ √ √ √
Soum Hosp. of Bulgan
Province
Dashinchiling √ √ √ √ X X X
Soum of Bulgan
Province
Maternity Hospital No. √ √ √ √ √ √ √
1
Maternity Hospital No. √ √ √ √ √ √ √
3
Khentii Aimag √ √ √ √ X √ √
Erdene Soum √ √ √ √ √ √ √
Umnudelger Soum √ √ X √ √ √ √
Baga-nuur District √ √ √ X √ √ √
Hospital
Private /NGOs
Khatagtai Private Mat. √ √ √ √ √ √ √
Hospital
24 Hrs. service
Marie Stopes Clinic, UB, √ √ X X X X X
Mongolia
Enkhgin Private Gynae √ X X X X X X
Clinic, Orkhon
IPPF/MFWA RH fee √ √ X X X X X
for service clinic

13 

 
Table 4: Availability at Government Stores, Pharmacies in Public Hospitals/Facilities, Private /NGO
Clinics and Pharmacies/Whole Sales Medicine Stores
Health Facility/Type Oxytocin Mag Calcium Ergo- Ampi- Genta- Metro-
Injection Sulphate gluconat metrine cillin mycin nidazol
injection e Injection Injection Injection Injection
Injection
Government/Public
Maternal Child Health √ √ X X √ √ √
Research Center (24 hrs)
Specialized
Baruun Buren RDF X √ X X √ √ √
Pharmacy

Maternity Hospital No. √ √ √ √ √ √ √

1
Maternity Hospital No. √ √ √ √ √ √ √
2
Khentii Aimag √ √ √ √ √ √ √
Erdene Soum √ √ √ √ X √ √
Umnudelger Soum √ √ X √ √ √ √
Baga-nuur District √ √ √ X √ √ √
Hospital
Private /NGOs
Khatagtai Private Mat. √ √ √ √ √ √ √
Hospital
24 Hrs. service
Marie Stopes Clinic, UB, √ √ X X X X X
Mongolia
IPPF/MFWA √ √ X X X X X
Emlin Private Pharmacy X √ √ X √ √ √
Khonkhondoi Private √ √ √ X √ √ √
Pharmacy
Sumber drug store X √ √ X √ √ √
MEIC Pharmacy X √ √ X √ √ √
MEIC warehouse √ √ √ √ √ √ √
Khentii
MEIC warehouse UB √ X √ √ √ √ √
Maternity Hospital No. √ √ √ √ X √ √
1
Maternity Hospital No. √ √ √ √ √ √ √
3
Baga-nuur District √ √ √ X √ √ √
Hospital

Issues Identified with the Availability:

• Overstocks of ergometrine in some visited sites

• Occasional stock outs of some selected medicines (from 1 week to 2 months) such as oxytocin, (mainly
in UB City) metronidazole (in rural areas because of high cost), and ampicillin ( because of excessive
demand and poor forecasting) were observed in some visited sites.
• There was no standardised guidelines for estimation of medicines

14 

 
Action recommendations for increasing availability:
• Capacity building on estimation/forecasting at all levels through the development and application of
standardised estimation and forecasting tools and relevant training and supervision
• MoH should systematically scale up the LMIS that had been initiated and supported by UNFPA by
establishing a clear mechanism for its institutionalisation using an official working group approach.

4. Standard Treatment Guidelines (STGs) and Protocols

On the day of the assessment visit the availability of treatment guidelines/protocols and educational materials for
prevention and treatment of PPH, management of pre-eclampsia/eclampsia and maternal and neonatal sepsis at
the lower levels of hospital care was generally greater than at the more specialized centres. Overall, 7 different
types of guideline were found at the health facilities visited. Usually the copies of the guidelines were found in
the ObGyn doctor’s office or the midwives office/desk at the facility. However, in a few cases the guidelines
were only found in the hospital director’s office. None of the guidelines observed were more recent than 2003.
In most health facilities there was evidence of training materials for Emergency Obstetric Care and Behavior
Change Communication and Information, Education and Communication training materials. All of the available
guidelines and training materials were in Mongolian and had been developed in partnership between the MoH,
WHO, UNFPA and professional associations.

All the treatment regimens for MgSO4 described in the currently available guidelines for the management of pre-
eclampsia and eclampsia were based on a 50% solution of MgSO4 and did not include a regimen for the 25%
solution of MgSO4, which is the strength that is widely available in Mongolia. There is currently no 50%
MgSO4 solution registered in Mongolia.

No nationally endorsed standard treatment algorithms for the prevention and treatment of PPH or for the
treatment of severe pre-eclampsia and eclampsia were found on display in any of the obstetric care delivery
points. There was evidence that several vertical initiatives had been undertaken by health professionals for
making treatment guidelines available in the delivery ward for all members of staff. Examples included
photocopies of pages from an obstetric textbook describing the use of Oxytocin for induction of labour and a
A4 size poster detailing the different dosage regimens for Magnesium Sulphate depending on the strength of
solution (50% or 25%) for the treatment of pre-eclampsia/eclampsia in one Soum Hospital, which had been
provided by the Maternal and Child Health Research Centre.

Table 5: Availability of guidelines at Health Facilities

Availability of Guidelines at Health Facility

Managing Managemen RHSC RHSCH RHSCH RHSCH Obstetri
complicatio t of high risk H Vol. 1 Vol. 2 Vol. 3 Vol. 4 c care
ns in pregnancies Infectio Obstetric Family Sexually and
pregnancy n Prevn s Plannin Trans. services
and 2003 2000 g 2000 Dx 2000
childbirth 2000 2003
2001
Organizations MoH, WHO, MoH, WHO, MoH, MoH, MoH, MoH, MoH,
involved in MFOG UNFPA, UNFPA, UNFPA, UNFPA, UNFPA, UNFPA,
guideline MCHRC WHO, WHO, WHO, WHO, WHO,
development AVSC AVSC Int. AVSC AVSC MCHRC
and publication Int. MFOG Int. Int.
MFOG MFOG MFOG
Name of Health
Facility
Maternity X X X √ X X X
Hospital No. 1

15 

 
Maternity √ X X X X X X
Hospital No. 3
Khentii Aimag √ √ √ √ √ √ √
General Hospital
Erdene Soum √ √ √ √ √ √ √
Hospital
Umnudelger √ √ √ √ √ √ √
Soum Hospital
Baga-nuur √ √ √ √ √ √ √
District Hospital
Maternal and √ √ X √ X X √
Child Health
Research Centre
Khatagtai Private √ X X X X X X
Maternity
Hospital
MSI Mongolia √ X X X X X X
Baruun Buren √ X X √ √ X X
Soum Hospital
Orkhon Aimag √ X X √ X X X
General Hospital
Enkhjin Private X X X X X X X
Clinic, Orkhon
Bulgan Aimag √ √ X √ √ X √
General Hospital
Khishig-Undur √ X X √ X X X
Soum Hosp
Dashinchilen √ X X √ X X X
Soum Hospital

Issues Identified with the availability and use of STGs/Algorithms/Protocols:

• Guidelines currently available in health facilities date from 2000-2003. May be out of date when
compared with the current evidence based practice recommended by WHO
• No nationally endorsed standardized treatment algorithms displayed in or near delivery room because of
lack of these officially approved algorithms. There was evidence that several vertical initiatives had been
undertaken by health professionals for making treatment algorithms available in or near the delivery
ward, but there was no consistency in the type and source of the information displayed. Examples
included photocopies of pages from an obstetric textbook describing the use of Oxytocin for induction
of labour and a A4 size poster detailing the different dosage regimens for Magnesium Sulphate,
depending on the strength of solution (50% or 25%), for the treatment of pre-eclampsia/eclampsia,
which had been provided by the Maternal and Child Health Research Centre. However, this was only
found in one Soum Hospital.
• WHO guidelines were not adapted to reflect the locally available strengths of magnesium sulphate

Action recommendations for STGs/Protocols:

• Review, revise and adapt the current handbooks and guidelines approved for Mongolia to be in-line the
latest WHO materials and update the Mongolian versions accordingly
• Develop standardized nationally endorsed posters of the treatment algorithms for prevention and
treatment of PPH; treatment of pre-eclampsia and eclampsia and management of maternal sepsis and
neonatal sepsis for display in facilities which provide delivery services and set up a mechanism for these
posters to be widely distributed in sufficient numbers to the facilities at all levels

16 

 
 • Set up a mechanisms for regular future revisions of guidelines that should include treatment regimens
based on the use of 25% solution of magnesium sulphate in line with revised treatment algorithms

5. Rational Use of Critical RH Medicines

The practices of healthcare providers and their use of life-saving RH medicines should be informed by the
guidelines set by the WHO-MOH.and regulated with the policies set down by law-makers and legislators.
Rational use was assessed by undertaking interviews with health professionals (Ob/Gyn doctors, midwives and
nurses working on the delivery ward) and reviewing available patient records. Generally the level of knowledge
for the indication, dose and contraindications for the tracer medicines was high and deemed appropriate for the
level of expertise and responsibility of the health professionals interviewed. There were a few inconsistencies
regarding the continuous dose of MgSO4 for the management of pre-eclampsia, with the timing of the
maintenance doses ranging from 4 to 12 hourly. Knowledge of the need to use Oxytocin 10 IU for every delivery
as part of the Active Management of the Third Stage of Labour was high, but there were some reports that not
all patients were being given Oxytocin 10 IU e.g. only for those deemed high risk for PPH and in one facility it
was reported that only 5 IU was being administered in order to save drug supplies. The patient record keeping
was of a high standard and it was possible to determine how the diagnosis was made and track the management
of the patient. There was evidence that the use of Oxytocin 10 IU for the active management of the third stage
of labour was being undertaken, although it was found that in some facilities only 5 IU was being administered
to patients as part of the AMTSL. Magnesium sulphate maintenance dose was not being given every 4 hours.

The study medicines could be bought from private pharmacies without prescription. It was reported that IV
antibiotics were often sold to patients without prescriptions. A review of prescriptions at these pharmacies
showed that there was no standardized official prescription form. Some prescriptions were unsigned pieces of
paper with just the name of a medicine written on them. Magnesium sulphate injection was being sold to
outpatients as a treatment for hypertension.

Issues Identified with the Rational Use:

• Critical knowledge practice gap exists regarding the appropriate use of oxytocin and magnesium sulphate
in some selected sites visited, but was not generalised.
• These selected tracer medicines can be bought from private pharmacies without prescriptions
• Magnesium sulphate injection is being sold to outpatients for the treatment of hypertension. Magnesium
sulphate is an anticonvulsant, not an antihypertensive medication. Irrational use of this medicine. Need
to investigate why it is being used as an outpatient treatment for hypertension.

