HOW CAN MONGOLIA ADDRESS THE GENDER GAP IN LIFE EXPECTANCY? A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE Forest Jarvis, Hillary C. Johnson, and Maude Ruest A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE 2 Forest Jarvis, Hillary C. Johnson, and Maude Ruest How Can Mongolia Address the Gender Gap in Life Expectancy A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE Forest Jarvis, Hillary C. Johnson, and Maude Ruest 2025 CHAPTER 2. 3 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE © 2025 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved. This work is a product of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. The boundaries, colors, denominations, links/ footnotes CONTENTS and other information shown in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or Acronyms and abbreviations 6 acceptance of such boundaries. The citation of works Executive Summary 7 authored by others does not mean the World Bank Introduction 10 endorses the views expressed by those authors or the content of their works. Scope and objectives of this report 12 Nothing herein shall constitute or be construed or Chapter 1. What Is Driving the 13 considered to be a limitation upon or waiver of the Gender Gap in Life Expectancy in privileges and immunities of The World Bank, all of which Mongolia? are specifically reserved. Risky behaviors, health seeking 19 Rights and Permissions behaviors, and gender norms may be influencing the gender The material in this work is subject to copyright. gap in life expectancy. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole Chapter 2: What are promising 20 or in part, for noncommercial purposes as long as full solutions for addressing these attribution to this work is given. challenges? #1: Interventions to Reduce 24 Attribution Smoking and Excessive Alcohol Consumpton Please cite the work as follows: “Jarvis, Forest, Hillary C. Johnson, and Maude Ruest. 2025. How Can Mongolia #2: Interventions to Increase 30 Address the Gender Gap in Life Expectancy?: A Review the Uptake of Preventive and of Promising Interventions Based on Global Evidence. © Primary Health Care World Bank.” #3: Interventions to Prevent 32 Suicide Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, #4: Interventions To Address 36 The World Bank, 1818 H Street NW, Washington, DC Norms around Masculinity 20433, USA; fax: 202- 522-2625; e mail: pubrights@ worldbank.org. Chapter 3. The Way Forward 39 References 46 4 Forest Jarvis, Hillary C. Johnson, and Maude Ruest ACKNOWLEDGMENTS This report was written by Forest Jarvis, Hillary C. Johnson, and Maude Ruest with inputs and support from Erdene Ochir Badarch, Sophia Georgieva, Sama Khan, Maria Ana Lugo, Kate Mandeville, M. Yaa Pokua Afriyie Oppong, Uranchimeg Tsevelvaanchig, and Fang Yang. The team thanks the peer reviewers who provided helpful feedback on the draft report, including Helle Buchhave, Badamchimeg Dondog, and Supriya Madhavan. The team is grateful for the collaboration and inputs provided by the National Committee for Gender Equality of Mongolia. The report was prepared under the guidance of Ingo Wiederhofer, Practice Manager for Social Development, and Tae Hyun Lee, Country Manager for Mongolia. Badamkhand Bold provided helpful administrative assistance. Mary Fisk copyedited the report, and Batbaatar Jambal designed it. CHAPTER 2. 5 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE ACRONYMS AND ABBREVIATIONS CHD Centre for Health Development NCDs noncommunicable diseases GGLE gender gap in life expectancy HALE healthy life expectancy ILO International Labour Organization mhGAP Mental Health Gap Action Programme NCGE National Committee on Gender Equality NSHWs nonspecialized health workers NSO National Statistics Office UNDP United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WB World Bank WHO World Health Organization 6 Forest Jarvis, Hillary C. Johnson, and Maude Ruest EXECUTIVE SUMMARY EXECUTIVE SUMMARY Mongolia has one of the highest gender gaps in life 59 percent of men reported only seeking medical expectancy in the world, with men living almost attention when ill, and 20 percent had never seen a a decade less than women. Gender differences doctor (World Bank 2020). Alcohol consumption and in mortality rates are particularly striking among smoking have been associated with masculinity in working-age adults: mortality rates of men between other contexts, and men’s reluctance to seek health the ages of 20 and 69 are two to three times care is linked with gender norms that. associate help- higher than those of women of similar ages. The seeking with femininity. Furthermore, gender norms main cause of death for both men and women is about men’s roles as breadwinners and protectors noncommunicable diseases (NCDs), which result further influence men’s exposure to health risks. from genetic, physiological, environmental, and In a context with a highly competitive labor market behavioral factors. Specifically, cardiovascular and few opportunities to earn competitive wages, disease and cancer are leading causes of death in men cannot always fulfill their traditional roles as Mongolia. Accidental poisoning (99 percent of which providers; consequently, they may turn to alcohol was accidental alcohol poisoning) is the third largest or tobacco to cope with this stress and may suffer cause of death in Mongolian men, highlighting a from reduced mental health. stark problem with excessive alcohol consumption. Moreover, between 75 and 88 percent of all Strong global evidence suggests the effectiveness accidents, suicides, and violence-related deaths and cost-effectiveness of strategies to reduce were among men in 2023, and male suicide rates in tobacco and excessive alcohol consumption (WHO Mongolia are among the highest in the world. 2024a). Indeed, the WHO NCD best buys and the MPOWER framework offer clear effective and cost- The gender gap in life expectancy in Mongolia effective solutions to reduce tobacco usage and has been linked with a higher rate of risky health excessive alcohol consumption. These solutions behaviors in men, including smoking and alcohol include the following: consumption, lower propensity to seek preventive and primary health care, and gender norms. Men • Further raising taxes on tobacco and alcohol in Mongolia are 13 times more likely to use tobacco products. and 3.4 times more likely to engage in chronic heavy • Enhancing bans on tobacco and alcohol drinking than women (Pengpid and Pelzer 2022). advertising, promotion, and sponsorship. Tobacco and alcohol consumption elevate men’s • Increasing alcohol sales restrictions to limit risk of NCDs and contribute to accident, violence, the physical availability of retail alcohol. and suicide-related deaths. Similar to men in other • Expanding 100 percent smoking bans to all parts of Asia and across the globe, men in Mongolia indoor workplaces and public spaces. are less likely than women to use primary health • Making smoking quit lines and counseling care to prevent, diagnose, or treat NCDs. A survey available. of men from four regions in Mongolia showed that • Rolling out mass media campaigns. 7 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE Although Mongolia is already implementing many health workers have been trained to increase access of these NCD interventions, more could be done to to mental health services. When mental health reduce the consumption of tobacco and excessive services are available, these workers can provide alcohol, particularly in men. Indeed, investing in six early identification of individuals at high risk of proven tobacco control measures could prevent suicide and offer follow-up programs with them to more than 19,200 deaths and avert MNT 2.4 trillion help reduce the rates of suicide. Working with the (US$ 705 million) in economic losses between media to develop and implement guidelines on the 2024 and 2037 (1,280 deaths and MNT 185 million responsible reporting of suicide is also considered a annually (US$54.2 million, UNDP 2024). best practice in suicide prevention. Although robust evidence suggests that limiting access to the means Broadly strengthening and targeting preventive of suicide is an effective intervention, implementing care and primary health care could help increase this in the context of Mongolia will be challenging the uptake of services, with targeted interventions given the most common methods used. for men. Men in Mongolia are less likely than women to seek primary health care, including to help Although more rigorous evidence is needed, detect and treat NCDs early. Strengthening primary workshops and safe spaces for dialogue about health care could start with reviewing the model masculinity and norms are promising ways to shift of care to improve the prevention, detection, and attitudes, beliefs, and health-related behaviors. management of NCDs. It is important to address the Workshops that engage men in a critical analysis of structural barriers to men’s care seeking and ensure gender roles and create a safe space to explore how that the available services meet and are tailored to gender norms affect them and their communities men’s needs. In addition, communication campaigns have helped shift attitudes and, in some cases, that promote preventive care and primary health health-related behavior. Additional support to care among patients and potential patients can be enable participants to become agents of change male-specific. Targeting other household members, in their communities, promote peer learning, and including spouses, can also be effective, as these foster role models can facilitate shifts in gender individuals can in turn encourage the men in their norms (Stewart et al. 2021). It is also crucial to lives to seek care. promote change in the community, build alliances with credible organizations, and recognize the Expanding mental health services and treatment multiple needs of men to achieve lasting change, could help reduce suicide attempts. School- such as employment (Barker and Ricardo 2005). based programs that raise awareness and provide Complementing interventions that target individuals psychological interventions can reduce the suicide with broader communications campaigns can be risk among adolescents; more generally, initiatives effective. Documentaries, social media campaigns, to build adolescents’ socioemotional skills can and edutainment interventions, which deliver help them to develop healthy coping strategies. messages through entertaining programs, have the Improving the accessibility of mental health services potential to support shifts in gender norms. for the broader population is critical, because most individuals who commit suicide struggle with mental health conditions. In some contexts, nonspecialized 8 Forest Jarvis, Hillary C. Johnson, and Maude Ruest EXECUTIVE SUMMARY Table 1: Summary of potential interventions suggested to reduce the gender gap in life expectancy Interventions to reduce smoking and excessive alcohol consumption Strengthen tobacco and alcohol excise taxes (increasing level and improving the design of taxes) Enhance bans on tobacco and alcohol advertising, promotion, and sponsorship Expand 100 percent smoking bans to all indoor workplaces and public places Increase alcohol sale restrictions to limit the physical availability of retailed alcohol Make smoking quit lines and counseling available Roll out mass media campaigns Interventions to increase the uptake of primary health care services focused on men Broadly strengthen primary health care and prevention, starting with reviewing the model of care Address structural barriers to men’s health care and create male-friendly services Encourage male care-seeking behavior Interventions to prevent suicide Foster socioemotional life skills in adolescents Improve access to mental health services Provide early identification, management, and follow-up with anyone with mental health conditions (including those affected by suicidal behaviors) Work with the media to encourage the responsible reporting of suicides Limit access to the means of suicide Interventions to address social norms around masculinity Offer workshops and provide safe spaces for dialogue about masculinity and norms Develop communication campaigns, including documentaries, movies, and entertaining programs 9 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE INTRODUCTION Mongolia has one of the highest gender gaps in life expectancy in the world, with men living almost a decade less than women. Life expectancy at birth in Mongolia has increased in the past several decades, but it has now largely stagnated for both men and women (figure 1) at 71 years of age.1 The gap between the life expectancy of men and that of women has grown from 2.3 years in 1965 to a persistent ~9.5 years since 2015 (figure 1); Mongolia has the 8th highest gender gap in life expectancy in the world.2 Figure 1: The gender gap in life expectancy has been growing Source: Center for Health Development and WHO 2023 However, women’s extra years of life are not as productive or disease free as they could be. Turning to healthy life expectancy—HALE, the average number of years a person can expect to live in “full health” by taking into account years lived in less than full health due to disease and/or injury—the gender gap in HALE was 5 years in 2021; women lived 5 healthy life years more than men, compared to 8 years looking at life expectancy only (figure 2). Indeed, the gap between healthy life expectancy and life expectancy is wider for women than for men, suggesting that women live longer but in worse health than the men who “survive.” 