Recommendations for surgical system strengthening in Mongolia and general comments on the Lancet surgical indicators
| Indicator | 2030 target | Mongolia 2016 | Recommendations for surgical system strengthening in Mongolia | General comments on the Lancet surgical indicators |
| 1. Access to timely essential surgery | 80% coverage | 80.1% coverage 60% coverage of population outside of capital | Increase the capacity of five key intersoum hospitals and consider five new hospitals in populated areas. Characterise access delays due to weather and traffic. | Understanding transportation challenges particular to each country is essential to determine accurate surgical access. Account for volume of bellwether procedures at a hospital when interpreting access. |
| 2. Specialist surgical workforce density | 20 SAO per 100 000 population | 47.4 SAO per 100 000 population | Ensure appropriate SAO skill set and distribution, especially to smaller surgical facilities. Quantify obstetricians able to perform procedures such as caesarean delivery. | Assess provider skill set and distribution along with SAO density. Only obstetricians able to perform caesarean delivery should count towards SAO. |
| 3. Surgical volume | 5000 per 100 000 population | 5784 per 100 000 population | Continue efforts to improve the scope of care and public perception in rural provinces. Engender trust in the health system to reduce surgical tourism through improved training, research and international outreach. Capture private surgical cases. | Monitor distribution of procedures to understand the scope of access to elective surgery. |
| 4. Perioperative mortality | Track and set national targets | 0.14% | Consider ways to track 30-day postoperative mortality. Explore the potential for error or under-reporting of postoperative mortality. Promote processes for quality improvement at the regional level. | While impractical in many LMICs, 30-day postoperative mortality may be important for overcoming cultural barriers. Consider stratifying mortality by procedure and emergent versus elective. |
| 5. Protection against impoverishing expenditure 6. Protection against catastrophic expenditure | 100% protection | C-section: 100% protection from impoverishing and catastrophic expenditures. Appendectomy: 99.4% protection from impoverishing expenditure, 98.4% protection from catastrophic expenditure. Laparoscopic cholecystectomy: 42.9% protection from impoverishing and catastrophic expenditures. Ex-fix femur: 75.4% protection from impoverishing expenditure, 50.7% protection from catastrophic expenditure. | Enact legislation to decrease formal out-of-pocket costs, especially for those procedures involving implants or technology. Decrease systemic dependence on informal out-of-pocket payments. Build trust and quality in the public healthcare system to decrease surgical tourism. | Assessment at the level of individual procedures may better characterise financial protection. Factor local customs and concerns into the cost of surgical care, including informal out-of-pocket payments. |
SAO, surgeons, anaesthesiologists and obstetricians.