Action recommendations for Rational Use:

• Provision of in-service training to practitioners to effectively use the guidelines and standards for the use
of Oxytocin 10 IU as a routine and essential part of AMTSL
• Ensure the application of the guidelines and recommended standard dose of continuous MgSO4
solution in accordance with the approved treatment algorithms and supportive in-service training.
• Good prescription and dispensing practice should be strengthened with the support of the Department
of Health and the Hospital Drug and Therapeutic Committees (DTC) through the provision of on-
going in-service training

6. Registration and Quality Assurance

During field visits, the team found 230 ampoules of one calcium gluconate brand, 10%, 10 ml from Russia
(Novosibrisk Pharma) in the Orkhon General Hospital Pharmacy with expiration in December 2009. Also there
is another brand of calcium gluconate found in few health facilities (Bulgan Provincial General Hospital, Emiin
Tsetseglen Family Clinic- Bulgan, and Mend Polka Family Group Practice-Orkhon) which was labeled as ‘TMH’
but did not have a manufacturer’s name or country of origin on the ampoule. The original packaging was not
available, so no further information about this brand could be elicited regarding the origins of this product. At
the Erdene Soum Hospital, 47 ampoules of an unregistered Russian brand (Vero Pharma) of Magnesium
17 

 
Sulphate 25%, 10ml, expiry date 03/2010 was found. The license for this brand of Magnesium Sulphate expired
in 2005 and no application for extension has ever been received by the Drug Registration and Information
Office.

Table 6: Summary of the current registration status of the critical RH medicines with Drug Registration
and Information Office, Health Department, MOH
Drug name and form Strength Number of Number/Name Year of first
registered of registration and
products manufacturing current validity
companies (range)
Oxytocin injection 5 IU/ml 2 1. Moscow 1.2003 (05/2012)
Endocrine Factory-
Russia
2. Gideon Richter- 2. 1999 (11/2012)
Hungary
Magnesium sulphate 10 ml (25%) 4 1. Mos Chem 1. 1998 (12/2011)
injection Pharm-Russia
2. Dali Chem 2. 1998 (11/2012)
Pharm-Russia
3.Tsombo, 3. 2008 (12/2013)
Mongolia
Calcium gluconate injection 10% 10 ml 2 1. SPIC-China 1. 2008 (06/2013)
2. Mos Chem 2. 1999 (05/2012)
Pharm-Russia
3. Tsombo, 3. 2008 (12/2013)
Mongolia
Ampicillin injection 250 mg 1 Bilim- Turkey 2006 (06/2010)

Ampicillin injection 500mg 5 1. NCP-China 1. 2005 (10/2009)

Ampicillin injection
Gentamicin injection
Metronidazole injection
2. Kras Pharma, 2. 2003 (12/2013)
Rus
3. Bilim- Turkey 3. 2006 (06/2010)
4. SPIC- China 4. 2008 (06/2013)
5. Harbin Pharma - 5. 2008 (04/2013)
China
1g 5 1. NCP-China 1. 2005 (10/2009)
2. Yanzhou Pharm 2. 2008 (10/2013)
– China
3. Bilim- Turkey 3. 2006 (06/2010)
4. SPIC- China 4. 2008 (06/2013)
5. Harbin Pharma- 5. 2008 (04/2013)
China
80 mg 2 ml 7 1.Bidipharm- 1. 2005 (05/2014)
Vietnam 2. 2005 (10/2009)
2. NCP-China 3. 2008 (06/2013)
3. SPIC-China 4. 2009 (05/2014)
4. CSPC-China 5. 2005 (11/2012)
5. Wuhan Pharma-
China
6. Mos Chem 6. 2001 (06/2010)
Pharm– Rus
7. Brinzalow - Rus 7. 2000 (11/2010)
500 mg 100 5 1.Rodex Medica- 1. 2004 (03/2012)
ml Germany
2. KRKA-Slovenia 2. 2003 (09/2012)
3. Unique Pharma- 3. 2006 (03/2012)
India
4. Insepta Pharma- 4. 2008 (09/2013)
Bangladesh

18 

 
 5. SPIC-China 5. 2008 (06/2013)

Issues Identified with the Registration and Quality Assurance:

• One unregistered brand of calcium gluconate (Novosibchem Pharma, Russia) was found to be in use in
3 of the surveyed health facilities that included an aimag general hospital (1) and FGPs (2)
• One unregistered brand of magnesium sulphate (Vero Pharm, Russia) was found to be in use at one of
the surveyed Soum Hospital

Action recommendations for Registration and Quality Assurance:

• The State General Inspection Agency in collaboration with the Department of Health should investigate
the unregistered calcium gluconate and magnesium sulphate products and take appropriate measures
and develop a framework approach for dealing with counterfeit and unregistered drugs

7. Storage (of Tracer Drugs)

Medicines are securely stored, and storage conditions of medicines are generally well controlled. It was found
that all the facilities had enough space with shelves. Most of the facilities visited were relatively clean and in
good order in spite of heavy workload, but the temperature is always dependent on ambient temperature.
Potential attention should be given to future storage condition for Oxytocin or provision of appropriate
Oxytocin. Most of the facilities are using Oxytocin which is not required for specific storage condition, a few of
them visited have kept the Oxytocin at ambient temperature that should have been stored below 2-8.This means
that there has been a certain possibility that the other facilities must have kept in that wrong way due to little
knowledge on special requirement for storage condition for Oxytocin.The team could find no evidence that cold
chain maintenance was ensured throughout the supply system. Therefore it might be the best and cost effective
option to purchase and provide appropriate Oxytocin (storage condition; below 25) for the cold chain.

Issues Identified with the Storage:

• There was widespread inappropriate storage of Oxytocin in most of the visited Facilities/pharmacies.
• It was also found at the same survey sites the manufacturer’s instructions for all these tracer medicines
were only in English or in Russian.

Action recommendations for Storage:

• MoH to demand that all procurement contracts include storage instructions and drug inserts in
Mongolian as an essential condition for selection during the tendering process. MoH should also
demand that approval of the registration of the drugs be conditional on commitment by the drug
manufacturer/supplier to provide storage instructions and drug inserts in Mongolian.
• MoH review the current storage facilities and conditions at the central and local level facilities and then
revise and update the standards for storage of drugs and other medical supplies.

19 

 
8. Procurement and Supply Chain Management

Drug supply system in Mongolia is fully privatized and the procurement is also decentralized. Before 1991 all
procurement and supply chain management was centralized.

The hospitals purchase pharmaceuticals through an open tendering process. The implementation of the
tendering process is based on the new procurement law. Under this law, the procurement is divided into several
rules depending on the size of the tender.

Currently, every Aimag manages their own procurement and supplies of medicines independently through
tendering. Ulaanbaatar city carries out a tender for all of its district hospitals. The larger National hospitals
(centrally located secondary, tertiary and specialized hospitals in Ulaanbaatar and 3 specialized provincial level
hospitals known as regional diagnostic centers) manage their own procurement and supplies of medicines and
medical devices independently through open tendering process. The smaller hospitals are clustered together in a
combined tender.

Apparently at the Soum levels there are different options of procurement: mostly through the Revolving Drug
Fund (RDF) mechanisms; or alternatively either integrated into the Aimag tendering process, or direct
procurement by individual soum or a mixed of these processes. About 30% of 330 soum hospitals do not have
facility, transportation and cold chain equipments to maintain quality of drug and medical devices at the required
level of standard. Soums don’t have human and technical capacity to make proper estimation, procurement,
inventory, storage and warehousing and distribution of drug and medical devices at acceptable level of quality.

Pharmaceutical sector is one of the first in Mongolia that was privatized. There are 38 drug manufacturers, 136
drug wholesale agencies, 1026 pharmacies work in the area of producing and procuring drug and medical
supplies including RH commodities. Mongolia imports 75-80% of its required drugs and medical supplies and
produces the rest domestically.
Since 1992 UNFPA has been providing about 90% of total contraceptives spending. Also UNFPA has been
providing almost all (90%) of Oxytocin and perhaps 100% of Ergometrine injections (except that the team
found only one private clinic who has been brining/importing a small amount of Ergometrine injections).

Although, Government spends considerable amount of funding for medical care related with pregnancy and
delivery, funding for RH commodities is not included as a separate line item in the state budget. Supply of drugs,
medical devices and equipments for essential obstetric and infant care is below 20% in rural areas, which
contributes to the relatively higher maternal and infant deaths and inadequate quality of care. (National strategy
on RH commodity security, 2009)

National RH Commodity Security Strategy 2009-2013

A Memorandum of Understanding between MOH and UNFPA signed in 2007 outlines series of mutual
commitments and serves as a basis for initiatives in the sustainable RH commodity security in the longer-term
basis. And eventually Mongolia was selected as a Stream 1 country for the UNFPA’s Global Programme to
enhance RHCS. As a result of effective advocacy efforts special article on “increasing government resources to
secure RH commodity needs of herders and the poor” was included into the Mid-Term Development
Framework of Mongolia for 2009-2011 and approved by the government of Mongolia. Also as it was mentioned
under target/indicator 1.1.1, the Government allocated for the first time US$ 50,000 (85 m Mongolia Tug) for
RH commodities including contraceptives in 2009 state budget. Consequently the National RHCS Strategy and
Plan of Action was developed and endorsed in April 2009 and it has 3 main objectives covering areas of
improving legal and regulatory mechanisms for RH commodity supply, the establishment of system at all levels
for RH commodity procurement, building national capacity, creating reliable financial sources and improving
accessibility of RH commodities to meet population needs and demands.

20 

 
Logistics Management Information System (LMIS and CHANNEL)

In 2002 LMIS was introduced for central and provincial levels. In 2007 UNFPA developed an integrated RH
HMIS and LMIS software to be implemented as a pilot project. Piloting of the UNFPA’s software for RH
commodities at soum level was initiated in three focus aimags (Bayan-Ulgii, Khovd and Uvs) with prior training
and logistics support. Evaluation of the pilot intervention in selected soums was undertaken in the same year and
was deemed to be successful. It was subsequently expanded to two other aimags (Gobi-Altai, Khuvsgul) in 2008.
So these whole pilot LMIS interventions included all the areas related to development of software, capacity
building (training of staff involved) and provisions of required logistics support. In addition, from early 2008
steps taken to introduce the UNFPA global CHANNEL software at the 21 aimags and 9 districts under
Ulaanbaatar for monitoring procurement and supply of RH commodities. For this CHANNEL has already been
translated into Mongolian, training conducted at the central level for the respective RH coordinators UNFPA
CO focal points. From April 2009, the UNFPA IT specialist started working to introduce CHANNEL as a web
based LMIS (which was shared in the Regional Workshop in Bangkok in May, 2009). Now UNFPA is working
closely with MOH, in consultation with the UNFPA HQ (Commodity Security Branch), for implementation (by
the 4th quarter of 2009) and follow up.

BOX 1: Excerpts from the assessment team National Level Questionnaire for RH Medicine
Procurement (from MOH)

Describe the public sector procurement process for essential medicines, including following information: Who buys? Who
supplies? Level of healthcare distribution.

According to the law of Tender, which was renewed in 2006, every government organization should
purchase goods, supplies and consultancy services through bidding altough the specific type of
procurement depends on the amount of the allocated budget.

In purchasing drugs, diagnostic reagents, and medical devices, each hospital has to establish a bidding
committee to evaluate and select the suppliers. Furthermore, according to the above mentioned law,
all tertiary and secondary level hospitals are required to purchase the essential medicines for the year
by bidding /open tendering/. In each aimag, soum level’s needed essential medicines are purchased
through centralized tenders organized by the aimag’s Health department.