1 World Bank World Development Indicators. 2 World Bank Gender Data Portal. https://genderdata.worldbank.org/en/indicator/sp-dyn-le00-in?gender=gender-gap#data-table-section. Top countries in order of highest gender gap are Armenia, Ukraine, Belarus, Russian Federation, Latvia, Georgia, and Viet Nam. 10 Forest Jarvis, Hillary C. Johnson, and Maude Ruest INTRODUCTION Figure 2: Women live longer but in worse health than the men who “survive” Source: World Health Organization Global Health Observatory database, latest data available. From about 20 years of age, more men than women die in every age group until 75 years of age (figure 3a). Gender differences in mortality rates are particularly striking among working-age adults; indeed, male mortality rates are two and three times higher than those of women between the ages of 20 and 69 (figure 3b). Men represent about 50 percent of Mongolians under age 64 but only 44 percent over age 65. Figure 3. More men die in all ages group than women until age 75 years Sources: Panel a based on data shared by the Mongolia Centre for Health Development; panel b based on data from the United Nations Population Prospect Data portal. 11 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE Scope and objectives of in behaviors, attitudes, and perceptions related to risk, as well as masculine gender norms, using this report novel quantitative and qualitative data. The current study builds on the previous work by reviewing The Government of Mongolia is committed global evidence on programs that can address to reducing the gender gap in life expectancy. the key underlying drivers of the gender gap in Reducing the gender gap in life expectancy is an life expectancy that were identified through the explicit objective of Mongolia’s Cross-Sectoral previous studies and engagements. Strategic Plan for Promoting Gender Equality in Mongolia (2022–31). A first plan to reduce the The primary objective of this report is to provide disparity in life expectancy was adopted for the a review of the global evidence of programs that period from 2020 to 2022; however, only about 60 hold promise for reducing Mongolia’s gender percent of the plan was implemented. Learning from gap in life expectancy. The focus for the literature the experience of the first plan, an interdisciplinary review was driven by the main contributors to male Working Group with representatives from different mortality and issues that predominately affect men. governmental and nongovernmental organizations The literature review draws on global evidence of prepared a second interdisciplinary plan to reduce what works to address these issues, privileging the disparities in life expectancy between men studies that adopt a rigorous methodology where and women. The plan was approved by the Prime possible3 and drawing from regional evidence when Minister of Mongolia in May 2024 and covers the available. The review also covers evidence from period from 2024 to 2027. Mongolia to provide recommendations on how to tailor the global evidence to the country’s context. This report builds upon previous World Bank research and technical assistance on the topic The report is structured into three sections. with the aim of informing the implementation of Chapter 1 of the report provides an updated the government’s new action plan. With support diagnostic of gender differences in mortality and from the World Bank, the National Committee on summarizes the key underlying drivers of the Gender Equality (NCGE) conducted a desk review gender gap in life expectancy identified in previous to understand the gender gap in life expectancy work (World Bank 2020). Based on this diagnostic, in 2019. The desk review covered a diagnostic of four types of policy and program interventions differences in mortality data for men and women are selected for the review of evidence in and an analysis of the policy documents and Chapter 2, including interventions to reduce programs related to life expectancy. The study tobacco and alcohol consumption, interventions highlighted a need for a deeper exploration of the to increase uptake of primary health care, suicide underlying factors that drive gender differences in prevention interventions, and interventions to exposure to diseases, accidents, and injuries that address gender norms. Finally, Chapter 3 highlights affect life expectancy. As a result, in 2020, the World the way forward, including a summary of evidence- Bank supported the Government of Mongolia with based recommendations and global evidence on a study that explored the underlying drivers of the the costs of implementing them. gender gap in life expectancy, including differences 3 Evidence from randomized controlled trials, which provide the highest level of internal validity, was privileged; however, other non-experimental methods that use a counterfactual analysis to identify impacts were also included. For areas where very little rigorous evidence was available, other methods such as descriptive analysis or qualitative work were included in the review, and studies that rely on less rigorous methods have been noted as such in the text. 12 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT IS DRIVING CHAPTER 1. THE GENDER GAP IN LIFE EXPECTANCY IN MONGOLIA? CHAPTER 2. 13 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE WHAT IS DRIVING THE GENDER GAP IN LIFE EXPECTANCY IN MONGOLIA? Noncommunicable diseases (NCDs) are the main disproportionately affected by both, accounting for cause of death in Mongolia, as well as globally; 60 percent of deaths due to all three main types of they were responsible for 71.5 percent of all NCDs, but 50 percent of the population. The top deaths in 2021 (76.5 percent of women and 68 three types of cancers for men in 2023 were liver percent of men; figure 4). NCDs, also known as cancer (36 percent of all cancers), stomach cancer chronic diseases, tend to be of long duration and are (23 percent), and lung cancer (10 percent) (CHD the result of a combination of genetic, physiological, and WHO 2023). These are all cancers that are environmental, and behavioral factors. The main influenced by risk factors such as drinking, smoking, types of NCD that kill Mongolian men and women and a poor diet. Men accounted for 8 out of 10 are cardiovascular diseases (such as heart attacks cases of lung cancer (CHD and WHO 2023). and stroke) and cancers (figure 5). Men are Figure 4. Noncommunicable diseases are the main cause of death in both men and women Source: IHME 2021 14 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT IS DRIVING THE GENDER GAP IN LIFE EXPECTANCY IN MONGOLIA? Figure 5. Cardiovascular diseases and cancers are leading causes of death, with men disproportionately affected by all top causes of deaths Source: Center for Health Development 2023 data Mongolia also continues to face challenges with of respondents agreed or strongly agreed that heavy communicable diseases, particularly tuberculosis episodic drinking of alcohol is common, and 35- to (TB).4 Mongolia is among the 30 countries with the 64-year-old men reported an average consumption highest TB rate globally and the top four in the region of 10 standard drinks per drinking occasion (Demaio (WHO 2023a). TB rates were higher in men (85 per et al. 2013). Furthermore, statistics from 2016 show 100,000) versus women (54 per 100,000) in 2023 that 28 percent of men over age 15 engaged in at (CHD and WHO 2023). Alcohol use disorders, smoking, least one episode of heavy drinking over the past and undernourishment are the three main risk factors month, and 60 percent of men who drink had driving high TB rates in Mongolia (WHO 2023b). engaged in one episode of heavy drinking.5 The most common reasons for heavy episodic drinking Accidental poisoning, 99 percent of which was include celebrations or social drinking; however, from alcohol, is the third largest cause of death 67 percent of youth ages 15–24 cite customs or in Mongolian men (figure 6), highlighting a stark traditions as the reason for heavy episodic drinking, problem with excessive alcohol consumption. The and 10 percent of men use alcohol as a stress coping rate of accidental poisoning deaths due to poisoning mechanism (Demaio et al. 2013). In adults, alcohol in Mongolia is 2.8 per 100,000 people. This rate is 2.5 poisoning was the fourth largest cause of death times higher than the global average of 1.1 and twice outside of hospitals in 2020; some of these deaths the average for the Western Pacific region of 1.4. are estimated to be avoidable if there were better Likely related to the high rate of alcohol poisoning is access to quality emergency care, which is currently heavy episodic drinking, which is a common problem fragmented and underdeveloped in Mongolia in Mongolia. In a representative survey, 90 percent (Sainbayar et al. 2023). 4 Sexually transmitted infections represented the largest share of infectious diseases (46 percent in 2022). Respiratory tract infections were the second largest type of communicable diseases (26 percent), and TB accounted for 38 percent. 5 WHO Global Health Observatory, latest data available. CHAPTER 1. 15 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE Deaths from other injuries (accidents, suicides, violence cause over 50 percent of deaths in men and violence-related) are much higher in men than between the ages of 10 and 39 and between 30 and women (figure 5 and figure 6). In 2023, between 50 percent of deaths in men between the ages of 75 and 88 percent of all accidents, suicides, and 40 and 54 (figure 7a). Suicide is the leading cause violence-related deaths were in men (figure 6). of death among young men ages 15-29 in Mongolia In 2023, 436 men died by suicide in Mongolia (88 (World Bank 2019), and the average suicide rate percent of recorded suicides). It is likely that some of Mongolian adolescents is five times higher than deaths categorized as “other accidents” might that of the East Asia and Pacific region (Badarch et also be the result of suicide, which may be under al. 2022). In Mongolia, 32 percent of adolescents recorded due to the social stigma. 94 percent of ages 13 to 18 reported having attempted suicide suicides were achieved by self-intentional hanging, in 2019 (Badarch et al. 2022), and almost half of strangulation, or suffocation. Male suicide rates Mongolian students at a university reported having in Mongolia are among the highest in the world, suicidal thoughts (Davaasambuu et al. 2017). Trends with 30.7 deaths per 100,000 individuals in 2019 in youth suicide behavior have been increasing over compared to a global average of 12.6.6 According to time: suicide mortality among youth ages 10–14 a suicide audit conducted by the Center for Training years increased from 3.3 percent in 2003 to 11.4 and Research at the General Prosecutor’s Office of percent in 2019 (Badarch et al. 2022). The second Mongolia, most suicides occurred in individuals with leading cause of death of men under age 30 is only primary and secondary education levels, and road accidents. For men in their 30s, unintentional 47 percent of individuals who committed suicide alcohol poisoning is the main cause of death, were unemployed. In most cases (58.5 percent), the followed by suicide (table 2). From the age of 50, person had been under the influence of alcohol in NCDs—in particular, cardiovascular diseases and the preceding 72 hours (World Bank 2020). cancers—become more prevalent as the main causes of death in men. When comparing the cause The major causes of death appear to change over of death share between men and women (figure 7a the life course of Mongolian men, starting with and figure 7b) the trend of accidents as the larger suicides and accidents and then transitioning to share of the cause of death in younger people, and NCDs from around age 35. Suicides, accidents, and Figure 6. Men account for most suicides, accidents, and violence-related deaths Source: Center for Health Development 2023 data 6 WHO database https://data.who.int/indicators/i/F08B4FD/16BBF41. 16 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT IS DRIVING THE GENDER GAP IN LIFE EXPECTANCY IN MONGOLIA? NCDs in older people, holds for men and women; are evident when comparing men and women. The however, NCDs become the cause of the majority of higher rates of death from cancer among women deaths at age 45 for men versus age 35 for women. are noticeable. The overwhelmingly higher rates of suicide in men Figure 7. Suicides and accidents cause most deaths in men ages 10 and 35, whereas NCDs are the main cause of deaths in older men Source: CHD and WHO 2023. CHAPTER 1. 