There has been progress in
the health sector through the construction and renovation of health
facilities, the development of Primary Health Care guidelines, the expansion of
the DOTs programme, the development of the Health Sector Strategic Plan, the
commencement of the Health Sector Support Project and the development of a
provincial annual operational planning process. The Annual Joint Health Sector
review is a welcome innovation to improve co-ordination among health sector
partners.
The NGO community has
consistently applauded progress made by the RGC in relation to education over
recent years: infrastructure development, new schools, improved learning
conditions for students, and increased enrolments.
The PAP process, while far from perfect, has delivered increased
resources to schools.
In order to improve nutrition,
a sub-decree concerning universal salt iodination was passed and signed by the
Prime Minister in October 2003. Vitamin
A supplements were distributed in 8 provinces.
However, the intake of iodised salt and vitamin A nationwide remains very
low.
Despite the above
improvements, Cambodia is not on track to achieve the CMDG health targets. Data from national household surveys suggests that child
mortality and infant mortality may have actually increased over the last decade,
while other statistics show a slight decline from a higher level.
Education statistics are more promising, with Cambodia well on track to
achieve its primary education enrolment CMDG targets, but falling behind its
secondary education enrolment targets.[1]
Within the priority sectors
of health and education, the RGC has committed itself to increased budget
allocation and a strong emphasis on pro-poor service delivery. This approach is
essential for the development and improvement of capabilities and is welcomed by
the NGO community. As with all such developments, it is important that those
commitments are translated into action at the most fundamental level of service
provision and support.
In the health and education
sectors the RGC has made commitments to increase budgets and improve support for
public health provision. The NGO community has been pleased to see these
increases and seeks to work with government to further facilitate improvements
within the sector. However, progress remains constrained by a failure to
disburse the funds committed to these sectors.
The RGC has made clear it
plans to increase salaries in order to address the current weak incentives for
effective service delivery. Whilst
these increases are welcome, they will not allow civil servants to receive a
living wage from their formal employment alone.
NGOs recommend that, in sectors such as health, part-time work of
government officials be recognised and better regulated and that additional
incentives provided through donor funding be standardised.
The Ministry of Economy and Finance could be asked to clarify how
additional allowances and incentives could be channelled through the PAP system.
In the health sector,
spending needs to be directed to lower operational levels.
Over the past few years, significant resources have gone to higher-level
activities such as research and strategy development. External support to the health sector needs to concentrate
less on a few “popular” diseases, and more on disease prevention, nutrition
and mother and child health. Health
posts in rural areas and health rooms in urban areas have shown excellent cost
effectiveness.
At the same time, the
private health sector, which accounts for a large proportion of medical
consultations, particularly in urban areas, is in need of clear and effective
regulation to ensure sound medical practices.
NGOs welcome the Ministry of
Health’s development of a Strategic Framework for Equity Funds to make health
services freely available to the poor. NGOs
look forward to further co-operating with the Ministry in this endeavour.
Strategic commitments to
increasing and improving health provision in specific areas are also important.
In particular, targets within both the NPRS and the CMDG in relation to infant,
under-five and maternal mortality need to be prioritised. This requires both improved
reproductive health care and efforts to improve nutrition.
Within the education
sector, the improvement in enrolment levels is welcome; but repetition and
dropout rates still remain high. Proactive strategies are needed, on both demand
and supply sides, to ensure equitable access for girls, who suffer from a low
enrolment and low retention rates, and for the inclusion of disabled children
and ethnic minorities within the public school system.
There are serious teacher
shortages in remote areas of the country, with pupil/teacher ratios of over 70:1
in some provinces. Redeployment
strategies are not working effectively due to inadequate incentives and other
constraints. Greater effort is
needed to recruit and train locally residing teachers.
The NGO community welcomed
the introduction of the Priority Action Programme (PAP) and the
publishing of targets for the disbursement of funds as a significant move
towards the development of a system of open and effective funding. In both
health and education, the problems surrounding the allocation of funding to the
public sector have been, and continue to be, a major factor in the ability of
government to provide these services in an equitable and effective way.
While welcoming the PAP
system of post-audit programmatic budget allocation, NGOs note, regrettably,
that there is little evidence that it has so far had a major impact upon budget
operations in the education and health sectors. Cash management problems
continue to occur with disbursements being irregular and delays tending to
result in budgets being back-loaded.
In education, 80
per cent of the 2002 PAP allocation and none of the 2003 PAP allocation had been
disbursed as of October 2003. This
is severely damaging to the ability of the education sector to honour its
commitments. Partly as a consequence of this, schools and teachers continue to
seek unofficial funding from their students, thus seriously limiting access to
education for poor families.
In health, as in
other sectors, there continues to be problems with the budget “dry
season”, as funding fails to flow efficiently and regularly to the sector.
Thus, during the first six months of the year field staff consistently face
serious problems in accessing their budgets and are therefore unable to deliver
health services effectively. The lack of available money during this period has
a devastating impact upon health service delivery.
The NGO community makes the
following recommendations in relation to health, education and nutrition:
The RGC must ensure transparency, predictability and accountability
in the allocation and disbursement of funding. Achieving these goals will
require not only technical assistance but also substantial political will.
Salaries and incentives for staff working in the health and education
sectors need to be linked to the cost of living. At the same time
anti-corruption strategies need to be enforced in order to ensure that
unofficial fees are not levied. Such fees are recognised as having a greater
negative effect upon the poor, seriously undermining their ability to gain
access to the very services that will assist in alleviating poverty-related
problems.
To increase the availability of teachers in remote areas, there needs
to be wider use of locally residing contract teachers, providing them with
opportunities for training and upgrading so that they have some prospect of
entering the teaching service permanently.
The entry point for pre-service training should be lowered to Grade 9
graduates for districts where there is no upper secondary school.
In order to ensure that the poor are targeted, the MDG targets for
health need to be complimented with targets for the poorest quintile of the
society.
Private sector provision of both health and education needs to be
subject to review by civil society and government together.
More resources need to be allocated to projects that tackle disease
prevention and nutrition rather than policy development.