Annualy about 40 drug and pharmaceutical supply tender processes are organized / 10 tertiary
hospitals’; 12 secondary hospitals’; 9 centralized, aimag and soum hospitals’/. Nationally, out of all
150 pharmaceutical wholesalers approximatelly 60 participate in tendering processes and about 15
pharmaceutical wholesalers supply more than 70 percent of all drugs purchased through tenders.

Issues Identified with the Procurement and Supply Chain Management:

• Most of the oxytocin and all of the ergometrine is currently provided and funded by UNFPA
• A variety of approaches (all within the procurement law) were employed by the various surveyed
facilities. These were 1) bulk procurement through an aimag tendering process, 2) direct procurement
from the wholesalers or 3) through the Revolving Drug Fund mechanisms.
• Inadequate capacity for estimation/forecasting RH essential medicines in terms of estimation and
forecasting methods used, knowledge and skills of the staff doing the forecasting/estimation,
unavailability of standardised forms/checklists with their associated guidelines and procedures for doing
estimations and forecasting requirements and weak or non functioning DTCs.

Action recommendations for Procurement and Supply Chain Management:

• The government should also examine a variety of sustainable mechanisms for procurement, storage and
distribution of all RH essential medicines, with special emphasis on oxytocin and ergometrine and select
the one suitable for implementation in Mongolia using the findings of the in-depth study referred to
earlier that is integrated with an expanded national LMIS also mentioned above.
21 

 
 • Further in-depth study of different supply methods for Soum Hospital for all essential medicines to
identify the essential components that would constitute a most efficient and cost-effective supply
system.
• Forecasting capability should be strengthened and integrated with the institutionalised LMIS, as
mentioned earlier.

9. Costs

Table 7: International Drug Price Indicator Guide, 2008 (Management Sciences for Health and WHO)
Drug Strength Median Lowest Highest H/L Defined
Price* Price* Price* Ratio Daily
Dose
Magnesium Sulfate 500mg/ml 0.098/Ml 0.038/Ml 0.170/Ml 4.45 2G
Calcium Gluconate 100mg/ml 0.023/Ml 0.017/Ml 0.028/Ml 1.61 3G
Oxytocin 10 IU 0.150/Ml 0.069/Ml 0.254/Ml 3.71 15U
Oxytocin 5 IU 0.138/Ml 0.130/Ml 0.145/Ml 1.12 15U
Ergometrine 0.2mg/ml 0.151/Ml 0.077/Ml 0.343/Ml 4.52 0.2Mg
Ergometrine 0.5mg/ml 0.397/Ml 0.290/Ml 0.456/Ml 1.57 0.2Mg
Ergometrine+Oxytocin 0.5mg+5iU/ml UNFPA, ATC Code G02AC01, Package 0f 100 one ml
amps. No buyer prices found
Ampicillin 1 G vial 0.17/vial 0.11/vial 0.273/vial 2.48 2G
Ampicillin 500mg vial 0.125/vial 0.08/vial 0.45/vial 5.65 2G
Ampicillin 250mg vial 0.13/vial 2G
Gentamicin 10mg/ml 0.039/Ml 0.030/Ml 0.117/Ml 3.90 0.24 G
Gentamicin 40mg/ml 0.040/Ml 0.024/Ml 0.141/Ml 5.93 0.24 G
Metronidazole 5mg/ml 0.005/Ml 0.003/Ml 0.013/Ml 4.32 1.5 G
• All prices are in US dollars.

Table 8: Cost of critical RH medicines in the govt. and private sectors

Medicines Formulation Ampoule size Retail price per Retail price per
ampoule (in Tugrik) ampoule
(USD)
Oxytocin injection 10 IU 1 ml - -
5 IU 1 ml 350-800 0.250-0.571
Magnesium sulphate 25% 10 ml vial 220-600 0.157-0.429
injection
Calcium Gluconate 10% 10 ml 350-700 0.250-0.500
Ergometrine Injection 200 mcg/ml 1 ml NA NA

Ampicillin injection 1 gm 1 g vial 270-650 (1 g) 0.193-0.464

500 mg 248-300 (500 mg) 0.177-0.214
Gentamicin injection 40mg/ml 2 ml ampoule 60-250 0.043-0.179
Metronidazole injection 0.5% 100 ml ampoule 950-2500 0.679-1.786

22 

 
Table 9: Cost to the patient of the WHO recommended treatment regimens based on retail prices
identified during the field visit
Medication Formulation Indication Recommended Number of Total Total cost
treatment regimen ampoules cost to in USD*
required patient
(Tugrik)
Magnesium 25% in 10 Severe Pre- Loading dose 4g 18 2700- 2.83-7.71
Sulphate ml ampoule eclampsia / IV+ 10g IM 10800
injection Eclampsia Maintenance dose:
5g IM every 4
hours for 24 hours

Oxytocin 10 IU in Prevention 10 IU immediately 1 (10 IU) NFS NFS

1ml of PPH after birth of baby 2(5 IU) 700-1600 0.50-1.15
ampoule Treatment 10 IU IM followed 5 (10 IU) NFS NFS
5 IU in 1 ml of PPH by IV infusion, 10(5 IU) 3500- 2.50-5.71
ampoule up to maximum 40 8000
IU

Ergometrine 200 mcg in Treatment 200 mcg IM/IV 2 NFS

1 ml of PPH if slowly. Repeat 200 Only
ampoule heavy mcg after 15 donated
bleeding minutes if heavy by
persists after bleeding persists. UNFPA
use of
Oxytocin
Ampicillin 1g First line of First dose 2 g 21 if 1 g 5670 - 4.05-9.75
Injection 500mg treatment IM/IV. Then 1g 13,650
for maternal IV/IM every 6
sepsis hours- for 5 days 42 if 500 mg 10416 - 7.44 - 9.00
maximum 12,600

Gentamicin 40 mg/ml, 2 Severe 80 mg IM every 8 15 900-3750 0.65-2.68

Injection ml ampoule abdominal hours (give until
pain; the woman is fever
dangerous free for 48hrs)-
fever/very max 5 days
severe
febrile
disease;
complicated
abortion,
uterine and
fetal
infection

23 

 
 Metronidazole 500 mg in Severe 500 mg or 100 ml 15 14250- 10.20-
Injection 100 ml abdominal infusion IV every 8 37500 26.79
pain; hours (give until
dangerous the woman is fever
fever/very free for 48hrs)-
severe max 5 days
febrile
disease;
complicated
abortion,
uterine and
fetal
infection
*Based on exchange rate of 1 USD = 1400 Tugrik.
NFS - Not for sale

Affordability is measured as the cost of treatment in relation to a person’s income. This is usually determined by
the comparison of the daily wage of the lowest paid unskilled government worker and the price paid. In
Mongolia the monthly salary of this worker is 108,000 tugrik - 3600 tugrik per day (USD 2.58 per day). Using
the prices we obtained during the assessment, a 5 day course of Metronidazole for the treatment of maternal
sepsis would require between 4 and 10 days wages.

Issues Identified with the Costs:

• Health Facilities have to contend with very wide variation in cost when procuring these tracer and other
medicines
• Metronidazole injection is very expensive especially in the rural areas (950-2500 tugrik; US $ 0.679-
1.786).
• The Drug Registration Process does not include a price ceiling conditionality

Action recommendations for the Costs:

• Government to obtain a commitment by drug manufacturers, importers, wholesalers and, where

applicable, retailers to adhere to a price ceiling and drug pricing policies and lists of the government as
an essential conditionality and prerequisite for the registration of all RH essential drugs and all
medicines on the EML
• Government (MoH and MoF) should establish a permanent mechanism for developing, periodically
reviewing and revising and enforcing, with adequate sanctions, a price list for all medicines on the EML
that is integrated with the national.

10. Coordination/Integration

While the actual contribution of donors as a proportion of total health expenditure has declined, donors’
influence on the health sector continues to be significant especially in the areas of maternal and child health. In
regards to maternal and newborn health, at least 21 international organizations are active in Mongolia. Among
these UNFPA, WHO, UNICEF, ADB, WB and the Italian Development Cooperation are providing significant
assistance in the implementation of activities for maternal and newborn health.

24 

 
Organizations active in Maternal and Newborn Health in Mongolia

FP, family planning; AC, antenatal care; SBA, skilled birth attendance, B-Em, basic emergency obstetric and
newborn care; C-Em, comprehensive obstetric and newborn care; PP, post-partum; NC, newborn care; MNN,
maternal and neonatal nutrition; WASH, Water Sanitation Hygiene

MNH-related activities

WAS
FP AC SBA B-Em C-Em PP NC MNN H

Asian Development Bank – X X X X X – X –

Italian Development Cooperation in – X X X X X X X –

China and Mongolia

Mongolian Federation of Obstetrics & X X X – X – – – –

Gynaecology

United Nations Population Fund X X X X X X X X X

United Nations International X X X X X X X X X

Children's Fund

World Bank X X – X X X – X X

World Health Organization X X X X X X X X X

Adapted from “Mongolia: External Partners’ Assistance Matrix.” 2008 by World Bank

The Health Sector Strategic Master Plan (HSSMP) is a medium-term policy framework for 2006-2015 which
represents the Ministry of Health’s first comprehensive documentation of its future health sector directions. It
incorporates the Mongolian government’s commitment to the MDGs and health sector reform using a Sector
Wide Approach.

In May 2009, MoH established Council on Coordination of Foreign Aid and Loan in the Health Sector chaired
by Vice Minister of Health (Minister’s Order 141 of 2009). This body represented by heads of international
partners active in the health sector including UN agencies.

UN Joint program on Maternal and Newborn Health

In 2008, current UN agency activities were mapped according to the WHO-UNFPA-UNICEF-World Bank
Joint Country Support for Accelerated Implementation of Maternal and Newborn Continuum of Care core
components and the UNDAF. Through this mapping exercise, opportunities for increased joint support and
impact were identified. Following this exercise, in order to improve coordination of international aid in the
health sector, the UN organizations jointly developed and have been implementing a harmonized programme

25 

 
approach since Feb 2009 in the form of the UN Joint Programme on Maternal and Newborn Health in
Mongolia.

Despite these efforts by the UN agencies to pool resources and technical expertise and the MoHs recent effort
towards having better coordination at national level, there is still a need to strengthen coordination and
communication between the different partners. During the assessment, stakeholders especially from private
sector and NGO community expressed their interest to improve partnerships between public and private
through increased involvement of private institutions and professional associations in the policy development,
monitoring and evaluation, regulation, as well as implementation efforts.