17 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE Table 2. Top three causes of male deaths, by age group, 2018 № Age group Cause Cause Cause 1 15–19 (1%) Intentional self-hanging, Unintentional exposure to gas Injuries from motorcycle acci- asphyxiation (20%) and steam, poisoning (10%) dent (7%) 2 20–24 (1%) Intentional self-hanging, Injuries from motorcycle acci- Other road accidents (10%) asphyxiation (25%) dents (10%) 3 25–29 (2%) Intentional self-hanging, Assault, murder (8%) Other road accident (7%) asphyxiation (23%) 4 30–34 (4%) Unintentional alcohol Intentional self-hanging, asphyx- poisoning (16%) Other road accident (5%) iation (14%) 5 35–39 (5%) Unintentional alcohol Intentional self-hanging, asphyx- Liver fibrosis and cirrhosis poisoning (17%) iation (9%) (8%) 6 40–44 (6%) Unintentional alcohol Stroke (7%) Heart ischemia (6%) poisoning (16%) 7 45–49 (11%) Subarachnoid hemorrhage Noninfectious gastritis and Death from falling (14%) (11%) colitis (8%) 8 50–54 (11%) Liver and bile duct can- Unintentional alcohol poison- Stroke (12%) cers (13%) ing (8%) 9 55–59 (12%) Liver and bile duct can- Stroke (12%) Heart ischemia (10%) cers (18%) 10 60+ (40%) Liver and bile duct cancers Other heart and cardiovascu- Heart ischemia (16%) (12%) lar disease (11%) Suicide Unintentional poisoning Accidents and violence Noncommunicable diseases Sources: World Bank 2019, using data from the Center for Health Development. 18 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT IS DRIVING THE GENDER GAP IN LIFE EXPECTANCY IN MONGOLIA? Risky behaviors, health seeking behaviors, and gender norms may be influencing the gender gap in life expectancy. The biological differences between men and in East Asia and Pacific (Yang, Yu, and Wen 2019), women cannot fully explain the gender gap in including the top causes of death in Mongolia, such life expectancy.  The available evidence suggests as heart disease, cancer, and respiratory disease; that male fetuses are biologically weaker and more men are disproportionately susceptible to lung vulnerable during pregnancy than female fetuses cancer from smoking (Tuvdendorj et al. 2020). The (Hossin 2021). However, if biology were the sole total annual estimated consumption of alcohol in cause of the gender gap in life expectancy, one men over age 15 years was 13 liters (of pure alcohol), could expect the gap to be relatively constant over compared to 3.8 liters in women.9 According to time and across societies (Hossin 2021).  Because a survey of over 2,000 men from four regions, 71 the gender gap in life expectancy in Mongolia is percent had consumed alcohol within the past year; significantly larger than in other countries and has 28 percent of men were likely or highly likely to been growing, biology alone cannot explain the gap. drink too much alcohol in public (World Bank 2020). Per capita consumption of alcohol in men increased The gender gap in life expectancy in Mongolia from 7.2 liters of pure alcohol per year (three-year has been linked with a higher rate of risky health average) in 2005 to 12.7 liters in 2019, compared behaviors in men, including smoking and alcohol to 1.9 to 3.4 liters for women.10 The heavy usage consumption, which elevate men’s risk of certain of alcohol in Mongolia has also been associated NCDs and can be a contributing factor in accident-, with social problems and mental health issues violence-, and suicide-related deaths. Gender (Lkhagvasuren et al. 2024). A recent study found gaps in mortality in Mongolia are associated with that approximately 15 percent of Mongolians were strong gender differences in alcohol and tobacco at moderate to high risk of alcohol dependence, consumption in Mongolia; men are 13 times more with men approximately 10 times more likely likely to engage in tobacco use and 3.4 times more than women to be at high risk (Tumur-Ochir et al. likely to engage in chronic heavy drinking than 2023). In addition, men face a higher burden from women (Pengpid and Pelzer 2022). With respect to unhealthy diet risk factors. Between 2000 and 2020, smoking, an estimated 52 percent of male adults the prevalence of obesity is estimated to have more smoke compared to 7 percent of female adults.7 than doubled among men ages 18 years and older, Rates of male tobacco consumption in Mongolia are from 8.6 percent to 20.9 percent; it almost doubled among the highest in the world and second largest among women of the same age, from 14.4 percent in Asia after Indonesia,8 and they are increasing to 26.5 percent.11 (Pengpid and Pelzer 2022). Tobacco consumption is strongly associated with higher all-cause mortality 7 WHO Global Health Observatory database, latest year available. 8 WHO Global Health Observatory database, latest year available. 9 WHO Global Health Observatory database. latest year available. 10 WHO Global Health Observatory database. 11 Global nutrition report database, latest data available, https://globalnutritionreport.org/resources/nutrition-profiles/asia/eastern-asia/mongolia/ CHAPTER 1. 19 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE The gender gap in life expectancy in Mongolia these diseases (World Bank 2020). At least in part, has also been linked to men being more averse to this discrepancy seems linked to later diagnosis seeking medical attention than women, a behavior of medical conditions for men, although other that can hinder efforts to prevent, diagnose, and factors, such as knowledge and implementation of treat medical issues, including NCDs. Despite men treatment regimens, may also contribute to the gap having disproportionally higher mortality from (World Bank 2019). preventable NCDs, they are much less likely than women to make use of primary health care for Norms about masculinity increase the rates of risky these issues. Men’s underutilization of medical care health behaviors among men, including smoking likely contributes to the gender gap in mortality, and alcohol consumption and a reluctance to seek particularly with respect to treatable diseases. health care. Alcohol consumption and smoking Although Mongolia has a higher-than-average have been associated with masculinity in other gender gap in life expectancy, men’s underutilization contexts (Demaio et al. 2014; Kodriati, Pursell, and of health care services is a global issue and has Hayati 2018; Ng, Weinehall, and Öhman 2007; been linked to gendered roles and expectations in Peralta 2007; Wells et al. 2014). In Mongolia, a wide variety of contexts, including in high-income men’s adherence to gender norms is positively countries (Galdas, Cheater, and Marshall 2005)12 and correlated with their engagement in risky health in Asia as a whole (Tong, Ho, and Tan 2010). A survey behaviors, including smoking, drinking, eating of men from four regions in Mongolia showed that poorly, and avoiding going to the doctor (World 59 percent of men reported only seeking medical Bank 2020). Men’s reluctance to seek health care attention when ill, and 20 percent had never seen may be linked with Mongolian gender norms that a doctor (World Bank 2020). Interviews with local associate help-seeking with femininity. Indeed, health representatives reported low rates of men showing vulnerability is considered to be a feminine visiting hospitals, particularly for preventive care; attribute in Mongolia (UNICEF 2020). Evidence there was a tendency for men to only see doctors from other contexts shows that men avoid seeking when conditions are severe (Worth Bank 2019). Of health care to assert their masculinity, especially people with hypertension, men are more likely than when other forms of affirming their masculinity, women to be unaware that they have hypertension; including productive employment, are unavailable only 36 percent of women and 23 percent of men (Courtenay 2000). Global evidence shows that are aware they have this condition. In addition, in norms affect not only the likelihood of seeking care those with diagnosed hypertension, the condition for physical health but also mental health care and is under control in only 19 percent of men and 33 outcomes. Meta-analysis shows that conformity to percent of women.13 In 2018, women were more certain masculine norms is associated with higher likely to be diagnosed with cancer and cardiovascular rates of mental health issues and less likelihood to diseases, although men were more likely to die from seek psychological health care (Wong et al. 2017). 12 This is an older reference, but it is a prominent review worth referencing. 13 NCD RisC Risk Factor Collaboration database, https://www.ncdrisc.org/data-downloads-hypertension.html. 20 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT IS DRIVING THE GENDER GAP IN LIFE EXPECTANCY IN MONGOLIA? Mongolian gender norms about men’s roles risks (World Bank 2020). Consequently, men are further influence men’s exposure to health risks, much more likely than women to experience including risky health behaviors, thereby affecting workplace injuries across sectors of activity (NSO the gender gap in life expectancy. In Mongolia, men 2024). Programs that boost job availability or quality are expected to be breadwinners, protectors, and and social protection programs hold the potential even aggressors (UNICEF 2020). Due to the highly to reduce the stress that men feel to provide; such competitive labor market with few opportunities reductions in stress could have overall physical and to earn adequate wages, men are unable to fulfill mental health benefits, as well as support access their traditional roles as providers for their families. to care in a context where cost is an impediment.14 Without sufficient employment, men can lose hope While these types of interventions are critical to and turn to alcohol or tobacco to alleviate their stress address broader structural issues affecting men’s from the pressures they face to fulfill their traditional health and the gender gap in life expectancy, they roles as breadwinners (World Bank 2020). Indeed, are not covered in this review.15 approximately 10 percent of men in Mongolia listed alcohol as a way to manage psychological stress in their everyday lives; the rates of turning to alcohol to cope with stress are higher among those ages 35 to 44 and those who are unemployed (Demaio et al. 2013). The pressure to provide resources for families and the challenges in doing so can breed mental health challenges and contribute to higher suicide rates. Emotional vulnerability is considered feminine in Mongolia (UNICEF 2020), creating a barrier for men to seek help to cope with the challenges they face. In addition, Mongolian men are often engaged in more laborious, heavy-duty work in risky environments and lack sufficient knowledge of appropriate occupational safety measures, which exposes them to greater health 14 World Bank (2020) shows that some men avoid seeking care due to cost issues. 15 See ILO (2024) for a review of social protection policies and interventions, Arévalo-Sánchez et al. (2024) for a review of interventions to promote economic inclusion, World Bank (2012) for analysis of jobs, and World Bank (2018) for analysis of how to respond to the changing nature of work. CHAPTER 1. 21 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE 22 Forest Jarvis, Hillary C. Johnson, and Maude Ruest CHAPTER 2. WHAT ARE PROMISING SOLUTIONS FOR ADDRESSING THESE CHALLENGES? CHAPTER 2. 23 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE WHAT ARE PROMISING SOLUTIONS FOR ADDRESSING THESE CHALLENGES? This evidence note provides a summary of international evidence on what works to address four issues related to the gender gap in life expectancy in Mongolia focusing on interventions to: 1. Reduce the rates of smoking and excessive alcohol consumption 2. Increase the uptake of primary health care services 3. Prevent suicides 4. Address social norms about masculinity.16 #1: Interventions to Reduce the most cost-effective and feasible by countries in all settings, with an average cost of less than Smoking and Excessive International $10018 per healthy life year gained in Alcohol Consumpton low-income and middle-income countries (figure 8). There are several frameworks to inform the Mongolia ranks at the highest level of performance effective and cost-effective measures that Mongolia in such categories as monitoring tobacco use, as can implement or improve to reduce the rates of well as health warnings and bans on advertising smoking and excessive alcohol consumption. The for nicotine products. However, it has lower MPOWER measures were developed by the World taxation on cigarettes than other countries in the Health Organization (WHO) to support country- region and lacks mass media campaigns and large- level implementation of the effective interventions scale cessation programs (WHO 2023b). Fully to reduce the demand for tobacco included in the implementing a package of six key policy actions WHO Framework Convention on Tobacco Control recommended by the WHO Framework Convention (promoting Monitoring of tobacco use, Protection on Tobacco Control could avoid 19,200 deaths and from second-hand smoke, Offering help quitting avert MNT 2.4 trillion (~US$ 705 million) in economic smoking, Warning about dangers of smoking, losses by 2037 due to reduced mortality, lower Enforcing smoking bans, and Raising taxes). The health care expenditures, and improved capacity for WHO selected the NCD best buys interventions productivity while at work (UNDP 2024). (WHO 2024a)17 because their implementation was 16 Although other interventions, such as those promoting occupational and road safety measures, may be relevant in the context, this note focuses on factors that would address the main causes of excess male mortality. Other interventions would support public health goals; however, they may not lead to large decreases in the gender gap in life expectancy, because they cause a smaller number of deaths. 