MEDiCAM- Advocacy

POSITION PAPER 2001

NGOs are active at all levels of the health system, from the central ministry level down to the village and community level. Working with all populations throughout the country, NGOs are therefore well placed to observe the impact of health care delivery on the Cambodian population. NGOs active in the health sector seek to use this knowledge and experience to provide feedback from the field straight to the central policymakers, thanks to the openness of the Ministry of Health (MoH) and to the MEDiCAM network.

Health services remains one of the main causes of indebtedness of the poor and vulnerable in Cambodia; this indebtedness often leads to irreversible poverty. A recent study underlined that 46% of landlessness originated in settling debts related to health expenditures. This brings an always bigger proportion of the population becoming unproductive, which seriously jeopardise the Royal Government economic growth and poverty reduction goals. Therefore, access to health services (in particular by the poor) remains a major challenge to meet in both rural and urban areas. In year 2000, the Ministry of Health has engaged itself in a Sector Wide Management process, which is a major step of the Health Sector Reform, and from which a Health Sector Master Plan will determine Cambodia National Health Policy for the next five years. Medicam supports this process. Medicam would like to insist on the three main following requirements to build a quality and affordable health care system:

1. Government management of health services

1.1. Budget disbursement and accountability

Medicam appreciates that the national health budget has increased in the year 2000 (US$2.1 per capita, moving from US$1 in 1998). However, the NGO "Contracting Out" experience shows that more is needed to run a quality and accessible health system. The current health budget is barely enough for running adequately minimum basic health services in the public sector, nation-wide. Yet, in reality, output and quality of the basic health services is still below even these minimum expectations. This is attributed mainly to a widespread problem of disbursement and accountability of the funds to health facilities.

Health provincial leadership plays a crucial role in the allocation and transfer of funds to the Operational Districts and Health Centres. Hyper-inflated payments in kind, long delays, and allocated resources not in accordance with health facilities’ requests have a negative impact on their general performance. The health provincial leadership is of critical importance at a time when the Ministry of Health plans to implement the contracting strategy within its own structures. In addition, a number of national public health expenditure accounting guidelines do not match provincial guidelines, what tend to hamper the efficient delivery of health services, such as outreach activities.

MEDiCAM recommends:

To strengthen the accountability of health budget through better monitoring of allocation of resources, including enforcing disciplinary measures in cases of abuse.

To make provincial and national accounting guidelines match each other.

The Ministry of Health to set the environment that allows contracting agreements to be implemented as planned.

1.2. Increase access to health services for the poor (Preventive services and Equity Funds)

Medicam encourages the Ministry of Health to provide all health promotion and preventive services to the population. This would allow the latter to less need expensive curative health services.

The implementation of user-fee schemes, encouraged by the Ministry of Health, is a positive and creative way to provide salary supplements to health personnel and facilitate management improvements and team building in health facilities. Although these schemes have generally contributed to an increase of access to health services in the public sector, Medicam encourages the Ministry of Health to establish equity funds to support the poor who do not have the means to pay the user fees. Exemption schemes are in their pilot phase and need to be evaluated to be rationalised and expanded.

MEDiCAM recommends:

To widely recognise that the cost of health care is currently the main impoverishing factor in Cambodia;

To focus more on set of preventive services;

To establish independent equity fund schemes, that do not jeopardise the economic viability of the public health facilities, to meet the exemption needs of 38.4%2 of Cambodia population living in extreme poverty.

2. Human Resource Development

The Sector Wide Management (SWIM) process mentioned above is a very positive step of the health sector reform. However, MEDiCAM is concerned by the capacity of the health sector to implement a possible too ambitious health sector Master Plan. This concerns technical and management staff capacities.

Quality health care remains a major challenge to meet in a public sector where health professionals still receive a salary so meagre that it does not even cover their families’ basic cost of surviving. The health professionals’ level of motivation and integrity is directly linked to this key issue.

The lack of specific technical field staff at the health centre level, and the continued unequal geographical distribution of staff are two increasing issues.

MEDiCAM recommends:

To involve all MoH Departments in the SWIM process, and to connect the future MoH Master Plan to available or realistically potential human resources;

To connect training programs building to field staff needs, and increase practical training in the existing health schools (such as practical effective internships);

To identify additional creative ways to increase health staff incomes;

To establish a clear policy of staff allocation, and provide incentives to staff asked to work in remote locations;

To increase opportunities for students from remote areas;

3. Regulations

NGOs are field witnesses that the commercially-driven private sector provides expensive and often poor quality health care, leading sometimes to dangerous practices, within an unregulated laissez-faire environment.

The fact that the mandatory public health MPA package remains unattractive to consumers brings patients to give more value to the private sector.

There is still a lack of enforcement of existing laws and regulations on drugs (drug safety, quality control, fake drugs) and qualified health professionals.

MEDiCAM recommends

To include private clinics’ medical staff in national training programs;

To increase awareness on quality health care;

To enforce laws and regulations on drugs and drug sale, and increase capacity and power granted to the Ministry of Health;

To enforce professional registration and develop professional bodies to regulate health professions;

To set up an environment which would allow to prohibit staff of public hospitals and health departments from engaging in conflicting commercial interests.

MEDiCAM is an umbrella organisation representing 110 organisations active in the Cambodian health sector. This position paper has been prepared and authorised by the elected MEDiCAM Steering Committee, with support from the MEDiCAM Secretariat. The observations represented in this paper arise from direct experience by NGOs with extensive long-term knowledge of the Cambodian health sector.