Paper short abstract:

This paper draws on ethnographic research among nomadic herders in rural Mongolia. It examines the ways in which environmental challenges, rural-to-urban migration and weak rural politics affect access to health services and impinges on national efforts to strengthen the health system.

Paper long abstract:

In the past decade, the role of national health systems and their need for strengthening has been moved onto the agenda by global health actors (Hafner & Shifman, 2012). Neoliberal efforts to create 'weak states', policies of structural adjustments and a technical bias related to processes of health systems' strengthening, are factors that have shaped the workings of public health delivery.

This paper critically examines Mongolia's health system and discusses how efforts to strengthen this 'system' have been hampered by a narrow focus on technicalities and management structures. Grounded in a longitudinal ethnographic study among nomadic herders in rural areas and of in-migration to the capital Ulaanbaatar, it is argued that a more comprehensive focus on the political and social relations that shape the health system must be taken into account in the efforts to strengthening the system. Considering the rapid changes that have taken place in Mongolia since the demise of socialism in 1990, such a comprehensive focus involves the state's political attitude to, and management of, the dynamic between the urban centre and the rural periphery. It further requires a focus on factors external to the health system that inflict on its ability to provide equitable health care. In Mongolia it is argued, these factors are grounded in weak rural politics, environmental challenges and a massive rural-to-urban migration coupled with increasing poverty and vulnerability among those most marginalized within the health system - the nomadic herders in rural areas and recent in-migrant herders to the capital Ulaanbaatar.