17 The best buys and recommended interventions present a menu of policy options and cost-effective and recommended interventions for each of the four key risk factors for NCDs (tobacco, harmful use of alcohol, unhealthy diet, and physical inactivity) and for four disease areas (cardiovascular disease, diabetes, chronic respiratory disease, and cancer). 18 An international dollar would buy in the cited country a comparable amount of goods and services that a US dollar would buy in the United States. 24 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT ARE PROMISING SOLUTIONS FOR ADDRESSING THESE CHALLENGES? Figure 8. Nine of the NCD best buy interventions target reduced tobacco use and the excessive use of alcohol Reduce tobacco use • Increase excise taxes and prices on tobacco product. • Implement large graphic health warnings on all tobacco packages, accompanied by plain/ standardized packaging. • Enact and enforce comprehensive bans on tobacco advertising. • Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places, and public transport. • Implement effective mass media campaings that educate the public about the harms of smoking/tobacco use and secondhand smoke and encourage behavior change. • Provide cost-covered effective population-wide support (including brief advice, national toll-free quit line services, and mCessation) for tobacco cessation users. Reduce the harmful use of alcohol • Increase excise taxes on alcholic beverages. • Enact and enforce bans or comprehensive restricitions on exposure to alcohol advertising across multiples types of media. • Enact and enforce restriction of the physical ability of retailed alcohol via reduced hours of sale. Source: WHO 2024a. Strengthen tobacco and alcohol excise increasing alcohol taxes reduces consumption and taxes (increasing and improving the has a stronger effect than any other prevention design). policy (Wagenaar, Salois, and Komro 2009). Taxation also strongly reduces alcohol-related mortality, Very strong evidence globally suggests that raising including overdoses, accidents, suicides, and traffic taxes on tobacco products is a cost-effective fatalities (Son and Topyan 2011; Wagenaar et al. measure to reduce tobacco usage, both by 2010). Additional evidence indicates that taxation preventing its take-up and by inducing quitting has been successful in reducing mortality in low- (Chaloupka, Yurekli, and Fong 2012). Increasing and middle-income countries, including in Asia tobacco taxes is particularly effective in low- and (Cook, Bond, and Greenfield 2014; Sornpaisarn et middle-income countries (Ranson et al. 2002), and al. 2020). in reducing tobacco usage among lower-income people (Verguet et al. 2015). Similar to the taxation Mongolia has a well-established system of taxes of tobacco, excise taxes on alcohol are a widely on alcohol and tobacco, but the lack of regular enacted strategy for reducing alcohol consumption. increases in the level of the taxes has resulted in low The amount of taxation sometimes varies by prices and improved affordability. Mongolia needs the alcohol content; stronger beverages have a to focus on increasing taxes on tobacco and alcohol higher tax rate. There is very strong evidence that meaningfully (in both absolute and relative terms). CHAPTER 2. 25 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE A snapshot of the tobacco and alcohol taxation in Alcohol taxes in Mongolia are significantly more Mongolia is noted in the following paragraphs: complex than tobacco; they vary according to the additional details and recommendations can be type of alcohol and reflect the greater heterogeneity found in the forthcoming World Bank “Mongolia in alcohol products on the market. Taxes on spirits Public Financing Review.” (the most consumed alcohol in Mongolia) have undergone reforms in recent years with further In Mongolia, total taxes on tobacco constitute 45 reforms scheduled every second year from 2023 percent of the retail price of the most sold brand to 2029. Currently, the share of the excise tax in of cigarettes. Specific excise taxes account for 36 the retail price ranges from 7 percent in beer to 30 percent of the retail price of tobacco products, percent for vodka. These reforms increase tax rates and the value added tax or sales tax accounts for and introduce greater granularity in alcohol content an additional 9 percent. Mongolia’s cigarette price tiers. Taxes on alcohol have declined in recent years, is among the lowest of the countries in the region. but the prices have continued to increase. These Since the beginning of 2014, the prices of domestic reforms are innovative and may generate stability cigarettes have increased by 29 percent in nominal in revenue and small improvements in health terms but declined by 17 percent in real terms outcomes, but their complexity may undermine (World Bank forthcoming). Notably, the lack of their intended impact. increases in excise taxes have resulted in cheaper cigarettes over time (Worth Bank forthcoming). Overall, Mongolia scores 1.5 out of 5 according to the Enhance bans on tobacco and cigarette tax scorecard, which is below the Western alcohol advertising, promotion, and Pacific region, the global average, and low-middle sponsorship. income countries.19 More specifically, Mongolia scores poorly for cigarette prices and tax share. Evidence shows that banning tobacco advertising According to the scorecard, Mongolia would greatly and sponsorship is one of the most cost-effective benefit from higher cigarette prices, reducing the ways to reduce tobacco demand20 and leads to a affordability of cigarettes, increasing the tax share reduction in the number of people who start and of price, and improving the tax structure. Increasing continue to smoke. Comprehensive advertising the tobacco tax to the WHO-recommended rate of bans reduce smoking initiation by an estimated 75 percent has been modeled as a highly effective average of 6 percent and smoking prevalence by intervention for Mongolia; it would be more cost- an estimated average of 4 percent; a partial ban effective and would lead to greater reductions is likely to only reduce prevalence and initiation in smoking than mass media campaigns, school by 2 percent (Levy, Chaloupla, and Gitchell 2004). programs, or cessation support (an estimated Similarly, global evidence indicates that restrictions 40,000 fewer smokers over a three-year period or bans on advertising are effective in reducing (Tuvdendorj, Feenstra, and Buskens 2023). alcohol consumption and associated public health 19 The newly released 3rd edition of the Tobacconomics Cigarette Tax Scorecard scores cigarette tax policy performance in 170 countries on a five-point scale using data from the WHO’s biennial Report on the Global Tobacco Epidemic, providing policy makers with an actionable assessment of their country’s cigarette tax policy. https://tobacconomics.org/cigarette-tax-scorecard/mn/ 20 https://www.who.int/europe/health-topics/tobacco/banning-tobacco-advertising-sponsorship-and-promotion#tab=tab_1. 26 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT ARE PROMISING SOLUTIONS FOR ADDRESSING THESE CHALLENGES? risks (Anderson 2009; Saffer and Dave 2010; drinking with the lower alcohol content beverages WHO 2017); in addition, restrictions can reduce that are frequently advertised (Dashpuntsag et al. incentives and social pressure to drink. Restrictions 2021). Mongolia’s state-run alcohol monopoly may are likely to be particularly effective in reducing make the enforcement of advertising somewhat consumption by adolescents, who are more easier than in other countries (Jiang et al. 2018). susceptible to advertising (Saffer and Dave 2006). Restrictions may include requiring alcohol products to include conspicuous warning labels, banning Expand 100 percent smoking bans advertisements on social media or other media, to all indoor workplaces and public banning promotions that target young people, places or banning sponsorship activities. They may also include increased investment in the enforcement of Smoking bans have been shown to reduce death already existing restrictions. Advertising restrictions rates and hospital admissions for ischemic heart have been found to be effective in middle-income diseases (Montes de Oca, Paraje, and Cuadrado countries (Cook, Bond, and Greenfield 2014), 2024), hospital admissions due to cardiovascular including in Asia (Sornpaisarn et al. 2020). However, diseases and lower incidence of lung cancer, and bans on advertising are often difficult to enforce asthma admission rates; bans have also been (Jones, Hall, and Munro 2009), particularly online associated with a lower risk of respiratory disease advertising (Gallopel-Morvan 2016). (Strassmann et al. 2023). By shifting norms about smoking, smoking bans in public places induce Mongolia has a comprehensive ban on direct voluntary restrictions on smoking in private homes, tobacco advertisement and a ban on many forms reducing overall exposure to secondhand smoke of tobacco promotion and sponsorship. Tobacco rather than displacing it (Monson and Arsenault products at the point of display are not explicitly 2017). Evidence from some countries indicates that banned (UNDP 2024); although, point of display partial bans are ineffective at reducing smoking, advertising increases smoking (Robertson et al. 2015; whereas full bans are effective (Catalano and WHO 2017). Banning point-of-sale product displays Gilleskie 2021; Pinilla, López-Valcárcel, and Negrin is estimated to generate a return on investment 2019). At least one study shows that partial bans equal to 66 times the amount of investment over can increase the frequency of smoking among a 5-year period in Mongolia when considering the smokers, likely due to peer effects when smokers expected reduction in mortality, avoided health care are concentrated in designated areas (Catalano and expenditure, and improved productivity at work Gilleskie 2021). (UNDP 2024). Mongolia also already has a ban on the advertising of high-content alcoholic beverages; Mongolia already has some 100 percent smoke- however, advertising and sponsorship are permitted free areas in places like hospitals and public for other products. Expanding advertising and transport. However, other public areas—including sponsorship bans to cover all alcoholic beverages, bars, restaurants, shopping centers, hotels, and including low-content ones, may be particularly businesses—are subject to a partial smoking ban effective in reducing alcohol consumption among that allows smoking in designated areas. Broadening young people, who reportedly started drinking due a 100 percent smoke-free policy to include more to advertising and who are more likely to begin public places—removing the option to have CHAPTER 2. 27 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE restricted smoking areas—could have a substantial states and the central levels of government, “taking impact on smoking rates and could reduce smoking- into account the number of people living in the related diseases, deaths, and hospital admissions. respective territory, territory size, the criminal and Indeed, recent estimates show that expanding public order situation, location of health, cultural smoking bans in Mongolia would have a 69:1 return and sports institutions, the students’ school and on investment over a 5-year period (UNDP 2024). dormitory, as well as  proposal of aimag21 and the capital city.”22 The hours that alcohol can be served depend on the permit and can be either from 11:00 Increase alcohol sale restrictions a.m. to 10:00 p.m. or from 2:00 p.m. until 4:00 a.m. to limit the physical availability of Alcohol cannot be sold to individuals under the retailed alcohol. age of 21 or to intoxicated individuals, and sales are restricted in a limited number of locations.23 In In addition to reducing the overall supply of practice, however, alcohol is widely available. The alcohol on the market, sale restrictions are often number of permits issued could be reviewed, and implemented as a means of reducing excessive stricter rules on the times and dates of sale are alcohol consumption. They may include restricting likely to be effective in reducing excessive drinking. sales of alcohol to dedicated public or private outlets Moreover, further restricting the venues where or restricting the days and times at which alcohol alcohol is commercially available may allow for can be sold. Strong evidence from lower-income stricter and more effective enforcement of laws countries suggests that restricting the days on already in place. which alcohol can be sold reduces excessive alcohol consumption and related harms (Middleton et al. 2010), while restrictions on the hours of sale have Make smoking quit lines and similar impacts (Hahn et al. 2010). Evidence from counseling available. low- and middle-income countries suggests that sale restrictions tend to be the strongest predictors Very strong global evidence on the effectiveness of of lower alcohol consumption compared to other quit lines shows that they are cost effective (Tomson, policies (Cook, Bond, and Greenfield 2014). Helgason, and Gilljam 2009); on average, they double the likelihood that users will quit smoking (Ali Mongolia currently has a state monopoly on alcohol et al. 2018). Quit lines have been proven effective and some restrictions on alcohol sales (WHO 2018). in higher income countries, including in Hong Kong Both alcohol producers and vendors are required SAR, China (Abdulla et al. 2004); the Republic of to acquire special permits, and the production Korea (Myung et al. 2008); and Thailand (Meeyai permits are managed by the central government. et al. 2014). Evidence from Korea suggests that quit The number of permits for selling and serving lines may be particularly effective for male smokers. alcoholic beverages are determined jointly by the Quit lines may be more effective if targeted to the 21 Aimags are the second administrative divisions of Mongolia, equivalent to provinces in rural areas. There are 21 aimags, which further divided into 330 soums— the first administrative units. A soum is further divided into baghs, which are made up of about 100 households. 