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Community mental health care
in Mongolia: adapting best
practice to local culture
Narmandakh Altanzul, Luvsandorj Erdenebayar,
Chee Ng, Sandag Byambasuren, Nalin Sharma and
Gombodorj Tsetsegdary
Objectives: The aim of this paper is to describe the development of
community mental health care in Mongolia, as exemplified by a best practice
model of care in the community.
Conclusion: Through the Asia-Pacific Community Mental Health Develop-
ment Project, Mongolia has identified local best practice such as the ‘Ger’
project that provides community psychosocial rehabilitation, which has been
adapted according to local conditions and culture. Cultural considerations are
important in producing effective clinical outcomes and a better quality of life for
people with mental illness. The project has also shown that it is possible for
persons with mental illness to receive rehabilitation effectively in local
community settings. Inter-sectoral collaboration with multiple stakeholders is
essential to achieve optimal community mental health service development.
Key words: community psychiatry, culture, models of care, Mongolia, service
delivery.
Mongolia is located in the northern part of Central Asia, between
Russia to the north and China to the south. A relatively small
number of people (2.8 million) live in a large geographical
territory of 1564 thousand square kilometres. The largest ethnic group is
Khalkh and 35.9% of the population is under the age of 15 years. The
official language is Mongolian. About one million people live in the capital
city, while 45% of the population live in rural areas. The country is a low-
income group country (based on World Bank 2000 criteria). The life
expectancy is 60.1 years for males and 65.9 years for females.
Mongolia has a Mental Health Law (adopted in 2000) and a National
Mental Health Program (formulated in 2002). The Law of Mongolia on
Mental Health covers accessibility to care, rights of the mentally ill person
and their legal representatives, involuntary hospitalization, provision of
security and social welfare assistance for mentally ill people and inter-
sectoral collaboration.
1
Components addressed in the 5-year policy and
plan include the development of community mental health services, the
mental health component of primary health care, human resources,
mental health advocacy and promotion, human rights protection of
mentally ill persons, mental health service financing, quality improvement
and system monitoring.
Studies showed that the prevalence of mental disorder per 1000 population
was 13.1 in the Khangai and Khentii mountainous areas, 18.3 in the
Dornod-steppe region, 9.8 in the Altai mountainous region, 23.5 in the
Gobi region, and 24.0 in the capital city Ulaanbaatar.
2,3
Results of a recent
epidemiological survey in 20022003 in Ulaanbaatar found that the
prevalence of mental disorder was 24 per 1000 population and of
Narmandakh Altanzul
Community Mental Health Team’s Leader, Prevention, Statistic,
Training and International Department, National Center of
Mental Health, Ulaanbaatar, Mongolia.
Luvsandorj Erdenebayar
Professor and General Director, National Center of Mental
Health, Ulaanbaatar, Mongolia.
Chee Ng
Associate Professor and Director, International Unit,
Department of Psychiatry, University of Melbourne and St
Vincent’s Mental Health, Melbourne, VIC, Australia.
Sandag Byambasuren
Professor and Head, Department of Mental Health, Health
Science’s University of Mongolia, Ulaanbaatar, Mongolia.
Nalin Sharma
Psychiatrist, SOS Medical Hospital, Ulaanbaatar, Mongolia.
Gombodorj Tsetsegdary
Senior Officer, Public Health Policy Coordination Department,
Ministry of Health, Ulaanbaatar, Mongolia.
Correspondence: Chee Ng, Associate Professor, International
Unit, St Vincent’s Mental Health, PO Box 2900, Fitzroy 3065,
Victoria, Australia.
Email: cng@unimelb.edu.au
PSYCHIATRIC
SERVICES
Australasian Psychiatry .Vol 17, No 5 .October 2009
doi: 10.1080/10398560903067595
#2009 The Royal Australian and New Zealand College of Psychiatrists 375
schizophrenia was 0.97 per 1000 population. The study
also highlighted that the number of suicides has
increased threefold since 1992 to 17.6 per 100 000.