Issues Identified with the Coordination/Integration:

• Co-ordination and harmonisation of project activities in the country related to LMIS and the regulation,
inspection, provision and use of essential RH and other medicines along with MCH and RH activities
between different organizations and partners is currently quite weak.
• Inadequate participation of private sector and domestic NGO partners in initiatives/projects
undertaken by the MoH in the area of reproductive health, such as training workshops, seminars and
capacity development activities

Action recommendations for Coordination/Integration:

• Promote a more integrated approach for planning, implementation and monitoring of RH interventions
through the use of the established MoH aid coordination mechanisms including setting up of working
group and/or focal point n the MoH
• Increase participation of private and domestic NGO partners in future initiatives/projects by MoH in
the area of reproductive health, including training activities and capacity building by mandating
representation on the strengthened coordination mechanisms mentioned earlier and through mandatory
participation of selected partner staff and stakeholder representatives, using mutually accepted selection
criteria.

26 

 
Chapter 3. Conclusion and Recommendations
This assessment report presents a “snapshot” of the current status of access to and rational use of selected
maternal health tracer drugs, which are not routinely monitored. The six selected critical medicines chosen for
the study were Oxytocin injection, Ergometrine injection, Magnesium sulphate injection and three antibiotics,
Ampicillin injection, Gentamicin injection and Metronidazole injection. These medicines were chosen because
they are the WHO recommended medicines for the prevention and treatment of three major causes of Maternal
Mortality: Haemorrhage, Eclampsia/eclampsia and Maternal/Neonatal Sepsis.

Demand for these medicines in Mongolia has being increasing by the implementation of the specific
Reproductive Health (RH) strategies to improve quality and accessibility to RH services and the implementation
of international standards and evidence-based practices for the management of pregnancy and child birth related
complication.

The assessment findings show that generally the availability of these tracer medicines at the health
facilities/pharmacies was good and stock outs were reported rare. Oxytocin, Magnesium Sulphate, Gentamicin,
Calcium gluconate and Ampicillin and Metronidazole are listed in the Mongolian EML (2005). The different
types of treatment guidelines/protocols and educational materials date from 2000-2003 were found at the health
facilities visited. The level of knowledge for the tracer medicines was high.

Also key issues were identified by the assessment with the EML, availability, rational use of these medicines as
well as supply chain management which are listed in the Executive Summary in detail.
In conclusion, we would like to highlight following major action recommendations to improve the availability,
accessibility and rational use of essential RH medicines.

• Forecasting capability should be strengthened at all levels through the development and application of
standardized tools and relevant training and supervision and integrate with the institutionalized LMIS.
• Systematically strengthen and scale up national LMIS by establishing a clear mechanism for its
institutionalization at all levels and provide in-service training.
• Further in-depth study on procurement, storage and distribution of all RH essential medicines, with
special emphasis on oxytocin and ergometrine should be undertaken to identify the essential
components of efficient and cost-effective supply management system which is most suitable for
Mongolia.
• Review, revise and adapt the current handbooks and guidelines according to the latest WHO materials in
collaboration and professional societies and training institutions and provide in-service training to
practitioners and develop standardized nationally endorsed posters for the treatment algorithms for
PPH, pre-eclampsia and eclampsia and management of sepsis.
• The Ministry of Health, through its Pharmacology Department and the Department of Health Drug
Registration Unit consult with the experts and professional organizations to review need to add
Ergometrine and Hydralazine to the EML, also establish a framework for systematically investigating the
availability and use of unregistered life saving RH medicines.
• Promote a more integrated approach for planning, implementation and monitoring of RH interventions
through the use of the established MoH aid coordination mechanisms including setting up of working
group and/or focal point n the MoH and increase participation of private and domestic NGO partners
in the area of reproductive health.

27 

 
ANNEXES

Annex A. Terms of Reference

TERMS OF REFERENCE

Review of current status in access to a core set of critical

Life-saving RH Medicines in Mongolia

UNFPA AND WHO JOINT INITIATIVE

In an effort to improve access to quality essential reproductive health (RH) medicines and medical devices,
WHO, UNFPA and partners are engaged in a series of activities aimed at promoting harmonized global
standards and technical assistance, developing guidance on sourcing good quality suppliers and products,
building procurement capacity in resource-limited countries, and removing barriers in the appropriate use of
these products.

These efforts are complementary to the objectives of the UNFPA Global Programme to Enhance Reproductive
Health Commodity Security, launched in November 2006. In 2007, Mongolia is selected one of first nine
countries to receive support from the Global RHCS Programme. The Global RHCS Programme is designed to
ensure that Reproductive Health commodity needs are met consistently and reliably for all who need them, and
to facilitate linkages between programmes and partners to enhance the capacity of national stakeholders to
improve systems for RH commodity supply, quality of care, demand and access to products and services.

A well-functioning supply chain capable of selecting, forecasting, quantifying, financing, procuring, and
delivering the medicines and related medical devices and consumables needed is a critical element in all efforts to
improve the health and well-being of mothers and children in developing countries.

The UNFPA Global Programme to Enhance Reproductive Health Commodity Security6 was created to provide
a structure for moving beyond ad hoc responses to stock outs of essential RH products towards more
predictable, planned and sustainable country-driven approaches for securing essential supplies and ensuring their
use. Focused at the needs of countries, this programme is intended to create a process that will galvanise,
institutionalise and coordinate national efforts to produce the following results:

• Reproductive health commodity needs met consistently and reliably for all who need them;
• Strong linkages between RHCS and national RH and HIV/AIDS programmes and policies;
• Enhanced capacity of national stakeholders and improved systems [particularly for RH commodity
supply, quality of care, demand and access];
• Mainstreaming of RHCS through gradual increases in government-controlled funding to finance
capacity and system enhancement and planned commodity provision;
• Increased national ownership and management of all aspects of RHCS.

Within the broad framework of enhancing RHCS, UNFPA, in collaboration with WHO and partners, plans to
assess the accessibility of some critical RH medicines in some selected countries and assessing their utilization
patterns and rational use. There are anecdotal evidences that some of these medicines are not available in many
facilities and/or they are not properly used and stored. The nine countries, identified as stream 1 countries, by

6
See: UNFPA Global Programme to Enhance Reproductive Health Commodity Security [2007-2011]
http://www.unfpa.org/news/news.cfm?ID=881
28 

 
the UNFPA Global Programme, including Mongolia, are selected for the initial assessment of critical RH
medicines to be undertaken in 2009.

The broad objectives of the assessment are:

• To obtain a snapshot of the current status of access to, quality and rational utilization of selected critical
essential medicines for RH, especially those not routinely monitored through other mechanisms.
• To guide Institutional support and capacity building in the areas RH commodities security.
• To develop core recommendations for country level coordination of supply strategies, quality assurance,
appropriate use of medicines and medical devices and pharmaceutical policy matters.

More specific objectives are:

• Take stock of logistics and information systems of the selected medicines.
• Review the functionality of supporting systems up to consumption of the end user.
• Obtain a snapshot of the current availability, access to, and rational utilization of selected life-saving RH
drugs those not routinely monitored.
• Review the mandate, current function and potential role of relevant departments and institutions to
manage supplies and logistics of RH commodities
• Summarize the current status to guide Institutional support and capacity building in the areas RH
commodities security.
• To develop core recommendations for country level coordination of supply strategies, quality assurance,
appropriate use of targeted medicines and policy matter

The targeted critical life-saving RH medicines

A small basket of tracer medicines not monitored routinely was selected as indicators to identify gaps in
information. The tracer medicines ideally will include those indicated for prevention and management of
anaemia, post-partum haemorrhage, obstructed labour, unsafe abortion and infection, namely:

Oxytocin, Ergometrine, Magnesium Sulfate, Calcium Gluconate, Ampicillin, Gentamycine and

Metronidazole

These medicines are life-saving for maternal health and their unavailability, poor quality, and improper use can
directly result in devastating consequences for the user.

29 

 
Approach and Methodology

UNFPA and WHO jointly developed a generic approach for the review of life-saving RH medicines and utilized
for the assessment in other countries that will be as basic tool for the proposed assessment. The generic
approach will be adapted to the country specific context. Assessment methodology will include document
reviews, key informants interviews, and selected site visits for purposes of tracking the need, demand and supply
of selected critical live-saving RH medicines from entry into the system to the site of use.

Assessment Team

As a first step, UNFPA and WHO propose MOH to nominate specialists to represent MOH and other relevant
authorities in the assessment team with following competencies: 1 supply chain specialist (alternatively
procurement specialist) from pharmaceutical division of MOH, 1 RH/Maternal Health program specialist from
MOH, 1 clinical obstetrician from the professional association and 1 drug quality assurance specialist from
National Professional/Drug Inspectorate Authority.

UNFPA and WHO also propose that a joint fact-finding mission team undertake country visit to Mongolia to
assist to national team in conducting the assessment at national and sub-national level. In addition, a national
consultant will be contracted for one month to document the current status of access to essential RH medicines
will be part of the assessment team.

One program specialist from each UNFPA and WHO also will work as assessment team members. UNFPA will
support one assessment team member from MOH and UNFPA CO focal point to participate in the same
assessment/attachment training in Philippines.

PROPOSED TIMELINES:

Set up a national assessment team: May, 2009

Participation of MOH/UNFPA CO representative in
Philippine assessment 17-30 May
Recruitment of national consultant 2 June-3 July
Document review and preparation for the assessment May-June
UNFPA WHO joint mission 17 June-3 July
Assessment and selected site visits 17 June-3 July
Consolidation of results and writing assessment report July-August
Next steps/dissemination assessment findings September-October

30 

 
Annex B. Mission Schedule

Schedule UNFPA WHO Joint Mission to review Critical Maternal Life-Saving Medicines
Ulaanbaatar, MONGOLIA
17 June-04 July, 2009

Team 1.
Dr. Kabir Ahmed, UNFPA HQ ( Team Leader)
Dr. Buyanjargal.Ya, MOH
Dr. Govind Salik, WHO, Mongolia
Dr. Enkhjargal Khorloo, UNFPA Mongolia
Dr. Altantuya.D. State Inspectorate Agency
Dr. Yanjinsuren, Lecturer of HSUM
Team 2.
Dr. Anna Ridge, WHO Geneva
Ms. Amarjargal Ch, MOH
Dr. Tsevelmaa.B, UNFPA Mongolia
Mr. Kang Nam, Population Center, DPRK
Mr. Kim Kwang Jin, Population Center, DPRK
Dr. Bold A, National Consultant
Dariimaa, Lecturer of HSUM

