Driven in part by a resurgent interest in social inequality and health, and in part by increasing scrutiny of the social and health consequences of neoliberal economic reform, principles of health equity and social justice, the centerpieces of the Health for All strategy drafted at Alma Ata in 1978, are once again at center stage in global public health debates. Whether and how equity in access to health care can be maintained in a context of market-based health sector reform has not been systematically addressed, particularly from the perspective of local communities. This paper will explore how health reform affects health care in post-socialist Mongolia. Through a mixed-methods household-based study of low-to-middle income communities in urban and rural Mongolia we find that despite explicit and concerted efforts to reduce inequities, the reform system is unable to provide equitable health care either vertically or horizontally. Emphasis on privatization of the secondary and tertiary sectors of the system, coupled with deployment of universally-accessible, but from a clinical standpoint, limited, version of essential primary care, produces a fragmented system. Particularly for the vulnerable poor, access to services beyond the primary care system is compromised by financial, opportunity, and informational cost barriers. This research suggests that new models of health reform are needed that will effectively bridge the growing gaps between public and private resources, primary and secondary and/or tertiary care, and clinical and public health services.

Beginning in 1990, Mongolia, a former client state of what was then the Soviet Union, undertook liberal economic reforms. These came as a great shock to Mongolia and Mongolians, and resulted in food shortages, reports of famine, widespread unemployment, and a collapse of public health and health care. Although economic conditions have stabilized in recent years, unemployment and poverty are still at disturbingly high levels. One important consequence of the transition has been the transformation of the rural, primarily pastoral, economy. With de-collectivization, herding households have been thrown into a highly insecure subsistence mode of production, and, as a consequence, have become vulnerable to local fluctuations in rainfall and availability and quality of forage, and many now lack access to traded staples and essential commodities. Household food insecurity, malnutrition, and migration of impoverished households to provincial centers and the capital of Ulaanbaatar are one result. Reductions to investments in the health sector have also eroded the quality of services in rural areas, and restricted access to those services still functioning. Evidence suggests that women are particularly vulnerable to these political-ecological changes, and that this vulnerability is manifested in increasing rates of poor reproductive health and maternal mortality. Drawing on case-study ethnographic and epidemiological data, this article explores the links between neoliberal economic reform and maternal mortality in Mongolia.

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