4
The mental health service in Mongolia is still largely
based in a stand-alone mental hospital which treats
17.7 patients per 100 000 population and has an
occupancy rate above 80%. The majority of psychiatric
beds in the country are provided by the mental
hospital (450 beds) followed by 21 smaller psychiatric
inpatient units with 515 beds each in the provincial
general hospitals. Nonetheless, there are now 35 out-
patient facilities, seven day care centres and about 12
residential (tent based) programmes that provide oc-
cupational rehabilitation and also 60 residential beds
for patients with chronic mental illness.
The Mongolian mental health system operates at the
primary, secondary and tertiary care levels but access
to mental health facilities is uneven across the coun-
try, favouring those living in or near the capital city.
This distribution of psychiatric beds (1.6 times greater
in the city) limits access to mental health services for
rural users. Inequity of access to mental health services
for other linguistic, ethnic or religious minority groups
such as the Kazak, Buriad, Tsaatan, or Durvud is a key
issue for the country.
Mongolia spends 2% of its total health budget on
mental health. At present, mental health financing is
mainly directed towards the only mental hospital in
the country, which accounts for 64% of all mental
health expenditure. All severe and some mild mental
disorders are covered by social insurance schemes.
Nearly 60% of registered patients are eligible for
essential psychotropic medicines, although the medi-
cations are not free. About 86% of psychiatric units
within general hospitals have at least one psychotropic
medicine of each therapeutic class (anti-psychotic,
antidepressant, mood stabilizer, anxiolytic and anti-
epileptic medicines) available in the facility. Primary
healthcare doctors can prescribe psychotropics, with
some restrictions, but primary healthcare nurses are
not allowed to do so. The provision of essential
psychotropic medicines is quite restricted in provinces
and patients who attend private clinics have to pay the
full price.
There are only 17 mental health professionals per
100 000 population in Mongolia.
5
There are very few
psychiatrists, psychologists and occupational thera-
pists, and no social workers. There is also a dispropor-
tionate distribution of human resources, with more
mental health professionals working in or near the
main city than in the rest of the country. Postgrad-
uate psychiatric education includes residential train-
ing, higher degree courses and refresher training
courses. Training programs for primary care doctors
in treating mental disorders, including the prescrip-
tion of psychotropic medications, are available as
well. Over the last 5 years, about 67% of all primary
health professionals attended training in primary
mental health care.
There are two consumer associations for alcohol and
substance abuse but there are no family associations.
There is formal collaboration between the government
departments responsible for mental health and pri-
mary health care/community health, HIV/AIDS, child
and adolescent health, substance abuse, child protec-
tion, education, employment, housing, welfare, the
elderly and criminal justice. About 15% of people who
receive social welfare benefits do so for a mental
disability.
COMMUNITY MENTAL HEALTH
DEVELOPMENT IN MONGOLIA
Since 1997, Mongolia has collaborated with the WHO
to implement community-based mental health care.
There has been slow but evident progress in the
development of community mental health services
since the establishment of a mental health database,
psychosocial rehabilitation services and primary men-
tal health care. Deinstitutionalization has been gradu-
ally implemented but remains under-developed and
not currently comprehensive. The numbers of patients
who receive primary mental health care and primary
healthcare units that provide mental health care have
increased. About 70% of the 509 primary health care
units provide primary mental health care to the
population.
6
In addition, mental health programs in
schools and mental health sub-programs and projects
in business organizations have been developed. At the
tertiary care level, the National Center of Mental
Health has also established a community mental
healthcare team.
Since 1999, there has been a 25% increase in bed
numbers in the only mental hospital in the country,
where the average length of stay is 28.2 days. This
situation was aggravated by the closing of the Resi-
dential Facility of Occupational Therapy in 2003. The
mental hospital provides acute care service for patients
referred from general hospitals and primary health,
and rehabilitation for patients needing a longer period
of care. Currently, chronically ill patients are still
being cared for in the mental hospital (60 beds were
built at the National Centre of Mental Health in 2006),
although they are gradually being transferred to the
long residential service.