Date/Time Particulars Venue Responsible

Person
Team 1 Team 2
Wednesday, 17 June
09.30 am Airport Pick up Mr. Kang Nam and Kim Kwang, DPRK Chingges Driver
OM224 and check in Ulaanbaatar Hotel Khaan UNFPA
10.40 pm. KE Airport Pick up Dr. Kabir UNFPA, HQ and check in Airport Driver
Ulaanbaatar Hotel UNFPA
Thursday, 18 June
8.45 am Hotel Pick up and proceeds to UNFPA Mongolia CO Driver
9.00-9.30 Meeting with UNFPA OIC UNFPA CO
9.30-10.00 UNFPA CO All Staff Meeting UNFPA CO
10.30 – 12.30 Joint Mission Team Work UNFPA CO A. Bold
• Planning
• Review the assessment tool
• Documentary review
1.00-2.00 Lunch break
2.30 – 5.30 Team work continues UNFPA CO A. Bold
5.45 Back to Hotel Driver
Program for Friday, 19 June
TBC Pick up Dr. Anna Ridge, WHO and check in Ulaanbaatar Chingges Driver
Hotel Khaan WHO
Airport
9.45 am Hotel pick up and proceeds to MOH Driver
10.00– 11.00 Combined meeting chaired by Vice Minister of Health MOH Ch. Amarjargal,
(Heads of Departments of Medical Services and Public MOH
Health Policy Implementation Coordination, OICs,
Representatives of UNFPA, WHO, UNICEF, HSMP
IMU)
11.00-12.30 Individual meetings with technical staff of MOH MOH Ch. Amarjargal,
11.00-11.30 meeting with Ya.Byanjargal, OIC, MoH MOH
11.30-12.00 meeting with HSMP team A.Bold
12.00-12.30 any additional meeting will be determined in Buyanjargal
the morning
1.00-2.00 Lunch meeting with Head of ObGyne Department, A.Bold, Enkhmaa
HSUM
(Prof.Jav, Kabir, Anna, Kang Nam Ill, Kim Kwong Jin,
Enkhjargal, Bold)
2.30– 3.30 Meeting with Head and OICs of Division for Medicine and MOH Ch. Amarjargal,
Medical Devices Policy, MOH and Chief and officials of MOH
Drug Registration and Information Division, the Health
Agency under MOH

31 

 
 (Ch.Munkhdelger, Head of Pharmacy and Medcal devices
Division, 4 staff)

4.00-6:00 Meeting with Director and relevant officials of State SPIA D. Altantuya
Professional (Drug ) Inspectorate and representatives from
city and district branches
(D.Gunibazar, Deputy director of SPI, D.Oyunchimeg,
Head of Health and Education Dept, 5 staff)
6.15 Back to Hotel
Program for Saturday, 20 June
10:00-1:00 Team 1. Visit MONOS Team 2. Visit MEIC Team 1 Altantuya
supermarket, 3rd district, supermarket, Bishrelt Team-2 Daariimaa
- Tavin Us pharmacy, 50 - Khonkhondoi pharmacy, Driver for Team 1:
district Urt stagaan Driver for Team 2:
- Khailaast, Khash - Bayanzurh, Amgalan
pharmacy pharmacy

Sunday, 21 June
FREE TIME
Program for Monday, 22 June
8:15 and 8.20 Hotel Pick up Proceeds to WHO office Driver
am
8.30-9.30 Meeting with WHO
10:00-12.00 Visit to MONGOLEMIMPEX company, central MEIC B. Tsevelmaa
warehouse, cold chain Driver for Team 1:
Driver for Team 2:
12:00-1:00 pm Team 1: Facility visit Team 2: Facility visit to Ya. Buyanjargal
Maternal Child Health Maternity Hospital # 1 in Driver for Team 1:
Research Center ObGyne UB Driver for Team 2:
Clinic
1:00-2:00 Lunch Meeting with Dr. Erkhembaatar, General Director Enkhmaa, UNFPA
of MCHRC
2.30-4:30 Team 1. Facility visit to Team 2. Facility visit to Ya. Buyanjargal
Khatagtai Private Maternity District Maternity Hospital
Hospital #3
5.00-6.00 Team 1. Facility visit to Team 2. Facility visit to Kh. Enkhjargal
MSIM (NGO) RH fee for IPPF/MFWA (NGO) RH B. Tsevelmaa -2
service clinic fee for service clinic
6.00 Back to Hotel
Program for Tuesday, 23 June
8:45 am Hotel Pick up and Proceeds to office of “Em holboo” Driver
(Team 1) and 2nd Maternity hospital (Team 2)
9.00-10.45 Team 1: Meeting with Team 2: Meeting with Amarjargal
Mongolian Pharmaceuticals Midwifes Association Buyanjargal
Association Driver for Team 1:
Driver for Team 2:
11.00-12.30 Visit Family Clinic and Visit ANC of Chingeltei A.Bold
pharmacy District Health Center and
pharmacy
1:00-2:30 Lunch
3.00-4.30 Attend in the meeting of WG on EMOC study in the MoH A. Bold

5:00-6.00 Team de-briefing and preparation for field visit UNFPA CO A. Bold
Wednesday, 24 June

Field Team 1. Orkon: Field Team 2. Khentii: Driver Team 1:

Kabir, Enkhjargal, Anna Ridge, Amarjargal, Driver Team 2:
Yanjinsuren, Altantuya Bold, Tsevelmaa, Kang Nam,
Kim Kwan
32 

 
8:15 am Meet UB Hotel main lobby
8:30 Field trip team 1: Proceeds to Field trip team 2: UB hotel
Orkhon aimag Proceeds to Khentii aimag

Facility visit to the rural Facility visit to the rural

Baruunburen soum hospital Erdene soum and meeting
and meeting with service with service providers and
providers and hospital pharmacy staff
pharmacy staff
6.00 pm Arrive in Orkhon aimag and Arrive in Khentii aimag and
check in hotel check in hotel
Thursday, 25 June
9:00 – 10:00 Meeting with Aimag General Meeting with Aimag General
Hospital Director, RH Hospital Director, RH
coordinator coordinator
10:00-12:00 Facility visit to maternity ward Facility visit to maternity
and meeting with service ward and meeting with
providers service providers
12:00-1:00 Visit hospital storage and Visit hospital storage and
meeting with logistician meeting with logistician
1:00 – 2:00 Lunch Break
2:00 – 2:40 Visit MONGOLEMIMPEX Visit MONGOLEMIMPEX
aimag warehouse, meeting aimag warehouse, meeting
with the Director and with the Director and
logistician logistician
3:00 – 3:40 Meeting with aimag Drug Meeting with aimag Drug
Control Staff Control Staff
4:00-5.00 Visit private pharmacies and Visit private pharmacies and
meeting meeting
6:00 Proceeds to Bulgan aimag and Back to hotel
check in hotel
Friday, 26 June
9:00 – 10:00 Meeting with Aimag General Proceed to Umnudelger soum
Hospital Director, RH of Khentii province ( rural
coordinator hospital)
10:00-12:00 Facility visit to maternity ward Visit to Umnudelger soum
and meeting with service hospital and pharmacy
providers
12:00-1:00 Visit hospital storage and Check in hotel
meeting with logistician
1:00 – 2:00 Lunch Break
2:00 – 2:40 Visit MONGOLEMIMPEX
aimag warehouse, meeting
with the Director and
logistician
3:00 – 3:40 Meeting with aimag Drug
Control Staff
4:00-5.00 Visit private pharmacies and
meeting
Saturday, 27 June
8.00 Proceeds to Khishig-Undur 10.00 Proceed to Baganuur
soum of Bulgan aimag district
Visit to Khishig-Undur soum 3.00 pm Arrive in Baganuur
hospital and pharmacy district check in hotel
12.00-1.00 Lunch 3.00-4.00 pm Lunch
pm
1.00 pm Proceed to Dashinchilen soum 3.00-6.00 pm Team work to
of Bulgan aimag fill summary sheets
Visit to Dashinchilen soum 6.00 pm Dinner
hospital and pharmacy, meet
33 

 
 with community health post
Check in hotel
Sunday, 28 June
9.00 am Proceeds to UB 9.00am-12.00 pm Facility visit
to Baganuur district hospital
and pharmacy
12.00-1.00pm Lunch
1.00 pm Proceeds to UB
12:00 pm Arrive in UB and check in 15.00 pm Arrive in UB and
hotel check in hotel
Monday, 29 June
9.00-1.00 Team work Ulaanbaatar A.Bold
• Identification of Information/Data Gap and Hotel Enkhmaa,
verification UNFPA
• Discussion and drafting of the Mission report
1.00-2.00 Lunch
2.00-6.00 Continues
Tuesday, 30 June
9.00-1.00 Team work Ulaanbaatar A.Bold
am • Preparation for Dissemination Forum Hotel Enkhmaa,
1.00-2.00 Lunch UNFPA
2:00-6.00 Continues
Wednesday, 1 July
10.00-12.30 Dissemination Meeting MOH Buyanjargal, Bold,
Conference Tsevelmaa,
room Enkhmaa
12.30-2.00 Lunch
2:30 – 3:00 De-briefing with UNFPA OIC and WHO Representative
Thursday, 2 July
8.45 Pick up at hotel and proceed to UNFPA CO Driver
9.00-12.30 Work on finalizing draft report UNFPA CO
1.00-2.00 Lunch break
2.30-6.00 Work on finalizing draft report UNFPA CO
6.00 Back to hotel Driver
18.05 Departure of Kang Nam and Kim Kwang Airport UNFPA Driver
OM223
Friday, 3 July
00.20 KE Departure of Dr. Kabir Airport UNFPA Driver
Saturday, 4 July
TBC Departure of Anna Ridge Airport WHO Driver

34 

 
Annex C. List of People Met
List of people met of TEAM-1:

Name Job title

1. Friday, 19 June 09 Meeting with MOH and HSUM

1 Ya. Buyanjargal OIC Maternal health, MOH
2 Dr.Yanjisuren Lecturer, Ob&Gyn Department, HSUM
3 Prof.B.Jav Head of Ob&Gyn Department, HSUM,
4 Ch.Munkhdelger Head of Pharmacy and Medical Devices
Department, MOH
5 Ch.Amarjargal OIC PMDD, MOH
6 P.Tsetsgee OIC PMDD, MOH
2. Friday, 19 June 09 Meeting with Drug Registration Unit of Health Department, GIA, MOH
1 D.Uranchimeg Head of Unit
2 Z.Zuzaan OIC, for Drug registration
3 M.Munkhzul OIC, for Database of Drug registration
3. Friday, 19 June 09 Meeting with State General Inspection Agency of the Government of Mongolia
1 D.Gunibazar Deputy Chairman
2 D.Altantuya Senior inspector of drug quality
3 L.Battsetseg Treatment and diagnosis quality inspector
4 Ch.Otgontsetseg Inspector of drug and bio preparation
5 J.Gambaa Treatment and diagnosis quality inspector
6 L. Altantsetseg Inspector of drug and bio preparation
4. Saturday, 20 June 09 Visit to MEIC, “Pharma” Supermarket
1 P.Oyuntsetseg Assistant pharmacist
2 N.Nyamsuren Pharmacist
3 S.Amarbayasgalan Cashier
4 B.Munkhsolongo Pharmacist
5. “Khonkhondoi” Pharmasy –Urt tsagaan
1 Ts.Sarantuya Assistant pharmacist
6. “Sumber” Pharmacy – Bayanzurkh district Amgalan
1 G.Tsatsral Head of pharmacy
2 M.Otgontsetseg Assistant pharmacist
3 Ts.Ulziiburen Assistant pharmacist
7. Saturday, 20 June Ulaanbaatar city, Tavin Us Pharma
1 E. Odgerel Pharmacist
2 B.Dashdulam Assistant
8. Saturday, 20 June Euro-Pharma Drug Wholesale Agency
1 B.Badamjunai Pharmacist
2 U.Munkh-Orgil Assistant pharmacist
3 D.Sarantuya Assistant
4 A.Yanjmaa Client
9. Saturday, 20 June Magda branch of Monos Drug Wholesale Agency
1 B.Sergelen Medicine Dispenser
10. Saturday, 20 June Khash Pharmacy in Khailaast
1 D.Erdenetsetseg Director of pharmacy
11. Monday, 22 June, Visit to Mongolemimpex company
1 Mr.Anar Foreign Trade Officer
2 Ms.Khongorzul Foreign Trade Officer
3 Ms.Chantsal Officer for Goods
4 Ms.Altantsetseg Quality manager
5 Ms.Bilguun Officer for Goods
12. Monday, 22 June, Maternal and Child Health Research Centre, Obstetrics and Gynecology Clinic
1 T.Erkhembaatar General Director of MCHRC
2 G.Sanjdorj Director