22 Mongolian Law on Control of the Circulation of Alcoholic Beverages and Combating Alcoholism, July 05, 2022, Article 15.7. 23 Mongolian Law on Control of the Circulation of Alcoholic Beverages and Combating Alcoholism, July 05, 2022. 28 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT ARE PROMISING SOLUTIONS FOR ADDRESSING THESE CHALLENGES? populations that are more likely to use tobacco, combined with other tobacco control measures including men and those living in urban areas. (Durkin et al. 2012). There is evidence that they are Similarly, although most of the evidence on the effective in middle-income countries and may even effectiveness of group therapy/counseling is from be more effective than in high-income countries higher income countries evidence from programs (Levy et al. 2018). When applying evidence from in middle-income countries (Akanbi et al. 2018), other middle-income countries to data from including in Asia suggest that it is successful in Mongolia, mass media campaigns were found to be reducing the rates of smoking (Mohamed et al. a cost-effective strategy due to preventing uptake by 2021). It has been found to be particularly effective new smokers and encouraging quitting by existing for men (Wenig et al. 2013) and effective when smokers (Tuvdendorj, Feenstra, and Buskens delivered in workplaces (Caponnetto et al. 2020). 2023); media campaigns are estimated to have a In Thailand, counseling was found to be more cost- 76:1 return on investment over a 5-year period in effective when combined with nicotine replacement Mongolia (UNDP 2024). Campaigns may be best therapy (Tosanguan and Chaiyakunapruk 2016). spread through both radio and television given the Non-experimental evidence from Mongolia very high rural population in Mongolia, and they can suggests that group counseling can be an effective be developed to target men. Using evidence from cessation measure (Baigalmaa et al. 2006). Given China, a cost-benefit analysis finds that school-based that smoking is concentrated in men of working age, interventions in Mongolia would be cost-saving, as workplace-based support to quit smoking, including they can significantly reduce the number of new counseling, may be particularly effective. Evidence smokers (Tuvdendorj, Feenstra, and Buskens 2023). from lower-income countries suggests that it may Youth interventions may be best combined with be a promising approach within the Mongolian other campaigns targeting adults, because parental context, particularly if adapted to local cultural influence is an important determining factor of norms. Therapy may be rolled out with other smoking in Mongolia (Rudatsikira et al. 2008). community-level interventions, such as community health workers and public information campaigns. Roll out mass media campaigns. Global evidence suggests that mass media campaigns to reduce tobacco usage are effective in both preventing new smokers from starting and convincing current smokers to quit (Bala et al. 2017). Campaigns are most effective when focusing on the negative health effects of smoking and when CHAPTER 2. 29 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE #2: Interventions to Increase are available is important for several reasons. These reasons include avoiding complications and the Uptake of Primary hospitalizations. The WHO has found that increasing Health Care screening for common NCDs, such as cardiovascular disease, would be a cost-effective health policy Despite the widely recognized gender gap in uptake (WHO 2024a), while screening for hypertension of primary health care, there is very little evidence has been demonstrated as effective in reducing the on which policies and interventions work to close risk of cardiovascular disease (Guirguis-Blake et al. it. Potential interventions to increase primary health 2021). Early contact with doctors can reduce the risk care usage to reduce the burden of NCDs include of deaths from heart disease (Kottke et al. 2009). supply-side measures, which make primary health care more accessible to patients, and demand- Mongolia has a strong health workforce, but side measures to incentivize patients to seek updating the service delivery model—including medical care. Baker (2018, 7) notes that “there is better management and coordination of the a recognition that, far from all men being simply workforce to ensure the right staff are located in “reckless and feckless,” many are already interested the right place—can help to ensure that Mongolia in health and actively engaged in self-care and is making the best use of available resources (World self-management and that significantly more men Bank forthcoming). An estimated 21 percent of would do so if provided with the right opportunities. hospital inpatient cases in 2021 could have been The most effective approaches acknowledge men’s avoided and treated in primary health care settings difficulties with respect to their health but attempt at much lower costs (World Bank forthcoming). A to build on their strengths and to work with them in simulation has shown that shifting 10 percent of a positive and supportive way.” inpatient care, to day surgeries or outpatient care could produce annual savings of between MNT 25 and 65 billion (~US$8 to US$20 million) to the Broadly strengthen primary health health sector (World Bank forthcoming). Expanding care, starting with reviewing the the scope of Mongolia’s Reaching Every District model of care. program is also promising; it has been successful in improving health access for vulnerable populations, International evidence suggests that health including the rural poor, although it has traditionally systems with a primary health care focus have focused on maternal and child health. better health outcomes  and lower health costs. With its emphasis on promotion and prevention, addressing determinants, and a people-centered Address the structural barriers approach, primary health care has proven to be to men’s health care and create a highly effective and efficient way to address the male-friendly services. main causes of, and risk factors for, poor health, as well as to handle the emerging challenges that may Both perceived and actual structural barriers can threaten health in the future (WHO and UNICEF inhibit men’s care-seeking, including the hours and 2018). Since NCDs are the leading cause of death availability of appointments that might conflict with for both men and women in Mongolia, making working hours, the lack of male providers, the need sure preventive care, screening, and treatment to disclose the reason for consultation at the time of 30 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT ARE PROMISING SOLUTIONS FOR ADDRESSING THESE CHALLENGES? booking, and a female-focused physical environment timing and pace of treatments (Seidler et al. 2024). (Mursa, Patterson, and Holcomb 2022). Programs Other suggestions include being aware of gender that take account of gender differences and male norms when developing services, capitalizing on the sensibilities are much more likely to work than key points in men’s lives (for example, becoming a many one-size-fits-all approaches (Baker 2018). father), and going to “where men are” (workplaces, In Brazil, one success under the National Policy sports clubs, and faith groups) to provide health of Comprehensive Healthcare to Men (PNAISH) education or check-ups (Baker 2018). included having family health units open for extended hours during the week and on Saturdays to Another option to improve men’s access to health accommodate working men’s schedules (Lima and care involves the use of technology to reach Schwarz 2018). Although the hours of operation did populations that are dispersed or that struggle to not change, a pilot of men’s clinics in Kenya hired get to health care centers during opening hours. male health workers to deliver free routine health Telehealth can improve health outcomes while care services exclusively to men in separate areas remaining a cost-effective way of delivering health of existing facilities where visits could be perceived care, as evidenced particularly during the COVID as more confidential and tailored to men’s needs as pandemic (Mahtta et al. 2021). However, barriers to patients. The men’s clinics increased both the total equal access have been raised (Connolly, Charness, number of visits and preventive care visits (Dowden and Miller 2023; Mahtta et al. 2021); the full et al. 2019). potential of telehealth is still largely underexplored and would benefit from additional research Working with skilled health workers to improve their (Sharma, Pruthi, and Sageena 2022). Mobile knowledge of how to engage men most effectively health (mHealth) interventions may be effective is also a promising strategy. To improve men’s in increasing the use of care in low- and middle- comfort in accessing primary health care, providers income countries, although there are few rigorous can reduce power dynamics during the visits by studies (Hurt et al. 2016). The evidence that they can creating interactions characterized by trust and improve other health-related behaviors is less solid shared decision-making, employing motivational than other interventions (Marcolino et al. 2018). interviewing techniques to encourage behavioral There is also inconsistent evidence that mHealth change and healthy habits, adopting screening tools interventions are effective in improving outcomes that are adapted to men’s age to cover important related to heart failure and cardiovascular disease and relevant issues for men in different stages of (Cajita et al. 2016), although they may be effective life, and connecting men to community resources in reducing and managing hypertension (Saleh et to improve their health information and facilitate al. 2018). Given Mongolia’s relatively disbursed and follow-up interventions (Rosu, Oliffe, and Kelly mobile population, piloting telehealth and mHealth 2017). Health care workers can tailor communication interventions may be relevant; however, such pilots to reach men, for example, through using humor, should be rigorously evaluated for effectiveness and directly raising issues, and encouraging men to tell equitable reach prior to scaling up investments. their stories, and through structuring treatment to respond to men’s needs by collaboratively setting goals; developing action-oriented, solution-focused treatment plans; and allowing flexibility in the CHAPTER 2. 