Nurturing Care in Mongolia

Mongolia, a traditionally nomadic country in Northeast Asia, has been transitioning from a post-communist state to a democracy over the past three decades. Within the framework of this transformative journey, the policies governing the country’s early childhood development (ECD) system have been continuously evolving. This intricate system encompasses a spectrum of interconnected policies, regulations, programs, and infrastructure, influencing the quality of public services that are essential domains for children’s well-being and development. The trajectory of a country's ECD system is of great significance, shaping the foundational developmental aspects of children from their conception until they step into school. Remarkably, it is during the first five years that 90% of a human’s brain development is completed. The quality of the caregiving environment of a child extends beyond its immediate impact on their personal development: it also influences their long-term educational and economic standing, as well as their potential for later contributions to society.

Aligned with Mongolia's ongoing transformation, the Nurturing Care Framework (NCF) was released jointly by the WHO, UNICEF, and the World Bank in 2018. It offers a roadmap for shaping policies in five key areas essential to providing every child with the chance to live in a stable environment sensitive to their health and nutritional needs. These five areas are: ensuring protection from threats, offering opportunities for early learning, and fostering interactions that are responsive, emotionally supportive, and developmentally stimulating.

This article aims to evaluate the current implementation of the NCF in Mongolia by assessing the key policies and regulations that shape the country's ECD system. Recognizing their close interconnection, the five key elements of the NCF are streamlined into three overarching categories within this article: health and nutrition, safety and security, and responsive caregiving and early learning.

With its primarily homogeneous population of 3.4 million, Mongolia can serve as an optimal environment for assessing the outcomes of promising social policies on nurturing care. Beyond this, exploring the Mongolian NCF context will offer unique insights that extend beyond the familiar territory of Western, educated, industrialized, rich, democratic societies.

Healthy Foundations

NCF interventions begin by addressing reproductive, maternal, newborn, and child health to mitigate adverse health outcomes for mothers and children. While statistics from 2018 indicate that 89% of pregnant women in Mongolia received four or more adequate antenatal care visits which is significantly higher than the global average, regional disparities are evident. Only 31% of pregnant women in the Western region received adequate antenatal care, compared to 84% in the capital city Ulaanbaatar.

Addressing acute respiratory infections, a major cause of under-five mortality worldwide, is a critical indicator of the NCF implementation progress. In 2018, 76% of Mongolian children suffering from this illness received the essential professional assistance they needed.

A shortage of healthcare professionals, particularly in rural areas, exacerbates the health issues for children and their mothers. Mongolia had only 6.7 pediatricians and 5.1 obstetricians and gynecologists per 10,000 children and pregnant women, respectively, as of 2021. Moreover, a near 1:1 physician-to-nurse ratio, as opposed to the 3:1 average in OECD countries, leads to a preference for private healthcare among those who can afford it, resulting in 36% of total health expenditures being paid out-of-pocket on average.

While the Mongolian state salary fund for healthcare professionals has doubled since 2016, the baseline salaries remain inadequate and the high inflation rates further diminish the economic attractiveness of the healthcare sector. Beyond wage increases, measures like reasonable working hours, a more adequate patient-to-professional ratio, and improved work facility conditions, especially in rural areas, are crucial to ensure the healthy wellbeing of every pregnant woman, child, and mother.

Nutrition presents a notable challenge in Mongolia, where 9% of children under five suffer from stunting, and 11% are overweight. While these figures may seem comparatively better than the global averages of 21.9% and 5.9%, respectively, it is crucial to recognize a significant shift in nutrition practices over the last 30 years. There has been a decline in breastfeeding rates, with currently only one in two mothers exclusively breastfeeding their babies for the first six months after birth. A primary reason for this trend is the limited integration of daycare at work and designated time for breastfeeding into the operational norms of most institutions in Mongolia – be it in the public or private sector, making it challenging for mothers to balance motherhood with their professional lives.

Beyond the obstacles posed by limited access to healthcare and the promotion of healthy nutrition practices, the financial strain related to covering health and nutrition expenses stands out as a major reason to undermine the wellbeing of young children. In response to this, the Mongolian Government extends several social welfare packages to caregivers, with the flagship initiative being the Child Money program. Mongolia is one of the few countries worldwide that provides universal child support to all its minor citizens, preventing discrimination and contributing to the real economy. Other social welfare programs, like the Paid Mothers program or the Order of Maternal Glory, target women at specific milestones in their motherhood. While the social welfare expenditures in Mongolia have moved steadily in favor of children and mothers, the living expenses, particularly in the capital city, are constantly on the rise, with inflation rates in double digits in the last years making these programs fall short of covering essential needs for young children and their mothers.

To comprehensively address challenges in ensuring a healthy foundation for every child, essential policy recommendations entail steadily strengthening the healthcare workforce by providing them with enhanced working conditions. Simultaneously, strategic investments in healthcare infrastructure, with a focus on enhancing its accessibility and quality in rural areas, are imperative. Additionally, evaluating the overall effectiveness of existing social welfare programs targeting children and their mothers to ensure that their basic needs are taken care of will be essential.

Enforcing Safety and Security

Until 2016, children's rights to protection from all types of violence and punishment were not legally secured in Mongolia. Consequently, as violence in households was not considered a criminal act until the last decade, the cultural shift towards taking the initiative to protect children from all forms of violence and reporting incidents when witnessing a case is a recent development in the Mongolian context. 49% of children aged 1-14 years in Mongolia experienced some degree of violent discipline and the number of new cases of injuries was highest among children under five, according to the most recent official data.