35 

 
 3 S.Bayasgalan Quality manager
4 Ts.Solongo Pharmacist
5 S.Amarmandakh Advisor Doctor of Reanimation Department
6 B.Tsedenkhorloo Advisor Doctor of 1st Maternity Ward
7 L.Chuluunbadam Midwife of 1st Maternity Ward
8 Kh.Baldanjav Director of Hospital Pharmacy
9 D.Ganchimeg Medicine Dispenser
7. Monday, 22 June, Ach Pharm Trade pharmacy
1 S.Altantuya Medicine Dispenser
8. Monday, 22 June, Khatagtai Private Maternity Hospital
1 A.Otgonbold Advisor Doctor
2 D.Ichinkhorloo Director
3 L.Ayurzana Anesthesiologist
4 Kh.Daariimaa Ob&Gyn doctor
9. Monday, 22 June, Marie Stops NGO Clinic
1 E.Bolormaa Manager
2 I.Oyumaa Nurse
3 T.Davaajav Ob&Gyn doctor
4 S.Unurmaa Ob&Gyn doctor
5 Ts.Erdenebat Project manager
10. Tuesday, 23 June, United Association of Pharmacies of Mongolia
1 O.Damba Executive director
11. Wednesday, 24 June, Visit to Baruunburen soum hospital of Selenge aimag
1 N.Otgonsuren Hospital director
2 S.Battur Midwife
12. Thursday, 25 June, Visit to Orkhon aimag Health Department
1 G.Gankhuyag Head of Department
2 Dr.Enkhjargal Officer for training and IEC
3 U.Delgermaa RH Coordinator
4 Ms.Oyunchimeg Officer for Medicine
13. Thursday, 25 June, Visit to Orkhon aimag General Hospital
1 L.Ganbold Advisor doctor of Ob&Gyn Department
2 Dr.Erdenebulgan Head of Ob&Gyn Department
3 Dr.Darisuren Ob&Gyn doctor of 2nd Maternity ward
4 S.Lkhagvasuren Ob&Gyn doctor of 2nd Maternity ward
5 Ts.Tuya Midwife of 1st Maternity ward
6 D.Uyanga Neonatologist
7 Sh.Bayarmaa Director of Pharmacy
8 B.Baasanbat Pharmacist
14. Thursday, 25 June, Visit to Orkhon Medicine Supply Co LTD
1 Sh.Jiidee Director
2 P.Baterdene General pharmacist
3 B.Oyunzul Director of pharmacy
15. Thursday, 25 June, Visit to Mednbulag FGP of Orkhon aimag
1 D.Oyunsaikhan Director of FGP
2 T.Enkhtuya Family doctor
16. Thursday, 25 June, Visit to Enkhjin clinic
1 Dr.Buyan-Ulzii Ob&Gyn doctor
17. Thursday, 25 June, Visit to Orkhon branch of Monos Pharm Trade company
1 Yu. Narantuya Director
2 J.Tsetsgee Sale person of supermarket
18. Thursday, 25 June, Visit to State Inspection Department of Orkhon aimag
1 B.Buyantsogt Head of Department for health, education, food,
animal husbandry and manufacture inspections
2 D.Erdenetungalag Inspector for diagnosis and treatment quality
inspection
3 Yo.Erdenechimeg Inspector for medicine and bio-preparation quality
inspection

36 

 
 19. Friday, 26 June, Visit to Bulgan Aimag Health Department
1 B. Myagmar Head of Department
2 M. Undarmaa RH Coordinator
3 U. Baasansuren Officer for Medicine
20. Friday, 26 June, Visit to Bulgan Aimag General Hospital
1 B. Shijirbaatar Director of Aimag General Hospital
2 R.Odgaram Quality manager
3 V.Manaljav Ob&Gyn doctor
4 Dr.Tsogtgerel Advisor doctor
5 Ya.Selenge Midwife
6 B.Enkhchimeg Pharmacist
21. Friday, 26 June, Visit to branch of Mongolemimpex company in Bulgan aimag
1 A. Oyungerel Director
2 G.Battsetseg Officer for trade and supply
22. Friday, 26 June, Visit to Tavan Od pharmacy
1 Yo. Khandsuren Director, pharmacist
2 L.Delgermaa Medicine Dispenser
23. Saturday, 27 June, Visit to Khishig-Undur Inter-soum Hospital of Bulgan aimag
1 O.Shurenchuluun Director
2 N.Saranchimeg Midwife
3 N.Otgonchimeg Midwife
4 P.Otgontuya Director of pharmacy
24. Saturday, 27 June, Visit to Dashinchilen soum Hospital of Bulgan aimag
1 N.Munkhbaatar Midwife
2 Z.Dogsmaa Statistician feldsher
5 T. Oyunchimeg Internal doctor
6 J.Oyumaa Director of pharmacy
List of people met of TEAM-2:
Name Job title

7. Monday, 22 June, 2009 Visit to MongolemImpex Concern (MEIC)

1 G.Anar Foreign relations manager
2 Sh.Khongorzul Director of Foreign relations and supply
3 D.Sarangerel Director of Administration Unit
8. Monday, 22 June, 2009 Visit to Maternity Hospital #1
1 Dr.Purevsukh General Doctor
2 Ms. Ariunaa Pharmacist
3 Dr.Lkhamaakhuu Statistician doctor
4 Dr.T.Ania Inspection unit
5 Ms.Tseinkhorloo Midwife, delivery ward -1
6 B.Gantuya Midwife, delivery ward-2
7 L.Tsermaa Midwife, delivery ward-2
8 N.Dolgorsuren Nurse, reanimation unit
9 Dr.Tserensambuu Head of delivery ward-1
10 Ms.Dulamsuren Midwife, delivery ward -1
11 B.Chimgee Manager of administration unit
12 L.Munkhdelger Midwife, delivery ward -1
9. Monday, 22 June, 2009 Visit to Maternity Hospital #3
1 Dr.Ganbold Deputy director
2 Ms. Altantuya Statistician doctor
3 Ms. Enkhsaikhan Manager
4 Ms. Khandsuren Pharmacist
10. Monday, 22 June, 2009 Visit to Mongolian Family Welfare Association
1 Ch.Semjidmaa Deputy Director
2 Dr.S.Demberelsuren Ob&Gyn doctor
3 D.Enkh-Oyun Project Manager (Hospital)
4 T.Gerelmaa Project Manager (Mobile service)
5 B.Munkhtsetseg Project Manager(Adolescent +HIV/AIDS)

37 

 
 6 G.Munkhzul Finance Manager
7 Mr.Zolbayar IEC officer
8 Ms.Narantsetseg Pharmacist (part time)
9 Ms.Tsetsegmaa Midwife
10 Ms.Ganchimeg Nurse
11 Ms.Dulamjav Assistant
12 J.Batbold Driver
11. Tuesday, 23 June, 2009 Meeting with Mongolian Midwifes Association
1 S. Davaasuren Midwife, Maternity Hospital #2
2 Ms.Ichinkhorloo Midwife, Maternity Hospital #1
3 Ms.Alinch bish Midwife, Maternity Hospital #2
4 Ms.Oyungerel Midwife, Maternity Hospital #1
12. Tuesday, 23 June, 2009 Visit to ANC of Chingeltei District Health Alliance and Pharmacy
1 D.Nemekhbat Director of Outpatient Department
2 B.Ulambayar Foreign relation manager
3 Dr.Ariumaa Ob&Gyn doctor
4 Dr.Dorjkhand Ob&Gyn doctor
13. Wednesday, 24 June, 2009 Visit to Erdene soum hospital of Tuv aimag
1 D. Badamkhand Director, General doctor
2 D.Narantsetseg Midwife
3 Ts.Tserenkhand Nurse
4 Ts.Ulzii Nurse
Thursday, 25 June, Visit to Khentii Aimag General Hospital
1 T.Bolormaa Director of Aimag Health Department
2 T.Urnaa Deputy Director AHD
3 N.Ariunaa Advisor doctor
4 J.Kherlentsetseg Quality manager of Treatment
5 Ts. Amgalanbuyan Ob&Gyn doctor
6 T.Ouynbileg Head of Ob&Gyn department
7 Kh.Mandakh Neonatologist
8 D.Purevdorj Ob&Gyn doctor
9 Ts.Jadambaa Midwife (RH)
10 Ch.Enkh-Amgalan Ob&Gyn doctor
11 D.Munkhchimeg Officer of AHD
Friday, 26 June, Visit to Umnudelger soum hospital of Khentii aimag
1 D.Munguntsatsral Director
2 J.Atartuya Ob&Gyn doctor
3 D.Ichinnorov Midwife
4 Dr.Javsanragchaa Pediatrician
5 B. Uugantstseg Officer of Public Health
Sunday, 28 June, Baganuur District Hospital of UB city
1 T.Budmaa Head of Ob&Gyn department
2 N.Selengesuljee Neonatologist
3 B.Bumaa Senior nurse
4 D.Shinebayar General practitioner
5 J.Narantsetseg Midwife
6 D.Altanzagas Midwife
7 D.Sarantuya Midwife
8 T.Altanzul Midwife
9 D.Enkhtuya Nurse
10 P. Battsetseg Nurse
11 Kh.Narantsetseg Nurse
12 B.Bayarsaikhan Nurse
13 P. Erdenetsetseg Nurse
14 D.Ouyntuya Nurse
15 B.Lkhagva Nurse
16 Dr.Badamtsetseg General practitioner