31 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE Encourage male care-seeking #3: Interventions to Prevent behavior. Suicide In addition to structural barriers, global evidence points to internal barriers—such as fear and The WHO has developed implementation guides embarrassment or the perception that care- that can provide more detailed information on how seeking is linked with weakness, vulnerability, or to operationalize evidence-based interventions femininity—as well as a lack of information about that include examples of best practices from other the role of general practice and its importance countries. These tools include the following: Live in delivering preventive care and advice (Mursa, Life: An Implementation Guide for Suicide Prevention Patterson, and Halcomb 2022). Male-sensitive in Countries (WHO 2021a) educational interventions can increase men’s intention to screen for health risks (Teo et al. 2018). • Mental Health Gap Action Programme Relatively simple measures, such as referral letters, (mhGAP) Guideline for Mental, Neurological, have been shown to be effective in increasing men’s and Substance Use Disorders (WHO 2023c) use of preventive care, including in lower-income • Guidelines on Mental Health Promotive and countries (Ciancio et al. 2021). Communications Preventive Interventions for Adolescents that include health education information with (WHO 2020). patient-specific invitations and reminders have been found to be effective in increasing preventive The WHO has also developed a toolkit to reduce care seeking (De Walque et al. 2022; Holland et. al. stigma and discrimination in mental health services 2005), as has communication with other household (WHO 2024b). Some of these interventions are members such as spouses who can support the relevant in the Mongolian context and are developed patient and encourage them to seek care (Holland in the next section, while others such as improving et al. 2005; Teo, Ling, and Ng 2018). Personalized mental health services should be explored in, and interventions may increase the uptake most among tailored for, the Mongolian context. those patients with underlying health conditions who will particularly benefit (Van Gestel et al. 2023). Foster socioemotional life skills in Health-related communications can be delivered adolescents. through digital means. For example, a rigorous study in Indonesia found that personalized and Fostering the life skills of young people is one of the targeted text messages were effective in increasing four core effective evidenced-based interventions the use of preventive care for NCDs (Marcus et al. recommended by the WHO’s Live Life guide and 2024). Cash incentives for utilizing preventive care has a solid evidence base showing its efficacy. may increase take-up but are more expensive (De Adolescence (ages 10–19 years) is a critical Walque et al. 2022). Nevertheless, there is a need period for socioemotional skill development, and for more robust interventions to boost men’s adolescents are at particular risk for the onset of demand for primary health care, particularly in low- mental health conditions (WHO 2021a). Targeted and middle-income countries (Fan and Song 2015). group-based interventions and cognitive behavioral therapy delivered through schools have been shown 32 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT ARE PROMISING SOLUTIONS FOR ADDRESSING THESE CHALLENGES? to reduce depressive symptoms and anxiety (Das et mobilized in other contexts to provide mental al. 2016), while school-based awareness programs health and psychosocial support; there is some have been shown to reduce suicide ideation and evidence that NSHWs can be mobilized to reduce attempts (Zalsman et al. 2016). Population-based the incidence of suicide and improve detection of interventions that address healthy coping strategies at-risk individuals (Malakouti et al. 2015). Programs and life skills development are particularly effective mobilizing NSHWs to deliver treatment have been in reducing suicide rates (Ayer et al. 2022). However, shown to boost recovery rates of adults suffering more evidence is needed to demonstrate the from depression, anxiety, or both in the 2–6 months effectiveness of school-based programs in low- and after treatment and to decrease the amount of middle-income countries (Bradshaw et al. 2021). alcohol consumed by people with alcohol-use disorders (Van Ginneken et al. 2013). A review With the support of UNICEF, the Mongolian Ministry of 55 randomized controlled trials showed that of Education and Science has introduced mental different types of NSHW interventions—individual health literacy and life skills programs in secondary psychotherapy, case management, collaborative schools in two provinces; these programs will support care—and a variety of NSHW care providers—health socioemotional learning; promote resilience; and professionals, community workers, and peers—can encourage communication with families, peers, alleviate depression (Bunn et al. 2021). and teachers. The programs also provide capacity building for doctors and social workers, integrate Mongolia’s primary health care system has counseling into national teacher in-service training, 334 general practice clinics that provide basic and organize parents’ evenings to educate parents mental health services and serve as gatekeepers. and reduce the stigma about mental health issues Secondary care is provided at general hospitals, and (UNICEF 2022). Lessons of what has worked well complex cases are referred to the National Center and what can be improved should be taken from the of Mental Health. However, resource limitations monitoring and evaluation of this program to inform in budget and service delivery capacity hinder the its potential scale-up. ability to provide sufficient mental health services, with 0.6 psychiatrists and 0.5 nurses per 10,000 Improve access to mental health individuals, which is lower than the global average services. (Lkhagvasuren et al. 2024). Community-based centers have been used previously in Mongolia Most individuals who commit suicide struggle with to improve access to mental health services. mental health issues, including depression and The Ger Project created centers with nurses, substance use disorders (Bertolote and Fleischmann occupational therapists, and psychiatrists who 2002; Bradvik 2018). Access to mental health provided a variety of services, including exercise services, including increased mental health staffing, and relaxation, life skills, self-care, vocational skills, can reduce suicide rates and associated mental psychoeducation, as well as counseling, treatment, health risk factors (Atkinson et al. 2018; Doty et and family support programs. This project reduced al. 2022; RAND 2018). Treatment for depression the relapse rate of mental disorders by 95 percent is recognized as an important intervention (Altanzul et al. 2009). for preventing suicides (Zalsman et al. 2016). Nonspecialized health workers (NSHWs) have been CHAPTER 2. 33 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE Provide early identification, established under the 2017 Youth Development law management, and follow-up of could be harnessed to help assess risk and connect anyone with mental health conditions, youth to services. including those affected by suicidal behaviors. Work with the media on the responsible reporting of suicides. Early identification, assessment, and follow-up is one of the four core effective evidence-based Interacting with the media on responsible interventions of the WHO’S Live Life program. reporting is one of the four core interventions Reviews of evidence have shown that early recommended by the WHO’s Live Life guide identification and response to identified risks (WHO 2021a). Sensational reporting on suicides of suicide can be effective suicide prevention has been shown to lead to an increase in suicides programs; however, early identification raises immediately after publication, with greater publicity challenges if mental health resources are not readily of the suicide leading to larger rises in subsequent available to support identified individuals (Ayer suicides (Cheng et al. 2007; Hawton and Williams et al. 2022). Randomized controlled trials from 2002). In Taiwan, China, sensational reporting of lower- and middle-income countries in Asia have celebrity suicides has been shown to increase the shown that brief intervention and contact protocols number of suicides and increases in the method delivered either in person or remotely by postcards of suicide used in the profiled deaths (Chen et or telephone have been effective in decreasing al. 2010; Cheng et al. 2010). A study in China the rates of suicide ideation, suicide attempts, and showed that mainstream publishers commonly use suicide (Doty et al. 2022). harmful reporting practices in reporting suicide on their social media; less than 0.1 percent of Mongolia collects data about suicide attempts articles provided information on available support among adolescent students ages 13 to 18 through programs (Lai et al. 2021). Moreover, most studies the Mongolian Global School-Based Health Survey of media reporting of suicide in Southeast Asia (Badarch et al. 2022). However, it is unclear whether have shown poor adherence to media guidelines by survey data are used to identify at-risk individuals most newspapers; barriers include lack of country- and connect them to services. There is a growing specific media guidelines, poor implementation number of programs to which identification and and monitoring of guidelines, or both (Arafat et follow-up programs could refer at-risk individuals. al. 2020). A systematic literature review found For example, Mongolia established a national mental that implementation of media guidelines about health hotline in 2019 (Xinhua 2019). In addition, the reporting of suicide successfully mitigated the Ministry of Education and Science introduced imitative suicides in some contexts; however, mental health counseling in secondary schools in there is variability in the significance of the impact two provinces with the support of UNICEF; UNICEF (Bohanna and Wang 2012). One systematic review also launched a campaign to train youth volunteers concluded that there is insufficient evidence on the to disseminate information about mental health possible benefits of media guidelines for suicide among their friends, communities, and loved ones prevention (Zalsman et al. 2016). Nevertheless, (UNICEF 2022). The Youth Development Centers working with the media on responsible reporting 34 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT ARE PROMISING SOLUTIONS FOR ADDRESSING THESE CHALLENGES? is often considered an important action in suicide in several countries (Fleischmann et al. 2016). prevention programming (Fleischmann et al. 2016; Despite the robust evidence of the effectiveness of WHO 2021a). Collaborating with the media on the limiting the means for suicide prevention, focusing development of guidelines and providing sufficient on these interventions may not substantially lower training on them is essential (Beautrais et al. 2008; suicide rates in Mongolia, given the most common Bohanna and Wang 2012). methods of suicide in the context. In 2023, 93 percent of confirmed suicides in Mongolia were done using hanging or asphyxiation as the method.24 Limit access to the means Given the commonality of objects that can be used of suicide. as ligatures and places that can be used as ligature Limiting access to the means of suicide is one of the points, preventing suicide by hanging outside of core evidenced-based interventions recommended an institutional setting is impractical (Gunnell et by the WHO’s Live Life guide, and a solid evidence al. 2005). In Mongolia, 2 percent of suicides used base shows it can be effective (Barber and Miller firearms;25 the Mongolian Law on Firearms provides 2014; Hawton, Duleeka, and Jane 2024). One- the right of Mongolian citizens and legal entities to third of the world’s suicides are carried out by own, possess, and use firearms. As such, lessons ingesting pesticides; a variety of measures exist to learned from other countries in reducing access prevent suicides by pesticides and to optimize the to firearms may be relevant: legislation restricting management of the medical care given to those firearm ownership has been associated with a who attempt suicide in this manner (Fleischmann reduction in firearm suicide rates in several countries et al. 2016). Several studies from Asia have shown (Fleischmann et al. 2016). Less than 1 percent of that restricting access to harmful pesticides through suicides in Mongolia use intentional poisoning by national bans or storage lockers has reduced pain medications or pesticides or intentional jumping suicide rates (Doty et al. 2022). Restricting access to from a height (World Bank 2019). As such, best charcoal by moving it from an open shelf to a locked practices from other countries in terms of limiting area accessible only by shop attendants reduced the access to harmful pesticides, limiting quantities of prevalence of charcoal burning deaths in Hong Kong medications, or reducing access to common jump SAR, China, without leading to an increase in the spots may not be a priority in the context. However, use of other methods (Yip et al. 2010). A systematic in 2023, 308 individuals, 81 percent of whom review showed that controlling analgesics and were men, died due to accidental falls, including reducing access to hot spots for suicide by jumping from high buildings. Although not classified as have been effective in reducing suicides (Zalsman suicides, evidence suggests that some suicides can et al. 2016). For example, reducing the pack size be classified as accidents if the circumstances of of paracetamol in England and Wales reduced the the death cannot be confirmed (Bakst et al. 2016; number of paracetamol-induced suicides by 43 Gray et al. 2014; Schmeckenbecher et al. 2024; percent in the 11 years following regulations on Timmermans 2005). If some of these accidents the size of packs (Hawton et al. 2013). Moreover, were suicides, limiting access to common jump legislation restricting firearm ownership has been sites, which has been effective in other places, could associated with a reduction in firearm suicide rates be effective in Mongolia. Moreover, installing safety mechanisms to limit the risk of falling from heights could prevent accidental falls. 24 CHD 2023 data. 25 CHD 2023 data. CHAPTER 2. 