It is therefore necessary to develop locally appropriate
community mental health service models to reduce
the excessive reliance on hospital services and facil-
ities. The Asia-Pacific Community Mental Health
Development Project convened by Asia-Australia Men-
tal Health aims to examine the current status of
community mental health systems in the region as
well as introduce a number of best practice community
care models for people with mental illness in the
region.
7
As part of this project, we describe below
Australasian Psychiatry .Vol 17, No 5 .October 2009
376
one such best practice model, the ‘Ger’ project, within
the Mongolian mental health system.
THE ‘GER’ PROJECT
Community-based day centres in Mongolian tented
and portable round houses called ‘gers’ were estab-
lished in 2000 in the grounds of two district healthcare
centres and four regional health centres in Erdenet,
Hovd, and Uvurkhangai and Orkhon provinces.
8
(A ger
is a round, portable, windowless, single-room tent with
a south-facing door and a small opening at the top,
called a ‘toono’ for the stove’s chimney; its floor is
made out of boards, the wall has a woollen felt
covering held by a criss-crossed structure and the
roof is supported by 5070 poles, thus making it easy
to put up or take down.) The ‘Ger’ Project is staffed by
general health care and was funded by WHO and
SOROS Foundation to run psychosocial rehabilitation
activities in the community. The aim of the Ger project
is to give people with chronic mental illness an
opportunity to increase their social and living skills
through activities focusing on psychosocial rehabilita-
tion. Such activities include life skills, self care, cook-
ing and effective vocational skills.
Project operation
Ger project day programs are placed in the community,
especially near the sub-districts where people live in
gers. Patients who are discharged from the mental
hospital are referred to the outpatient service where
their psychosocial rehabilitation needs are evaluated.
After assessment for suitability, consenting patients can
either be referred by psychiatrists in the outpatient
service or by general practitioners in the community
to attend the psychosocial rehabilitation program of-
fered by the Ger project (Figures 1 and 2). Patients with
acute psychosis and unstable or severe mental illness are
excluded from the program. About 1520 persons with
mental illness per month participate in the program
which runs over 6 hours (09.00 to 15.00) daily. The
program staff include nurses, occupational therapists
and psychiatrists.
On their first day at the Ger project, the psychiatrist,
nurse and occupational therapist assess the patient’s
life skills, self care and social life to determine what
activities will benefit them. The occupational therapist
and nurse, who have attended psychosocial rehabilita-
tion training for 13 months, are responsible for
teaching and monitoring the patient’s physical ex-
ercise and relaxation, life skills, self care and voca-
tional skills (e.g. handicraft, vegetable-growing,
gardening, carpentry, embroidery and other voca-
tional training).
The Ger project also provides psychoeducation, coun-
selling, continuing psychiatric treatment and family
support for patients and their families. The psychoe-
ducational program provides patients and their
families with information about mental illness (such
as depression, psychotic disorder, alcohol and sub-
stance abuse), coping skills and how to manage stress.
Of note, the program strives to develop vocational
skills appropriate to the patient (cooking, bakery, arts
andcrafts)thatcanhelpthemfindmeaningfulworkor
jobs. The Ger project not only includes medical
services, but also employment services, social welfare
and transportation services.
Project outcome
Over a 6-year period (20022007), a total of 500
patients attended the Ger project. In 20042005, 349
patients (38% male, 62% female) participated; of
these, 136 had specific living skills training and 209
had specific vocational skills training, and 12 patients
obtained independent employment. In this period, it
was shown that the relapse of mental disorders among
participants was reduced by 95%.
8
Such improvement
has also been demonstrated by the findings of a recent
national study of 192 patients participating in psy-
chosocial rehabilitation programs in Mongolia, where
vocational training was associated with a significantly
lower relapse rate and greater improvement in dis-
ability compared to those receiving psychotherapy
alone.
9
Psychosocial
Ger Project
GP and family
doctors
Psychiatric
outpatient service
District/Province Mental Hospital
Intake
Figure 1: Referral process for the Ger project.