38 

 
Annex D. Key Documents Reviewed
1. Annual report, NSO, 2008
2. Assessment of medicines regulatory system, Mission Report, Mr Jun Yoshida, Technical Officer, Mr
EshetuWondemagegnehu, Technical Officer and Focal PersonWHO Headquarters, Ulaanbaatar, Mongolia, June
2005
3. Clinical guidelines, ADB, 2005
4. Diagnosis and treatment of newborns, WHO
5. Ensuring drug accessibility, quality and safety, presented by Ms T. Gandhi, Minister of Health at the 5th
Conference of the National Drug Policy.
6. Essential and Complementary Package of Services, MoH, Mongolia, 2004
7. Integrated Management of Pregnancy and Childbirth Pregnancy, Childbirth, Postpartum and Newborn Care: A
guide for essential practice, World Health Organization, Geneva, 2006
8. Implementation of Clinical Pharmacy Curriculum in the Health Sciences University of Mongolia, , Mission
Report, Dr Syed Azhar Syed Sulaiman, WHO Consultant, Ulaanbaatar, Mongolia, September 2005
9. Good Manufacturing Practices (GMP), Mission Report, Mr Alain Kupferman
WHO Consultant, Ulaanbaatar, Mongolia, July 2007
10. Guideline for pregnancy, delivery, postnatal and neonatal care, WHO, 2002
11. Government Policy on Drugs, State Great Khural Resolution No. 68 of 2002
12. Health Sector Strategic Master Plan, Implementation Framework, 2006-2010, MoH, Mongolia
13. Health Indicators, 2008, MoH, Mongolia
14. Law of Mongolia on Health, 1998
15. Law of Mongolia on Medicines and Medical Devices, 1998
16. Management of pregnancy and delivery complications, UNFPA, WHO, 2001
17. Maternal mortality reduction strategy, 2005-2010
18. Mid-term Review of UNFPA’s 4th Country Programme of Assistance for Mongolia, 2007-2011, May 2009
19. Mongolia Pharmaceutical Sector Assessment Report, Ministry of Health, December 2004;
20. National RH Commodity Security Strategy 2009-2013, MoH, Mongolia, 2009

21. Order of the Minister of Health Mongolia: Approval of the revised rules for drug registration, 7 July 2003,
No.177;
22. Protocol of inspection;
23. Revised Drug Law (draft);
24. Rule for issuing import license for medicines and medical equipment (Appendix of the degree 296 of the
Minister of Health, 13 December 2002)
25. Rules of the National Drug Council (Appendix 2 to the Government Resolution 121 of 1998);
26. Rules and operational procedures for inspection 2003 (Order of the Minister of Inspection);
27. The Introduction of the State Specialized Inspection Agency, Regulatory Agency of the Government of
Mongolia;
28. Third National Reproductive Health Programme, 2007-2011
29. The Fifth List of National Essential Drugs, 2005
30. United Nations Joint Programme on Maternal and Newborn Health in Mongolia, 2009-2011
31. 1 World Health Organization. 2000. Integrated Management of Pregnancy and Childbirth. Managing Complications in
Pregnancy and Childbirth. A guide for midwives and doctors. Geneva: World Health Organization
32. 1 World Health Organization. 2006. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. 2nd ed.
Geneva: World Health Organization
33. Why did women die?, ADB, MCHRC, 2006

39 

 
 Annex E. Checklists (Health Facility; Medical Stores/Pharmacies; National Level questionnaire for
RH Medicine Procurement, Product Specific Survey)

REPRODUCTIVE HEALTH COMMODITIES SURVEY ( Health Facility Survey )

Country: City: Date of survey:

Name of health facility

Data collector name: Contact email:

SPECIALIZED HOSPITAL SOUM HOSPITAL Maternity Ward

Health facility type:
DISTRICTHOSPITAL PRIVATE CLINIC Obs and Gynae ward

AIMAG HOSPITAL Labour ward Neonatal unit

Other (specify)…………………………………………………………………………..

1. Assessing level of need and demand

Estimated workload of facility Number in last year Comment on how numbers were verified
(June 2008 - June 2009) (Records reviewed or verbal report)
Pregnant women attending for ANC at facility

Women who deliver at facility

Number of cases of pre-eclampsia in last year

Number of cases of eclampsia in last year

Number of cases of PPH in last year

Number of cases of maternal sepsis/severe infections in last

year

Number of cases of neonatal sepsis/severe infections in last

year

• Does the facility provide 24 hour care? Yes No

• Is the facility a designated provider of emergency obstetric care? Yes No

Please indicate the total number of healthcare workers currently employed for the management of obstetric and neonatal care in the health facility:

Current members of staff Total number Staff on duty at time of visit

Obstetrician
General Doctor
Medical officer
Midwife
Staff Nurse
Healthcare assistant
Other (please specify)

2. Availability of treatment guidelines/protocols/training manual

a) Copy of Essential Medicine List available and year of publication:

Yes No

Year of publication:_______________

b) Copy of Standard Treatment Guideline available and year of publication:

40 

 
 Yes No

Year of publication:_______________

Treatment guideline/protocol/training manual available Yes No Displayed/ available in Year published Organization(s) involved in producing
for: maternity ward/delivery guideline
room
Active Management of the Third Stage of Labour (AMTSL)

Post Partum Haemorrhage (PPH)

Pre-eclampsia and eclampsia

Maternal sepsis/severe infections

Neonatal sepsis/severe infections

Additional comments regarding treatment guidelines/protocols in use at the facility:

……………………………………………………………………………………………………………………………………………………………………………………………………………………

escription Review

Verify and copy the patient record/prescription if available of the last three patients when these drugs have been used. When reviewing the patient record, check:
• Indication for requested medicine
• Dose of medicine prescribed
• Evidence that dose was actually administered (e.g. signature of staff member who administered dose)
• If indication was pre-eclampsia/eclampsia check that BP and level of proteinuria were recorded + other signs and symptoms of pre-eclampsia/eclampsia (e.g. headache, seizures, confusion,
oedema, nausea and vomiting)
• If indication was PPH check that estimated blood loss, BP and pulse were recorded
• If indication was severe maternal infection check that temperature and BP were recorded

Prescription/Patient record according to Treatment Guideline

Prescription/Patient record (tick most appropriate box for each)
1
Indication for use Dose

Recorded Recorded Uncertain Prescribed Correctly Prescribed Uncertain

correctly Incorrectly Incorrect
MgSO4

Oxytocin

Ergometrine

Ampicillin

Gentamicin

Metronidazole

Prescription/Patient record according to Treatment Guideline

Prescription/Patient record (tick most appropriate box for each)
2
Indication for use Dose

Recorded Recorded Uncertain Prescribed Correctly Prescribed Uncertain

correctly Incorrectly Incorrect
MgSO4

Oxytocin

Ergometrine

Ampicillin

Gentamicin

Metronidazole

Prescription/Patient record according to Treatment Guideline

Prescription/Patient record 3 (tick most appropriate box for each)

Indication for use Dose

Recorded Recorded Uncertain Prescribed Correctly Prescribed Uncertain

correctly Incorrectly Incorrect
MgSO4

Oxytocin

Ergometrine

Ampicillin

Gentamicin

Metronidazole

41 

 
4. Questions for staff at facility:

1. What are the indications for using these medications?

2. What dose should be given?
3. What are the contraindications for these medications?

MgSO4 Oxytocin Ergometrine Ampicillin injection Gentamicin injection Metronidazole injection

injection injection

Indications Severe pre-eclampsia and
eclampsia
Dose Loading: dose 4g IV +
10g IM; followed by
maintenance dose of 5g
IM every 4 hours for 24
hours
Contraindications Myasthesia gravis
Nifedipine within 4
hours
50 % MgSO4 must be
dililuted to 20% solution
prior to IV
administration
Prevention of PPH
Treatment of PPH
Prevention: 10 IU IM
immediately after
birth
Treatment: 10 IU IM,
followed by IV
infusion (Total 40 IU)
Do not give as IV
bolus
If heavy bleeding after Severe abdominal pain; Severe abdominal pain; Severe abdominal pain;
Oxytocin dangerous fever/very dangerous fever/very dangerous fever/very
severe febrile disease; severe febrile disease; severe febrile disease;
complicated abortion, complicated abortion, complicated abortion,
uterine and fetal infection uterine and fetal infection uterine and fetal infection
IM/IV 200 mcg slowly First dose 2 g IM/IV. 80 mg IM every 8 hours 500 mg or 100 ml infusion
Continuing dose: repeat Then 1g IV/IM every 6 (give until the woman is IV every 8 hours (give until
200 mcg IM after 15 hours (give until the fever free for 48hrs) the woman is fever free for
minutes if heavy woman is fever free for 48hrs)
bleeding persists. Max 5 48hrs)
doses, total 1.0 mg.
Hypertension Penicillin allergy Myasthenia gravis Do not give IM
Pre-eclampsia eclampsia
Heart disease
Rhesus negative

Using the above matrix, fill in the following tables for up to 3 members of staff on duty at the time of the visit:

Designation of staff member________________________________________

Responses to questions (tick most appropriate box for each)

Indication for use Dose Contraindications

Level of knowledge All Some None Correct Incorrect All Some None

MgSO4

Oxytocin

Ergometrine

Ampicillin

Gentamicin

Metronidazole

Designation of staff member________________________________________

Responses to questions (tick most appropriate box for each)

Indication for use Dose Contraindications

Level of knowledge All Some None Correct Incorrect All Some None

MgSO4

Oxytocin

Ergometrine

Ampicillin

Gentamicin

Metronidazole

Designation of staff member________________________________________

Responses to questions (tick most appropriate box for each)

Indication for use Dose Contraindications

Level of knowledge All Some None Correct Incorrect All Some None

42 

 
MgSO4

Oxytocin

Ergometrine

Ampicillin

Gentamicin

Metronidazole

43 

 
 REPRODUCTIVE HEALTH COMMODITIES SURVEY
(MEDICAL STORES/PHARMACIES)

Country: City: Date of survey:

Name of facility

Data collector name: Contact email:

SPECIALIZED HOSPITAL SOUM HOSPITAL Maternity Ward

Facility type:
DISTRICT HOSPITAL PRIVATE CLINIC Obs and Gynae ward

AIMAG HOSPITAL Labour ward Neonatal unit

GOVERNMENT MEDICAL STORE HOSPITAL PHARMACY (private)

HOSPITAL PHARMACY (Public) PRIVATE PHARMACY (outside health facility)

Other (specify)……………………..…………………………..

Please indicate the level of training and number of pharmacists currently employed by the facility:

Current members of staff Level of training Total number Staff on duty at time of visit
Pharmacist

Assistant Pharmacist

Other (please specify)

How are they dispensing medicines?

Yes No

Prescription required

Instructions for use given

Other information provided (if yes, please specify)

Description of medicine supply systems

INTRODUCTORY QUESTIONS
1 Describe how medicines are procured at the moment:
• How are products ordered ?

• Where do they come from ?

• How often are orders placed?

• How are suppliers selected ?

• How are payments made ?

• How is the quality assured ?

• What procurement fees apply ? What fees do the facility

pay/charge ?
2 What is the policy on donations ? How are donated medicines integrated
into the supply chain ?

3 Describe how inventory control is done

• Stock cards or computerized ?

44 

 
 • How long ( number of years ) records kept at the facility?

• Do you produce monthly reports on quantities used?

• If yes, where is this information sent to?