To enforce these policies, initiatives such as the nationwide toll-free 24/7 child helpline, 108, were launched through collaboration of international stakeholders and the Government of Mongolia. Given that young children under the age of five will require assistance from individuals in a position to report cases on their behalf, the need to cultivate a culture that ensures defenseless young children are kept safe and secure is high.

Beyond the issue of the existing shortage of spots at specialized shelters for children who experienced domestic abuse, it is crucial to track the impact on children of regulations governing their separation from violent caregivers and their reunification process, as well as changes in caregiving rights. Furthermore, the absence of an efficient child protection monitoring system poses a substantial operational limitation for those in the children's protection sector.

To fix these issues, Mongolian public authorities need to start with strengthening their professional capacity and addressing the shortage of full-time child protection officers at the primary administrative level. Currently, staff members of legal committees on child rights and child rights inspectors carry this additional responsibility alongside their core duties. Therefore, there is an urgent need for dedicated child protection officers at the local level to ensure the prompt and effective care of children experiencing violence.

In establishing a more efficient child protection system, drawing insights from countries with comparable population sizes and similar social and cultural dynamics is recommended. Nations like Finland and New Zealand, with a relatively small population and predominantly ethnically homogeneous societies, have implemented child protection systems prioritizing family involvement and community engagement, whilst maintaining cultural sensitivity. Such an approach might be suitable for Mongolia.

Enhancing Responsive Caregiving and Early Learning

Every child's learning journey begins in their caregiving environment, where everyday knowledge shared and communicated by caregivers, often parents, forms the foundation of their lifelong growth in cognitive, physical, social, and emotional dimensions. The NCF defines responsive caregiving as the ability of caregivers to observe and respond to children's movements, sounds, gestures, and verbal requests.

Therefore, the primary systematic approach to implementing the NCF in any country involves providing young adults with essential skills for responsive caregiving. In Mongolia, however, the current education curricula lack comprehensive components addressing these skills, both in school and higher education.

Looking beyond formal education, the information available in public, especially on social media platforms like Facebook, often lacks references to scientific research and tends to be non-systematic and overwhelming. A couple of projects and programs are implemented by international and foreign institutions to improve the information landscape on responsive caregiving in Mongolian. For instance, funded by the Government of Canada, IDLO partnered with Mongolian authorities to launch an online platform called familycenter.mn. As a pioneering effort, this website offers caregivers access to professional advice and psychological support on family-related issues. Moreover, several international non-profit organizations are actively collaborating with local family centers in economically challenged neighborhoods, providing caregivers with firsthand education related to the NCF and building communities around responsive caregiving.

To empower caregivers and make systematic knowledge in responsive caregiving more accessible, various policy measures and programs can be implemented. Initially, awareness campaigns on responsive caregiving proven successful elsewhere, such as the Sisimpur program by Sesame Street in South Asia, can be employed. By doing so, it is crucial to address language and cultural barriers faced by Mongolian caregivers. This involves both literal language translation and adapting practices to be culturally relevant in the Mongolian context.

Beyond the challenge of accessing quality education on responsive caregiving, many parents also suffer from inadequate quality time to spend with their children. It is also crucial to acknowledge the unequal distribution of parenting roles between fathers and mothers from the beginning: female employees receive 120 days of paid maternity leave, while male employees are entitled to only ten days of paid leave under the current law. Parenting roles remain strongly gendered, with mothers often taking a more active day-to-day role in the lives of their children.

Concerning access to early learning opportunities for children, as of 2023, 88% of children aged three to five years in Mongolia had access to kindergartens. However, public kindergartens are frequently oversubscribed, and in some cases, a teacher and their assistant are responsible for over 50 children simultaneously. In such circumstances, receiving tailored responsive caregiving becomes nearly impossible for a child. Apart from the insufficient number of kindergarten spots, many children are excluded from early learning opportunities due to their geographic location and socioeconomic background. Currently, early childhood education institutions primarily serve families in larger cities and towns, leaving over 20% of the Mongolian population, who continue living a nomadic lifestyle, from accessing these services. Introducing alternative early childhood education facility models, such as the opportunity for caregivers to run community-based childcare facilities after completing a certification training on responsive caregiving, are in the pilot phase.

Limitations

The limitations of this article include the absence of ongoing progress measurement and evaluation of implemented policies regarding safety and security, access to responsive caregiving, and early learning opportunities for children in Mongolia. Holistic, longitudinal data on children’s development and their socio-economic standing post-implementation are crucial for future informed policy decisions to be made. 

Additionally, it is essential to note that the often-overlooked challenges faced by mothers and children with disabilities in Mongolia, resulting from insufficient public awareness, collected data, and a shortage of trained professionals capable of adequately covering and highlighting their experiences and needs within the existing policy sphere, were not addressed in this article.

Conclusion

In essence, the NCF is all about ensuring secure attachments and positive relationships between children and their caregivers, recognizing their pivotal role in establishing the foundation for children's long-term development. The landscape of the ECD system in Mongolia presents a dual reality of challenges and opportunities in translating the concepts of the NCF into practical implementation.

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Table 1: Summary of the main achievements and room for improvement in the policies covered within this article that are primarily shaping the ECD system in Mongolia.

To ensure a more promising future for Mongolia's children, there is a pressing need to improve the interconnectedness and comprehensiveness of key policy areas, focusing on health, education, labor, and human development. Finally, enhancing local professional capacity, especially in health and child protection, is crucial for effectively implementing the NCF.

The views expressed in this article are those of the author and do not represent those of any previous or current employers, the editorial body of SIPR, the Freeman Spogili Institute, or Stanford University.