Health
(i) Introduction
Good health is often understood as an outcome of development but it is also an important condition promoting economic development and reducing poverty[1]. As a matter of fact, health care remains a serious factor of impoverishment in Cambodia, when each Cambodian needs to spend each year an average of US$29 for health care[2] (Cambodia GDP per capita is as low as US$275 per year). Thus, Medicam understands the crucial role of government public health and social safety nets to prevent increases in the number of Cambodians living under the poverty line.
The Medicam network, with its 113 NGOs and Associate Members is very pleased to have participated year after year in the progress of the health sector. Among the most notable achievements in 2002 and 2003 are:
1) An increased budget and the success of Cambodia in rounds one and two of the Global Fund,
2) Construction and renovation of health facilities, achieving more than 80 percent of the 1996 revised health coverage plan,
3) The development of the Primary Health Care guidelines,
4) The expansion of the DOTS program for TB and the IMCI strategies for child health,
5) The development of the Health Sector Strategic Plan and its implementation framework,
6) The development and beginning of implementation of the Health Sector Support Project,
7) The Annual Joint Health Sector Review, as an attempt to improve the coordination among health partners, both local and international, and
8) The development of a comprehensive provincial annual operational planning process with active involvement from health facilities (health centers and referral hospitals). These are all important achievements.
In partnership with the Ministry of Health, NGOs have been actively contributing in the implementation of health sector reform projects, which have contributed significantly to the above achievements. NGOs have been providing technical, material, and financial assistance as well as a lot of human resources to support local health facilities development. NGOs are implementers, and their field experience is an additional important resource that is brought to the Royal Government. Medicam is a place to gather field experience, conduct research associated with this field experience and analyze it. Consequently, Medicam is in a position to hereby summarize the main issues that the NGO community involved in the health sector understands as some of the major current challenges facing the development of the health sector of Cambodia:
(ii)
Key Issues and Recommendations
Focus
on the poorest groups:
A recent discussion paper from the World Bank[3]
puts into question the possibility of real progress toward the Millennium
Development Goals (MDGs) targets for health
“because
the MDGs health targets, unlike most other prominent Millennium Development
Goals targets, are stated in terms of improvement in societal averages rather
than in terms of gains among poor groups within societies. Since improvements in
any group, including the better-off, would produce improvements in societal
averages, progress toward targets expressed in those terms do not necessarily
reflect improvements in conditions among the poor”.
Considering that 36 percent of Cambodia’s population live under the poverty line, Medicam would recommend that:
The
government and the Ministry of Health in particular, use indicators
disaggregated into five groups in quintiles, so that it can better monitor the
impact of its programs on the poorest groups.
Budget dry season: Medicam congratulates the government’s commitment to an annual increase in the budget for health, but wonders what the impact on the health of people will be if the implementers of the government’s strategies and the field people who deliver health services, implement outreach activities and educate people regarding “health seeking” behaviours do not have access to their budget on a more regular basis. Therefore, Medicam calls on:
Both the Royal Government and the donor community to make public the action plans and strategies of the existing “Cash Management Committee”, “Cash Management Task Force” and other technical working groups that have been established to address the increasing delays in budget disbursement, which occur particularly during the first six months of each year.
Allowances/Incentives payments: Although the salary increases planned in the Public Administration reform are impressive in terms of percentage, they will not allow civil servants, and public health workers in particular, to receive a living wage from their formal employment alone. Also, the Public Administrative Reform neither takes into account part-time work nor regulates the use of public working hours by civil servants to generate additional incomes and make a living wage. Yet, this regulation would prevent many conflicts of interest and would better structure service delivery. Currently, in addition to salary supplements collected from user fees, which still do not allow field workers to reach a living wage, many NGOs and bilateral donors are providing, or are planning to provide, allowances/salary incentives to improve staff motivation, availability, quality and quantity of services. NGOs are worried about the sustainability of these incentive schemes and would appreciate to learn from the government how they could be taken over by the PAP budget or some other mechanisms. Also, since incentives vary from program to program, Medicam suggests that:
The government makes a request to all donors that they plan for incentives in all of their budgeting for programs
That the MoH, donors and the NGO community set recommended standards for levels of incentives, linked to performance and quality of services, in order to do away with the competition that results between programs, and
That the Ministry of Economy and Finance clarify how additional allowances and incentives could be paid from the PAP budget in areas not supported by donors or NGOs, so that line ministries could ensure a minimum level of motivation of their teams in order that availability of services is ensured and results produced.
More spending on services at lower level: Distance and transportation costs are two major obstacles for people who need to utilize public health facilities. Health posts in the rural areas and health rooms[4] in urban areas have shown excellent cost/effectiveness ratios. NGOs would like to encourage :
The Ministry of Health to invest more in lower tier services to address health problems of the poor.
The Ministry of Health to provide more resources to community health workers and village health support groups who are key groups to promote behavior change.