35 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE #4: Interventions To Address have deployed facilitated group-discussion formats to address norms around masculinity and the Norms around Masculinity impacts of these norms on health-related outcomes (Peacock and Levack 2004). For example: Global health programming has shifted away from gender-neutral to gender-sensitive and gender- transformative programming, addressing the • Program H in Brazil involved interactive expectations of what it means to be a man and the activities for young men to reflect on gender gender role conflict men may experience in fearing norms that promote risky behavior and create they cannot live up to masculine norms (Dworkin et support for gender norms that promote care al. 2015). Gender-sensitive programs that account and communication.26 The results of eight, for the different constraints that men and women mostly quasi-experimental studies on Program face and transformative programs that seek to H adaptations around the world have found reshape gender relations have been more effective evidence of positive changes among program than gender-neutral programs in improving a participants: from more gender-equitable variety of health outcomes (WHO 2007). Integrated attitudes and behaviors generally, to improved approaches that combine various activities, such as couple communication, reduced gender-based group education, service-based interventions, and violence, and improved attitudes around community outreach tend to be more effective, caregiving.27 because they consider multiple systems and • One Man Can workshops with men in South relationships that influence beliefs and behaviors Africa aimed to cultivate reflection on gender, (Barker et al. 2010). Although Mongolia has taken power, and health and how masculinities are steps to address this challenge in its National practiced in relationships with women, other Program on Gender Equality (2017–21), including men, and the broader communities. Qualitative working through the Media Council of Mongolia, work shows the program shifted views of more could be done. women’s rights, changed attitudes to more gender-equal decision-making and division of Offer workshops and safe space for labor, and reduced violence (Dworkin et al. dialogue about masculinity and norms. 2015). Expanding the One Man Can program through community mobilization—which added Although more rigorous evidence is needed, community action teams, community outreach, workshops and safe spaces for dialogue about theater, discussions, and engagements with masculinity and norms are promising ways to shift community leadership—shifted men’s adherence attitudes, beliefs, and health-related behaviors. to conservative gender norms; however, it did Most studies rely on descriptive or qualitative not lead to widespread behavior change (Pettifor evidence; however, several promising interventions et al. 2018). 26 https://www.thensmc.com/resources/showcase/program-h#:~:text=Program%20H%20seeks%20to%20encourage,sexual%20agency%20as%20do%20men. 27 https://www.equimundo.org/programs/program-h/. 36 Forest Jarvis, Hillary C. Johnson, and Maude Ruest WHAT ARE PROMISING SOLUTIONS FOR ADDRESSING THESE CHALLENGES? • The Shape Up intervention in the United States (Tsogtsaikhan 2019). In addition, interventions to reduced hypermasculinity beliefs and increased engage with men and boys on positive masculinities Black manhood vulnerability beliefs through are part of the United Nation’s Population Fund’s a culturally responsive intervention delivered (UNFPA) program in Mongolia in 2023–27 (UNFPA through barbershops (Stevenson et al. 2021). 2022). Moreover, some NGOs in Mongolia run workshops on topics related to gender equality.29 • Men’s Sheds,28 which began in Australia and have Although these workshops may not target men spread to several other countries, create safe and boys or pose questions of masculinity, lessons spaces where men can gather and engage on learned from their approach could be useful in collaborative projects, often with woodworking expanding the scope of these types of activities. or metalworking. These organizations aim to improve members’ health and well-being, and they combine activities with visits from health practitioners and health promotion events Develop communication campaigns, (Foettinger et al. 2022). including documentaries, movies, and entertaining programs. Keys to successful programs include deliberate efforts to engage men in the critical analysis of It is important to work for structural- and gender roles, with the goal of creating enabling community-level changes, not just individual-level environments that can promote changes in social changes, to ensure that the impacts are sustainable norms among peer groups and communities; and that those who adopt more gender-equal building broader alliances by working with credible behaviors are not relegated to subordinated status national organizations; and recognizing the multiple by their peers (Dworkin et al. 2015). Addressing needs of men, such as employment, to achieve structural barriers may include communication with lasting change (Barker and Ricardo 2005). Moreover, employees and health facilities to shift attitudes supporting participants to become agents of change and practices. Communications campaigns, such in their communities, promoting peer learning, and as documentaries, edutainment interventions including role modeling in intervention design can that communicate messages through entertaining be impactful ways to support shifts in gender norms programs and social media campaigns, may be (Stewart et al. 2021). a scalable way to begin shifting attitudes at the community level. The evidence is limited on the Mongolia’s National Program on Gender Equality impact of edutainment interventions on norms 2017–21 includes working with male audiences related to masculinity or men’s health-seeking to change gender stereotypes and promote the behaviors. However, rigorous evidence suggests progressive elements of traditions and traditional the effectiveness of edutainment interventions practices through trainings, campaigns, programs, in shifting other gender norms, including gender- and projects with the participation of men and boys based violence (Arias 2019; Banerjee, La Ferrara, 28 https://mensshed.org/. 29 See, for example, Women For Change Mongolia, an NGO that hosts weekly workshops on topics related to gender equality. CHAPTER 2. 37 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE and Orozco 2019) and girls’ schooling (Orozco- Mongolia’s National Program on Gender Equality Olvera and Rascon-Ramirez 2023). Edutainment has 2017—21 called for several activities to shift also been shown to reduce risky sexual behaviors norms and stereotypes using the media, including among youth (Orozco-Olvera, Shen, and Cluver providing media training; developing image-making 2019) and exposure to gender-based violence campaigns on changing gender stereotypes; (Green, Wilke, and Cooper 2020). Communication mainstreaming gender in art and cultural sector campaigns involving celebrities have also been policies and implementation; and encouraging shown to shift health-related beliefs and behavior. male role models, leaders, and public figures to For example, celebrity tweets endorsing vaccination promote progressive messages (Tsogtsaikhan 2019). influenced beliefs about vaccination and knowledge Lessons learned from these efforts can inform of immunization-seeking behavior in Indonesia future communications campaigns addressing (Alatas et al. 2019). Short videos of a local celebrity masculinities. In addition, the Media Council of promoting COVID-19 precautions in India led to Mongolia—an independent self-regulator for print, an increase in the use of preventive measures, broadcast, and online media—launched the News including those not explicitly promoted in the video for Equality coalition in 2021 with a mandate to (Banerjee, La Ferrara, and Orozco 2020). In an boost gender-sensitive reporting.30 The comic strip Australian documentary called “Man Up,” a well- campaign initiated by the NGO Women for Change known radio and television personality interviewed Mongolia has also used communications campaigns men from all walks of life who modeled positive to address norms about gender (Tali 2017). The health behaviors and explicitly addressed the program has focused on how women are portrayed link between masculinity and health outcomes. in the media, but these efforts could be expanded A randomized controlled trial that screened this to cover the portrayal of masculinity. film showed that it increased men’s intentions to seek help, to make recommendations to friends to seek help, and to reduce conformity to gender norms (King et al. 2018). The keys to the success of the program were its ability to relate to men in meaningful ways, recognize the societal pressures they face, delve into the complexity of issues including suicide, and combine heartfelt stories with scientific data (Pirkis et al. 2019). 30 “Reflecting Reality in Mongolia,” https://www.reflectreality.internews.org/chapter-5/reflecting-reality-in-mongolia. 38 Forest Jarvis, Hillary C. Johnson, and Maude Ruest CHAPTER 3. THE WAY FORWARD CHAPTER 2. 39 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE THE WAY FORWARD Policy responses to the gender gap in life it must have a gender-sensitive approach. On the expectancy will need to be evidence-based, age other hand, it will be important to address issues and sex specific, and multifaceted to address this that disproportionately affect men, such as suicide. complex issue. Life expectancy is a cross-sectoral Addressing the gender gap in life expectancy will issue that will require interventions on multiple need a coordinated multisectoral approach driven fronts and the targeting of the social determinants by a strategy detailing roles and responsibilities, of health. Many ministries and agencies will have to priority actions and timelines, and a clear agenda for get involved in addition to the Ministry of Health, the country. Partnerships can also play a key role in such as the Ministry of Education and Science; ensuring the successful rollout of a national strategy, the Ministry of Finance; and the Ministry of Food, as in the case of Brazil (box 1). Addressing structural Agriculture and Light Industry. On the one hand, factors and barriers, including the availability of safe it is critical to address the largest drivers of male and well-remunerated jobs and social protection mortality, including the prevention, detection, and programs, is important to reduce the gender gap in management of NCDs, which are also the leading life expectancy, although a comprehensive review cause of mortality for women. Programming for of these programs is outside the scope of this study. disease prevention, detection, and management will likely target the population more broadly, but 40 Forest Jarvis, Hillary C. Johnson, and Maude Ruest THE WAY FORWARD Box 1. Case Study of (PNAISH) in Brazil The National Policy of Comprehensive Healthcare to Men (PNAISH) was established within the Brazilian Unified Health System in August 2009 as the main path to achieve a reduction in male mortality through tackling risk factors and facilitating men’s access to comprehensive health care services and actions. The PNAISH recognized sociocultural and political-economic contexts. It started with 26 pilot projects (one city per state); by 2014, all 26 states and the federal district of the capital Brasilia had established local men’s health units. The PNAISH included five strategic areas targeting adult men: • Improving access to health services, with a focus on primary health care. • Engaging men in sexual and reproductive health. • Engaging men in fatherhood and caregiving. • Preventing morbidity and mortality by external causes, including violence, accidents and suicide. • Preventing chronic diseases. The PNAISH legitimized and called attention to the specific issue of men’s health, such as (1) raising aware- ness of the father’s active involvement in sexual and reproductive health initiatives, pregnancy, birth, care of children, and (2) creating a positive entrance door to primary services and health promotion among men. It also broke down some structural barriers, such as extending opening hours in family health units and opening on Saturdays to attract working men. However, research indicated a need to focus on the quality of services provided, as well as the increased engagement of the Ministry of Health to train local level workers on the policy and to support implemen- tation. In addition, the implementation was hindered by inconsistent annual budget allocations. There was little engagement of men in the policy debate or in the decision-making process, and there was no orga- nized men’s movement to drive the issue and push for political recognition of its importance. Other chal- lenges to the implementation of the PNAISH included a concentration of health services in larger cities and more developed regions; the tendency of some groups to target their messaging to more narrow issues like prostate cancer rather than broader health concerns; and the unmet need to consider the way that men’s health unit teams were formed and explore staff turnover, which is often through political appointment or administrative expertise rather than expertise on gender/men’s health. Lessons from the implementation of the PNAISH that could be used to adapt a policy and scale up to Mon- golia include the following: • Developing political and advocacy strategies early in the process to ensure political commit- ment and sustainability of policy implementation. • Partnering with civil society and academic institutions to develop a gender transformative approach to men’s health. • Including practical guidance and training for health administrators and staff at all levels to implement the policy. • Including gender transformative indicators in the evaluation plan. Sources: Lima and Schwarz 2018; Spindler 2015. CHAPTER 3. 