4 Who is responsible for the planning of procurement?

5 Provide a description of the tender cycle

• Tender duration (e.g. 1yr, 2yrs)
• Record current tender start date
• Record current tender end date

6 How are procurement quantities estimated ? ( √ Tick all that apply )

• Based on population data

• Based on consumption rate

• Based on own past experience

• Other, describe

STORAGE CONDITIONS CHECKLIST - indicate Yes or No

1 Medicines securely stored, locked

2 Temperature control as best as possible ( curtain, painted window, location

of store )

3 Shelving available

4 Space adequate ( estimate on the day of visit )

5 Arrangement of stock according to generic name

6 Medicines stored off the floor

7 Fridge available for heat sensitive products other than vaccines

8 Oxytocin injection stored according to storage instructions on

manufacturer's label

9 Ergometrine injection stored according to storage instructions on

manufacturer's label

Other comments:

……………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………........
………………………………………………

45 

 
National Level questionnaire for RH Medicine Procurement study

1. Name of country …………………………………………………………

2. Please provide a list of all the formulations registered with the name of the licence holder and date of registration for the following medicines:

Medicine as listed in WHO Registered with DRA Formulation(s) /strength(s) Date of registration Name of licence holder
EML registered

Magnesium Sulphate injection

Oxytocin injection

Ergometrine injection

3. Describe the public sector procurement process for essential medicines, including the following information:
• Who buys
• Who supplies
• Level of healthcare distribution
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
………….

4. Organization(s) in-charge of public sector procurement of RH study medicines (tick all those that apply):

Organization Procuring RH study medicines Procuring other EML medicines

Ministry of Health
UNICEF
UNFPA
WHO
Other (please specify)

5. Procurement data

a) Please provide information about tender cycle for RH study medicines:

• Tender duration………………………………………………………………….
• Tender start date…………………………………………………………………
• Tender end date…………………………………………………………………..
Please provide data for medicines included in government tender documents:

Procurement 2003
Medicine Total volume procured Value per tender cycle (total Purchase price (excluding tax, freight and insurance)
(number of vials/tablets) value procured in tender cycle) per pack
Pack size Price (state currency)
Magnesium Sulphate injection

Oxytocin injection

Ergometrine injection

Please provide data for medicines supplied by donors in the same period:

Procurement 2003
Medicine Name of supplier Total volume procured (number of Value per tender cycle (total value
vials/tablets) procured in tender cycle)
Magnesium Sulphate injection

Oxytocin injection

Ergometrine injection

Please provide data for medicines included in government tender documents:

Procurement 2006
Medicine Total volume procured Value per tender cycle (total Purchase price (excluding tax, freight and insurance)
(number of vials/tablets) value procured in tender cycle) per pack

46 

 
 Pack size Price (state currency)
Magnesium Sulphate injection

Oxytocin injection

Ergometrine injection

Please provide data for medicines supplied by donors in the same period:

Procurement 2006
Medicine Name of supplier Total volume procured (number of Value per tender cycle (total value
vials/tablets) procured in tender cycle)
Magnesium Sulphate injection

Oxytocin injection

Ergometrine injection

Please provide data for medicines included in government tender documents:

Medicine
Magnesium Sulphate injection
Procurement 2007
Total volume procured Value per tender cycle (total Purchase price (excluding tax, freight and insurance)
(number of vials/tablets) value procured in tender cycle) per pack
Pack size Price (state currency)

Oxytocin injection

Ergometrine injection

Please provide data for medicines supplied by donors in the same period:

Procurement 2007
Medicine Name of supplier Total volume procured (number of Value per tender cycle (total value
vials/tablets) procured in tender cycle)
Magnesium Sulphate injection

Oxytocin injection

Ergometrine injection

Please provide data for medicines included in government tender documents:

Medicine
Magnesium Sulphate injection
Procurement 2008
Total volume procured Value per tender cycle (total Purchase price (excluding tax, freight and insurance)
(number of vials/tablets) value procured in tender cycle) per pack
Pack size Price (state currency)

Oxytocin injection

Ergometrine injection

Please provide data for medicines supplied by donors in the same period:

Procurement 2008
Medicine Name of supplier Total volume procured (number of Value per tender cycle (total value
vials/tablets) procured in tender cycle)
Magnesium Sulphate injection

Oxytocin injection

Ergometrine injection

47 

 
 REPRODUCTIVE HEALTH COMMODITIES SURVEY ( Facility Survey - Product Specific )

Country: City: Date of survey:

Name of facility

Data collector name: Contact email:

SPECIALIZED HOSPITAL SOUM HOSPITAL Maternity Ward

Facility type:
DISTRICT HOSPITAL PRIVATE CLINIC Obs and Gynae ward

AIMAG HOSPITAL Labour ward Neonatal unit

GOVERNMENT MEDICAL STORE HOSPITAL PHARMACY (private)

HOSPITAL PHARMACY (Public) PRIVATE PHARMACY (outside health facility)

Other (specify)……………………..…………………………..

PRODUCT SPECIFIC QUESTIONS Magnesium Calcium Oxytocin Ergometrine Ampicillin Gentamicin Metronida
Sulphate Gluconate injection injection injection injection zole
injection injection injection
1 Supplier of product on shelf ( manufacturer )**

2 Strength of product on shelf (mg)

3 Volume of product on shelf (ml/vial)
4 Number of vials / tablets per pack (pack size)
5 Expiration date of product on the shelf
6 Total number of packs on the shelf on day of
visit
7 Total number of vials procured

a • In 2008

b • In 2007

c • In 2006

d • In 2003

8 Value procured (state currency procured in)

a • Last 12 months

b • Last 3 years

9 Are there problems with expired stock

a • Number of expired vials/tablets
on day of visit
b • Number of expired vials/tablets
in last 12 months
10 Number of days out of stock
a • Last 3 months

b • Last 12 months
11 Purchase price as per invoice, excl freight,
insurance

12 How much will patient pay today (per vial /

tablet or capsule) ?

13 How often are stocks checked by a higher

authority? (record date of last stock check and
name/designation of higher authority)
• Every 6 months
• Once a year
• Never
• Other
**All supplier/manufacturer names of the individual medicines available on the day of the visit should be recorded, including expiration date and cost of the product

48 

 
Annex F. List of Acronyms
UNFPA United Nation’s Fund for Population Activities

RH Reproductive Health

MOH Ministry of Health,

MSI Marie Stops International Mongolia

CO Country Office

HQ Headquarter

AVSC Int The Association for Voluntary Surgical Contraception International

HMIS Health Management Information System

USD United States Dollar

GIA Government Implementation Agency

FGP Family Group Practices

MEIC Mongolemimpex Concern

MFOG Mongolian Federation of Obstetrics and Gynecology Doctors

IV Intravenus

IM Intramuscular

ADB Asian Development Bank

WB World Bank

WHO World Health Organization

UNICEF The United Nations Children's Fund

JICWELS Japan International Corporation of Welfare Services,

MFWA Mongolian Family Welfare Association

UB Ulaanbaatar

IPPF International Planned Parenthood Federation

RDF Revolving Drug Fund

NFS Not for sale

UNDAF United Nations Development Assistance Framework

RHCS Reproductive Health Commodity Security

HSUM Health Sciences University of Mongolia

OIC Officer in Charge

EML Essential Medicines List

IU International Unit

49 

 
AMTSL Active Management of Third Stage of Labour

DTC Drug and Therapeutic Committee

MoF Ministry of Finance

LMIS Logistics Management Information System

MCH Maternal and Child Health

NSO National Statistics Office

PPH Post-partum Haemorrhage

NGO Non Governmental Organizaion

HSMP Health Sector Master Plan

ANC Antenatal care

STGs Standard Treatment Guidelines

Ob&Gyn Obstetrics and Gynecology

MCHRC Maternal and Child Health Research Centre

PCPNC The Pregnancy, Childbirth, Postpartum and Neonatal Care

DPRK Democratic People’s Republic of Korea

IMPAC Integrated Management of Pregnancy and Childbirth

WG Working group

EmOC Basic Emergency Obstetric Care

50 

 
 Annex G. Map of Mongolia

51 

 
Annex H. Organizational Structure of MOH (with focus on drug supply)

Cabinet

Ministry of Health
General State
Inspectorate Agency

Specialized Centres and Dept of Health, State

Clinics Implementation Agency
(Drug registration)

Tertiary Level
Ulaanbaatar Specialized Regional Diagnostic
Mayor’s Office Centres/Hospitals Treatment Centres

City Department of Private Sector Drug Wholesale

State Inspectorate Agencies

Secondary Level UB City Health District Mayor’s Branches

Aimag Mayor’s
Office
Department Office

Aimag Health
District Health Department
District Department of Aimag Department of
Alliance
State Inspectorate State Inspectorate
Aimag hospital
Private Sector District hospital and and ambulatory Private Sector
ambulatories

Khoroo Mayor’s Soum Mayor’s

Primary Level Office Office

Private street
pharmacies Soum/ Intersoum Revolving
Sector hospitals Drug Funds
FGPs FGPs

Bagh feldsher 52 

posts
Annex I. List of People Attended/Participated in Dissemination Meeting
29 June 2009, MoH, Meeting Hall

# Name and Organization Position

Ministry of Health
1 S.Tugsdelger Head of Public Health Policy Implementation Department
2 Ch.Munkhdelger Head of Medicine and Medical Devices Division
3 Ya.Amarjargal Deputy Head of Medical Services Policy Implementation
Department
4 G. Tsetsegdari OIC, Public Health Policy Implementation Department
5 Z.Zuzaan OIC, for Drug registration, GIA, Health Department, MoH
6 M.Munkhzul OIC, for Database of Drug registration, GIA, Health
Department, MoH
7 Т. Erkhembaatar Director, MCHRC, MoH
8 S. Purevsukh Director, 1st Maternity Hospital
9 D. Bat-Ochir Director, 3rd Maternity Hospital
International partners
10 Jose Ferraris OIC for Resident Representative, UNFPA
11 Wiwat Rojanapithayakorn Resident Representative, WHO
12 Yameen Mazumder UNICEF
13 V. Surenchimeg UNICEF
14 Kabir Ahmed Team Leader, UNFPA HQ
15 Anna Ridge Team member, WHO, Geneva
16 S. Navchaa Deputy Representative, UNFPA, Mongolia
17 Kh. Enkhjargal Program Officer, UNFPA, Mongolia
18 B. Shinetugs RH consultant, , UNFPA, Mongolia
19 Ts. Enkhmaa Program Assistant
20 D. Enkhchimeg Translator, UNFPA, Mongolia
21 B. Tsedmaa Project Coordinator, UNFPA, Mongolia
22 D.Jargalsaikhan Director SHSDP, ADB
Associations and NGOs
23 O.Damba Executive Director, Em Association
24 S. Davaasuren Executive Director, Mongolian Midwifes Association
25 B.Jav Board Member, MFOG
26 О.Bayanjargal Board Member, MFOG
27 B.Bolormaa Executive Director, Mongolemimpex Concern
28 D.Bolormaa Project manager, MSI
29 А.Otgonbold Advisor doctor, Kharagtai Private Maternity Hospital
Team members
30 Ya.Buyanjargal OIC, Team member, Medical services Policy Implementation
Department
31 Ch. Amarjargal OIC, Team member, Medicine and Medical Devices Division
32 Kim Kwong Jin Team member, DPRK
33 Kang Nam Team member, DPRK
34 А.Bold Team member, UNFPA National consultant
35 B. Tsevelmaa Team member, UNFPA RH project staff
36 D.Altantuya Team member, Central Professional Inspectorate Agency
37 D.Yanjinsuren Team member, Lecturer of HSUM
38 Kh. Daariimaa Team member, Lecturer of HSUM

53