Increased focus and effort on quality: Medicam congratulates the Ministry of Health for having prioritized quality of services in its strategic plan. Improving the quality of public health services is not only required in order to stop the downward trend of the utilization rate of public health facilities, but it is also a requirement if any health insurance scheme were to be established. Medicam encourages
The Ministry of Health to implement the quality component of the “Implementation Framework” of the Health Sector Strategic Plan.
Collaboration between private and public sectors: Although private health providers should contribute to the quality of health services, 49 percent of Phnom Penh private medical consultations result in potentially hazardous treatment[5]. The private health sector is not only challenging the publicly financed health system, it is also a real challenge for public health itself. This does not necessarily have to be seen in a negative way. NGOs believe that a practical strategy needs to be established to address these issues. Medicam encourages:
The Ministry of Health and the Medical Council to work with private health sector providers more openly and encourage them to practice regulations that are already in place, such as licensing and accreditation.
Also, Medicam suggests that the differing (and complimentary) roles of the private and public sectors be more creatively explored, keeping in mind a focus on clients’ needs for affordable quality services. Ways should be explored to have public and private providers work together or better complement one another with the end goal being quality, affordable services for clients. For example;
Training should be provided to both public and private providers without discrimination;
The promotion and distribution of a number of health-related products through private distributors can be expanded; and,
Clarification of the role of public providers working privately needs to be established. Medicam believes there is room for practical partnerships between the private and public sectors that will result in enhanced quality of services in both the private and public sectors.
More financial resources on prevention, nutrition, as well as at the operational level: External support to the health sector in Cambodia has a tendency to focus on a few specific “popular” diseases, which consequently channel a disproportionate share of financial resources at the expense of neglecting some important health intervention areas, such as disease prevention, nutrition and mother and child health. In addition, sudden policy/strategy changes of funding agencies badly affect the development and the implementation of field projects in particular those of Local NGOs who are therefore pushed into donor-driven project formulation instead of reflecting grassroots needs. Medicam appeals
To all donors to provide a strong focus on grassroots clients’ needs, and be more responsive to field partners who work at the grassroots level and can sometimes play an effective third party role.
Besides, NGOs analyze that, for the last few years, a lot of energy and financial resources have been spent on research and strategies. The Medicam network believes that the time has come to concentrate on implementation at the operational level and less on research and strategy development.
Equity Fund: Medicam welcomes progress made with the Strategic Framework for Equity Funds by the Ministry of Health. Medicam applauds the government’s willingness to turn Equity Funds into a sustainable national policy. NGOs strongly believe that social assistance for health care to the poor must be a major component of any future global strategy for poverty reduction in Cambodia. NGOs have accumulated a unique knowledge on the livelihoods of the poor. Many international and national NGOs have been very dynamic in developing new solutions for improving the conditions of the poor. The Equity Fund is just one of these numerous initiatives. Medicam’s vision for Cambodia is a social sector jointly steered and operated by the government and civil society. The Equity Fund Program is a unique opportunity to develop this societal model. Along this vision, Medicam would favor
A model that would institutionalize a fair representation of the NGOs in the different bodies in charge of the strategy, including the steering of the policy, the awarding of contracts, the strategy design and the monitoring and evaluation of the sub-contractors.
Roles of NGOs: More widely, whilst NGOs and government workers share the same goal of development and poverty reduction and complement each other, there is often a lack of definition of partners’ roles, and in particular NGOs’ roles for the implementation of national strategies to reduce poverty. This sometimes creates misunderstandings, a sense of competition, and in some cases mistrust. Medicam would recommend
The Ministry of Health and the health NGOs to agree on a framework within which NGOs could work at field level.
The health sector environment is changing rapidly. However, all partners, including NGOs, agree on the key role of the Ministry of Health to coordinate, regulate, promote health seeking behaviors and provide a minimum level of quality public health service delivery. NGOs are impressed by the tremendous efforts of the Ministry of Health in reforming the public health system. The above-selected important issues have been selected as the most important needing to be considered and resolved through strategy and policy changes. The Medicam network, NGOs, and health partners adamantly believe this will mean the public health system will be strengthened, the quality of health service delivery enhanced, people will have better health, and ultimately, this will contribute to poverty reduction in Cambodia, where it is believed NGOs, working with the Ministry of Health, can further contribute to the progress being made in public health.
For more information on the issues raised in this paper, please contact:
MEDiCAM,
Tel: 023 211-486, Email: medicam@online.com.kh
[1]
OECD Commission on Macroeconomics and Health (CMH), October 2001.
[2]
CDHS 2000
[3]
“Who Would Gain most from Efforts to Reach the Millennium Development
Goals for Health? An Inquiry into the Possibility of Progress that Fails to
Reach the Poor”, by Davidson Gwatkin, Principal Health and Poverty
Specialist.