41 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE Policy responses should take into account both cost-effectiveness and noneconomic considerations to have the greatest impact. Focusing on cost-effective interventions is important to make every dollar go further, but other noneconomic considerations play a role when choosing and implementing interventions (box 2). It is important to ensure that a strategy does not leave some men behind and that interventions are both socially acceptable and feasible to implement while maintaining quality. Some interventions may cost more but may be justified due to their transformational impact. Better men’s health also improves women and children’s health, including women’s sexual and reproductive health. Healthier men also reduce men’s dependency on female careers, boost family incomes, and positively impact mental health and substance misuse (Baker 2018). Box 2. Cost-effectiveness and noneconomic considerations Cost-effectiveness  analysis is a method for assessing the gains in  health relative to the costs of differ- ent health interventions (for example, how many extra years would someone live or live in good health because of spending an amount of money for an intervention (that is, comparing the cost to the outcome of the intervention). Cost-effectiveness analysis is a useful tool, but it has limitations and should not be used as the sole basis for decision-making. When selecting interventions to address the gender gap in life expectancy, consideration should be given to both economic criteria, such as cost-effectiveness and affordability, and noneconomic criteria, according to the Mongolian context, because both will affect the implementation and impact of interventions. Noneconomic implementation considerations—such as effectiveness and health impact, ac- ceptability, sustainability, scalability, health equity, ethics, multisectoral actions, training needs, suitability of existing facilities, and monitoring—are essential and should be considered before the decision to imple- ment any interventions. Source: WHO 2024a. There is strong global evidence on cost-effective The 2024 United Nations Development Program interventions to reduce death and disability (UNDP) Investment case for tobacco control gives related to NCDs, as well as on the effectiveness the government a clear direction to implement of expanding access and quality of primary health policy actions that will deliver substantial economic care to improve outcomes and reduce costs. and public health benefits to the country. There are Mongolia has made overall good progress on the also significant policy gaps in promoting healthy WHO best buy policies to prevent and control NCDs, diets, nutrition, and physical activity. More can be and most health care services targeting NCDs are done across the board to facilitate the NCD best buy covered by the public health system. However, the policy implementation. Mongolia has the necessary country is not yet taking full advantage of these numbers of skilled health workers to improve public policies. Policies are in place to help control tobacco health and primary health care. Reviewing service and alcohol use; however, gaps exist between these delivery models to focus resources (including policies and full implementation of best practices. human resources) on primary health care rather 42 Forest Jarvis, Hillary C. Johnson, and Maude Ruest THE WAY FORWARD than hospital care would lead to more efficient Suicide is a serious public health problem that and equitable health care. The forthcoming health requires a public health response; timely, evidence- chapter of the Mongolia Public Financial Review based, and often low-cost interventions can help provides more detailed recommendations (World prevent suicides.31 A comprehensive multisectoral Bank, forthcoming). suicide prevention strategy is needed for national responses to be effective. Indeed, the reasons for The challenge for Mongolia will be to design suicide are multifaceted and are influenced by social, interventions that specifically target men and cultural, biological, psychological, and environmental address gender norms to reduce the gender gap in factors across the life-course. Consideration should life expectancy. Communication and interventions be given to the need to implement a combination need to be specifically targeted at men and should of policy interventions at the population level and take gender norms that are associated with men’s interventions at the individual level. risky health behaviors into account in their design and messaging. More information is needed to design the ideal interventions to address these Allocating sufficient financial and human resources norms, because the most appropriate intervention to reduce the gender gap in life expectancy will depends on how deeply a norm is entrenched and be critical to ensuring the success of programs. the specific obstacles to the widespread adoption of Indeed, insufficient and unstable annual funding and a different norm (Muñoz Boudet et al. 2023). Ideally, skills mismatches of staff working on the strategy interventions should aim to transform gender implementation hindered the implementation of a norms that drive tobacco and alcohol consumption similar strategy to improve men’s health and lower and impede help-seeking behaviors, such as those the gender gap in life expectancy in Brazil (box that link alcohol and tobacco consumption with 1). Although sufficient and consistent allocation masculinity and help-seeking with femininity. It may of funds will be critical to success, international be possible to leverage other widely accepted norms evidence suggests that many interventions can be to support transformation, for example, by linking carried out at a reasonable price tag. For example, seeking care and adoption of a healthy lifestyle a study of 62 low- and middle-income countries with the continued ability to provide for one’s estimated that the recommended tobacco- and family. Globally, there is limited rigorous evidence alcohol-related policies can each be implemented of effective ways to transform gender norms, for less than US$0.30 per person per year (table and there is little or no evidence from Mongolia. 3). Many other promising interventions to reduce Norms are highly localized, which highlights the the gender gap in life expectancy in Mongolia have need for context-specific interventions. As such, been implemented in other countries for less than a interventions developed to address gender norms dollar per person per year, suggesting that progress associated with risky health behaviors among can be made even with limited budgets.32 men in Mongolia should be rigorously piloted and evaluated to ensure their appropriateness and effectiveness prior to being scaled-up. 31 WHO fact sheet on suicide (August 2024), https://www.who.int/news-room/fact-sheets/detail/suicide. 32 Table 3 provides cost information for similar interventions carried out in other countries to serve as a reference and inform policy discussions; however, a more detailed costing study would be needed to infer what the likely costs may be to implement policies in the Mongolian context. CHAPTER 3. 43 A REVIEW OF PROMISING INTERVENTIONS BASED ON GLOBAL EVIDENCE Table 3. Global estimates of program implementation costs Intervention Approximate cost per person Source Study location per year (US$) Interventions to reduce smoking and excessive alcohol consumption Strengthen tobacco and alcohol excise taxes by $0.01* (tobacco) WHO 2022 Upper-middle-income increasing and improving the design $0.04* (alcohol) countries Enhance bans on tobacco and alcohol advertising, $0.01* (tobacco) WHO 2022 Upper-middle-income promotion, and sponsorship $0.03* (alcohol) countries Expand 100 percent smoking bans to all indoor $0.02* WHO 2022 Upper-middle-income workplaces and public places countries Increase alcohol sale restrictions to limit the physi- $0.05* WHO 2022 Upper-middle-income cal availability of retail alcohol countries Make smoking quit lines and counseling available $0.09* (tobacco) WHO 2022 Upper-middle-income $0.29* (brief alcohol coun- countries seling) Roll out mass media campaigns $0.10* (tobacco) WHO 2022 Upper-middle-income countries Interventions to increase the uptake of preventive and primary health care services focused on men Strengthen primary health care and prevention, < $1.00* (most screening and WHO 2022 Upper-middle-income starting with reviewing the model of care primary care interventions for countries common NCDs) Address structural barriers to men’s health care and $26 (median cost of in-service Rowe et al. Low- and middle-income create male-friendly services training for health care profes- 2021 countries sionals per day of training)33 Encourage male care-seeking behavior $0.40 (text message campaign) Marcus et al. Indonesia 2024 Interventions to prevent suicide Foster socioemotional life skills in adolescents $0.10-0.50* WHO 2021b Upper-middle- and high-income countries Improve access to mental health services $0.10-0.50* (basic psychoso- WHO 2021b Upper-middle- and cial support for depression) high-income countries $0.50-1.00* (psychological treatment of recurrent depres- sion) Provide early identification, management, and fol- $640 (6 follow-up sessions Alvi et al. 2022 Pakistan low-up with anyone with mental health conditions, with a trained psychologist) including those affected by suicidal behaviors $96 (initial assessment plus 4 Ross et al. United States follow-up calls) 2021 Work with the media on the responsible reporting $0.04 Flego et al., Australia of suicide 202234 33 The content of the studied training was not on creating male-friendly services; however, if training on how to better meet men’s needs and tailor support to male patients was offered, it is likely to be aligned with other training costs. 34 The year 1 costs for program implementation reported in Flego et al. 2022 were converted to US$ using the average exchange rate for 2018 published in the International Monetary Fund’s International Financial Statistics and adjusted to a per-person rate by dividing by the population of Australia in 2018 as reported by the World Bank’s World Development Indicators. 44 Forest Jarvis, Hillary C. Johnson, and Maude Ruest THE WAY FORWARD Limit access to the means of suicide $0.43 (limiting access to jump Bandara et al. Australia sites) 202235 < $0.01* (regulatory bans of WHO 2021b Upper-middle- and highly hazardous pesticides) high-income countries Interventions to address social norms around masculinity Offer workshops and safe spaces for dialogue about $108 Workshop only Remme et al. Brazil masculinity and norms $161 (Workshop plus commu- 2014 nity-wide messaging cam- paign) Develop communication campaigns, including $0.0005 (SMS messaging Seitz 2021 Tajikistan documentaries, movies, and entertaining programs campaign) $0.16 (edutainment campaign) Remme et al. South Africa 2014 Note: *These costs are given in international dollars, which account for differences in purchasing power parity between the US and the countries studied. Although this evidence note points to several quasi-experimental approaches to assess the promising evidence-based interventions to impact of norms-transformative interventions. As address the gender gap in life expectancy, it such, further evidence is needed on ways to shift also highlights the need for future research masculinities and how this can change men’s health- and evaluation of programs and action plans, related behaviors and outcomes. Rigorous impact particularly related to promoting primary health evaluations and research studies are needed to care and transforming gender norms. There is test these types of interventions. In addition, much minimal evidence on the effectiveness of male- can be learned by strengthening the monitoring friendly clinics in increasing men’s demand for and evaluation of programs, strategies, and action primary health care; more evidence is needed on plans to address the gender gap in life expectancy the optimal ways to make clinics more male-friendly. to ensure that knowledge of what has worked well Moreover, many studies exploring ways to change and challenges in implementation can inform future gender norms have focused more on equalizing policy and programmatic engagements on this topic. gender norms to improve outcomes related to gender-based violence or HIV transmission; most of these studies rely on qualitative evidence or 35 The average cost of installing barriers on one bridge reported in Bandara et al. 2022 is used, and the per-person cost is inferred by dividing by the population of Australia (where the study takes place) in the reference year used in the study (2018). 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