Australasian Psychiatry .Vol 17, No 5 .October 2009
377
DISCUSSION
As the emphasis in mental health care is shifting from
hospital-based treatment to community-based ser-
vices, suitable and effective models of care need to be
identified.
10
Community mental health care is based
on the evidence that the majority of people with
mental problems can be effectively treated in commu-
nity settings, resulting in greater autonomy and a
better quality of life. Public mental health care should
therefore provide services that enable patients to be
treated and rehabilitated in or near their usual place of
residence as much as possible. Ideally, the services
should also incorporate the local cultural elements and
traditional lifestyles.
11
To address the gaps in mental health care within the
Mongolian mental health system, it is necessary to
develop adequate community mental health services
and to implement best practice models which are
culturally appropriate and sustainable. The best practice
model exemplified here has shown that it is possible for
patients with mental illness to recover in the commu-
nity, that relapses can be reduced, and that the indivi-
dual can be assisted to cope with stress. In addition, it is
recognized that mental health services should not work
alone to develop community services, but should in-
volve and collaborate with consumers, families, the
community, NGOs and international organizations to
achieve optimal mental health service development.
Although the rehabilitation of people with mental
disabilities requires an extended period of time,
programs such as the Ger project can successfully
deliver locally appropriate psychosocial programs close
to the patient’s home in the community. The effec-
tiveness of treatment is increased, and the social and
living skills are enhanced. Moreover, some of the Ger
program participants even managed to obtain work
that can significantly increase their quality of life. Key
advantages of the program include the low cost of the
ger, the mobility of the treatment site, the traditional
settings that are acceptable to the local community
and the reduction of stigma and discrimination
through the involvement of the community and
families. However, advocacy at the government level
is important for the sustainability of the project as
ongoing support from international aid is lacking.
The experience of psychosocial rehabilitation in the
Ger project has shown that it is possible for persons
with mental illness in Mongolia to recover to their full
potential in community settings, and reduce the rate
of illness relapse. In addition, interagency collabora-
tion and cooperation with healthcare services can
adequately support people with mental illness in the
community. Hence the involvement of families,
consumers and NGOs by the mental health services is
essential to develop an effective community-
based psychosocial rehabilitation program. Increased
governmental funding for the Ger project and close
collaboration with other NGOs with similar activities
can help foster the expansion of such evidence-based
programs at all level across Mongolia (Table 1).
The mental health system in Mongolia has a range of
mental health facilities. However, the existing mental
health system is still largely hospital based. A move
towards community care will require a change in
direction of mental health funding towards commu-
nity mental health facilities and promotion of mental
health in the community.
12
Options in the psychoso-
cial rehabilitation of those with mental illness could
include day care centres and community residential
homes. To deliver such programs extensively, the
development of training programs would be needed
for various professionals, including medical students,
nurses, psychologists, social workers and psychiatrists
in the field of mental health and substance abuse.
Family psychoeducation groups and family support
groups need to be established to support the long-term
community care of mentally ill patients. Furthermore,
the intersectoral collaboration among social welfare,
Figure 2: A ‘Ger’ in Mongolia.
Table 1: Plan of action to scale up community
mental health care in Mongolia
Expand the number of psychosocial rehabilitation
centres (Ger projects).
Provide comprehensive psychosocial rehabilitation
services for mentally ill patients near to their home
based on individual needs.
Allocate governmental budget for psychosocial reha-
bilitation programs.
Increase involvement of consumers and families in
treatment programs.
Increase inter-agency collaboration including other
NGOs.
Provide training of both medical and non-medical staff
in psychosocial rehabilitation.
Australasian Psychiatry .Vol 17, No 5 .October 2009
378
housing, legal, employment and education sectors
should be improved.
ACKNOWLEDGEMENT
The first author (NA) was supported by a WHO Global Fellowship and the Royal Australian
and New Zealand College of Psychiatrists when she prepared this work during her study
placement in the POST Program at St. Vincent’s Mental Health in 2007. The authors would
like to acknowledge Margaret Goding and Bronwen Merner of Asia-Australia Mental
Health for their assistance with editing.
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