World Journal of Surgery

, Volume 35, Issue 2, pp 272–279

Quantifying Surgical and Anesthetic Availability at Primary Health Facilities in Mongolia

  • David A. Spiegel
  • Shelly Choo
  • Meena Cherian
  • Sergelen Orgoi
  • Beat Kehrer
  • Raymond R. Price
  • Salik Govind



Significant barriers limit the safe and timely provision of surgical and anaesthetic care in low- and middle-income countries. Nearly one-half of Mongolia’s population resides in rural areas where the austere geography makes travel for adequate surgical care very difficult. Our goal was to characterize the availability of surgical and anaesthetic services, in terms of infrastructure capability, physical resources (supplies and equipment), and human resources for health at primary level health facilities in Mongolia.


A situational analysis of the capacity to deliver emergency and essential surgical care (EESC) was performed in a nonrandom sample of 44 primary health facilities throughout Mongolia.


Significant shortfalls were noted in the capacity to deliver surgical and anesthetic services. Deficiencies in infrastructure and supplies were common, and there were no trained surgeons or anaesthesiologists at any of the health facilities sampled. Most procedures were performed by general doctors and paraprofessionals, and occasionally visiting surgeons from higher levels of the health system. While basic interventions such as suturing or abscess drainage were commonly performed, the availability of many essential interventions was absent at a significant number of facilities.


This situational analysis of the availability of essential surgical and anesthetic services identified significant deficiencies in infrastructure, supplies, and equipment, as well as a lack of human resources at the primary referral level facilities in Mongolia. Given the significant travel distances to secondary level facilities for the majority of the rural population, there is an urgent need to strengthen the delivery of essential surgical and anaesthetic services at the primary referral level (soum and intersoum). This will require a multidisciplinary, multi-sectoral effort aimed to improve infrastructure, procure and maintain essential equipment and supplies, and train appropriate health professionals.


  1. 1.
    Debas HT, Gosselin RA, McCord C et al (2006) Surgery. In: Jamison D, Evans D, Alleyne G, Jha P, Breman J, Measham A et al (eds) Disease control priorities in developing countries, 2nd edn. Oxford University Press, New York, pp 1245–1260Google Scholar
  2. 2.
    Spiegel DA, Gosselin RA (2007) Surgical services in low-income and middle-income countries. Lancet 370:1013–1015CrossRefPubMedGoogle Scholar
  3. 3.
    Ivers LC, Garfein ES, Augustin J et al (2008) Increasing access to surgical services for the poor in rural Haiti: surgery as a public good for public health. World J Surg 32:537–542CrossRefPubMedGoogle Scholar
  4. 4.
    Laxminarayanan R, Mills AJ, Breman JG et al (2006) Advancement of global health: key messages from the disease control priorities project. Lancet 367:1193–1208CrossRefGoogle Scholar
  5. 5.
    Gosselin RA, Thind AA, Bellardinelli A (2006) Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribution of different services? World J Surg 30:505–511CrossRefPubMedGoogle Scholar
  6. 6.
    Gosselin RA, Heitto M (2008) Cost-effectiveness of a district trauma hospital in Battambang, Cambodia. World J Surg 32:2450–2453CrossRefPubMedGoogle Scholar
  7. 7.
    McCord C, Chowdhury Q (2003) A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet 81:83–92CrossRefPubMedGoogle Scholar
  8. 8.
    Mathauer I, Imhoff I (2006) Health worker motivation in Africa: the role of non-financial incentives and human resource management tools. Hum Res Health 4:24CrossRefGoogle Scholar
  9. 9.
    Hagopian A, Zuyderduin A, Kyobutungi N et al (2009) Job satisfaction and morale in the Ugandan health workforce. Health Affairs 28:w863–w875CrossRefPubMedGoogle Scholar
  10. 10.
    Country Health Information Profiles: Mongolia. Available at Accessed 23 Dec 2009
  11. 11.
    Health Statistics Yearbook (2008) National Statistical Office, MongoliaGoogle Scholar
  12. 12.
    Mongolia Health Information System: Assessment Report, Health Metrics Network, Ministry of Health (Mongolia), March 2008Google Scholar
  13. 13.
    Health indicators (2008) Department of Health, MongoliaGoogle Scholar
  14. 14.
    Gunsensoodol D, Nachin B, Dashzeveg T (2006) Surgery in Mongolia. Arch Surg 141:154–1257CrossRefGoogle Scholar
  15. 15.
    WHO tool for situational analysis to assess emergency and essential surgical care. Available at Accessed 24 Dec 2009
  16. 16.
    Kushner AL, Cherian MN, Noel LPJ et al. Addressing the millennium development goals from a surgical perspective: Deficiencies in the capacity to deliver safe surgery and anaesthesia in eight low and middle-income countries. Arch Surg 145:154–159Google Scholar
  17. 17.
    Kingham TP, Kamara TB, Cherian MN et al (2009) Quantifying surgical capacity in Sierra Leone. A guide for improving surgical care. Arch Surg 144:122–127CrossRefPubMedGoogle Scholar
  18. 18.
    Weiser TG, Regenbogen SE, Thompson KD et al (2008) An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet 372:139–144CrossRefPubMedGoogle Scholar
  19. 19.
    Bolormaa T, Natsafdorj TS, Tumurbat B et al (2007) Mongolia: health system review. Health Syst Transit 9:1–151Google Scholar
  20. 20.
    Kotilainen H (2001) Rehabilitation of the hospital infrastructure in a developing country. World Hosp Health Serv 37:25–28PubMedGoogle Scholar
  21. 21.
    Report on the assessment of health facilities in responding to emergencies. Ministry of Health, Mongolia, 2006Google Scholar
  22. 22.
    Mock C, Nguyen S, Quansah R et al (2006) Evaluation of trauma care capabilities in four countries using the WHO-IATSIC Guidelines for Essential Trauma Care. World J Surg 30:946–956CrossRefPubMedGoogle Scholar
  23. 23.
    Son NT, Thu NH, Tu NTH et al (2007) Assessment of the status of resources for essential trauma care in hanio and Khanh Hoa, Vietnam. Injury 38:1014–1022CrossRefPubMedGoogle Scholar
  24. 24.
    Dunser MW, Baelani I, Ganbold L (2006) A review and analysis of intensive care medicine in the least developed countries. Crit Care Med 34:1234–1242CrossRefPubMedGoogle Scholar
  25. 25.
    Mathauer I, Imhoff I (2006) Health worker motivation in Africa: the role of non-financial incentives and human resource management tools. Hum Res Health 4:24CrossRefGoogle Scholar
  26. 26.
    Hagopian A, Zuyderduin A, Kyobutungi N et al (2009) Job satisfaction and morale in the Ugandan health workforce. Health Affairs 28:w863–w875CrossRefPubMedGoogle Scholar
  27. 27.
    McCord C, Mbaruku G, Pereira C et al (2009) The quality of emergency obstetrical surgery by assistant medical officers in Tanzanian district hospitals. Health Affairs 28:w876–w885CrossRefPubMedGoogle Scholar
  28. 28.
    McPake B, Mensah K (2008) Task shifting in health care in resource-poor countries. Lancet 372:8870–8871CrossRefGoogle Scholar
  29. 29.
    Mullan F, Frehywot S (2007) Non-physician clinicians in 47 sub-Saharan African countries. Lancet 370:2158–2163CrossRefPubMedGoogle Scholar
  30. 30.
    Mkandawire N, Ngulube C, Lavy C (2008) Orthopaedic clinical officer program in Malawi: a model for providing orthopaedic care. Clin Orthop Relat Res 466:2385–2391CrossRefPubMedGoogle Scholar
  31. 31.
    Garrido PI (1997) Training of medical assistants in Mozambique for surgery in rural settings. S Afr J Surg 35:144–145PubMedGoogle Scholar
  32. 32.
    Laloe V (1999) Training programme for general practitioners in emergency surgery and obstetrics in Woldya, Ethiopia. Trauma Q 14:339–344CrossRefGoogle Scholar
  33. 33.
    Vaz F, Bergstrom S, da Luz Vaz M et al (1999) Training medical assistants for surgery. Bull WHO 77:688–691PubMedGoogle Scholar
  34. 34.
    Pereira C, Bugalho A, Bergstrom S et al (1996) A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique. Br J Obstet Gynaecol 103:508–512CrossRefPubMedGoogle Scholar
  35. 35.
    Chilopora G, Pereira C, Kamwendo F et al (2007) Postoperative outcome of caesarean sections and other major obstetric surgery by clinical officers and medical officers in Malawi. Hum Res Health 5:17CrossRefGoogle Scholar
  36. 36.
    Fenton M, Whitty CJ, Reynolds F (2003) Cesaerean section in Malawi: prospective study of early maternal and perinatal mortality. BMJ 327:587CrossRefPubMedGoogle Scholar
  37. 37.
    Integrated Management of Emergency and Essential Surgical Care. World Health Organization. Available at Accessed 24 Dec 2009
  38. 38.
    Surgical Care at the District Hospital. World Health Organization, Geneva (2003) Accessed 24 Dec 2009
  39. 39.
    Cherian MN, Noel L, Buyanjargal Y et al (2004) Essential emergency surgical procedures in resource-limited facilities: a WHO workshop in Mongolia. World Hosp Health Serv 40:24–29PubMedGoogle Scholar
  40. 40.
    World Health Organization (2010) Integrated Management Emergency and Essential Surgical Care (IMEESC) tool, 2010. Available at Accessed 7 Mar 2010
  41. 41.
    World Health Organization (2005) Global Initiative for Emergency and Essential Surgical Care. Available at Accessed 24 Dec 2009
  42. 42.
    Service Availability Mapping (SAM), World health Organization Accessed 24 Dec 2009

Copyright information

© Société Internationale de Chirurgie 2010

Authors and Affiliations

  • David A. Spiegel
    • 1
  • Shelly Choo
    • 7
  • Meena Cherian
    • 5
  • Sergelen Orgoi
    • 2
  • Beat Kehrer
    • 6
  • Raymond R. Price
    • 3
  • Salik Govind
    • 4
  1. 1.Division of Orthopaedic SurgeryChildrens Hospital of PhiladelphiaPhiladelphiaUSA
  2. 2.Department of Surgery S1Health Sciences UniversityUlaanbaatarMongolia
  3. 3.Swanson Family Foundation, Intermountain HealthcareSalt Lake CityUSA
  4. 4.Department of Public HealthWHO Representative OfficeUlaanbaatarMongolia
  5. 5.Emergency and Essential Surgical Care Project, Clinical Procedures Unit, Department of Essential Health TechnologiesWorld Health OrganizationGenevaSwitzerland
  6. 6.Swiss Surgical TeamInternational College of Surgeons (ICS)St. GallenSwitzerland
  7. 7.Johns Hopkins UniversityBaltimoreUSA

Personalised recommendations