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Cambodia is one of the poorest countries in South-east Asia, with approximately 34.7% of its total population living below the poverty line. Cambodia is still emerging from decades of civil war and political instability, which had devastating effects on its health systems. Although there has been steady improvement in its health indicators in recent years, the health status of its population is among the worst in Asia and pacific region, with high infant, child and maternal mortality rates. The health sector reform which occurred after the war has resulted in remarkable successes in the national health system. However, despite these successes, several challenges and issues still exist in the health system which can be addressed with feasible strategies (Walford, 2008).
Critical Analysis of key challenges and successes within Cambodia's health system:
Governance arrangements focusing on Organization and Management of the Health System:
The governance arrangement originated from the health sector reforms which lead to the formation of a three tier system: Central, Provincial and District levels. The Central level is managed by the Minister of Health as the chief executive, and comprises of three directorates-health, finance and administration, and Inspection, with their respective directorate generals who supervise and monitor the various subsidiary departments and offices. The Provincial level is managed by the provincial directors who supervise service delivery and ensure effective utilisation of resources in their respective operational districts. The District level is managed through public-private partnership by district health care managers and middle level managers from Non-governmental organizations (N.G.Os) who supervise health service delivery in their respective districts (MOH, 2009).
According to Bhushan and Sheryl (2006), the public-private partnership has shown significant success in achieving dramatic increase in health service coverage and reduction in private expenditures. A study done in Mamut province showed an improvement in the management of health facilities in terms of availability of 24 hour service, availability of equipment and supplies, supervisory visits and presence of health staff when they are scheduled to be on duty.
However, despite these successes, the health system governance and management capacity at the provincial level is limited, resulting in the provincial directors having limited authority and supervisory capacity over their respective middle level managers from the non-governmental organizations at the district levels (Zant, 2008).
Resource Generation, Allocation and Management:
Cambodia's health sector is financed by Government revenue, external donor aid and private (out-of-the pocket payment). The government's budget for health has increased significantly in recent years reaching $9.4 per capital in 2009, which is quite high in South-east Asia. External donor aid is twice government revenue, with the health sector highly dependent on donor funding (MOH, 2009).
However, despite the increasing investment in health finance from government budgets and external donors, private expenditure still accounts for the largest portion of health expenditure which is spent on unregulated private health care. Furthermore, despite total increase in health expenditure, key health indicators are still weaker than in neighbouring countries that spend less money on health. The challenge however is more of allocation and effective use of funds rather than inadequate finances (WHO, 2009).
Budget execution has improved in recent years with timely releases. However, allocation of funds to the provincial and district levels tends to be very slow at the beginning of the year due to the number of approval steps that have to be met before the funds are allocated. When the funds are finally released, health facilities below the provincial level do not have a detailed budget plan and are not accountable for the use of finance leading to ineffective use of resources (MOH, 2008).
The quantity of health professionals is low with a low staff to population ratio of 1:1000: half of the WHO's recommendation. When compared to Sub-Saharan Africa, Cambodia has about twice the number of doctors per population. The main challenge is shortage of health staff in rural areas especially midwives and nurses due to poor staff reimbursement and the inadequate skill and competence of health workers, resulting in ineffective delivery of health services (WHO, 2009).
Main National and International influences and their effects on equity:
The many years of war and political turmoil resulted in the limited health facilities and health workers especially in rural areas. After the war, several health reforms were enacted in the areas of health financing, health coverage plan and health management which aimed at promoting equity, increasing coverage and reducing urban-rural disparities in accessing health care services(Samson,2006).
The health equity fund being financed by the government and non-governmental organizations has provided the less wealthy access to free and quality health care services. In a study in Kampong Cham the biggest province in Cambodia, the number of child deliveries in health facilities had increased by 28% after the introduction of the fund scheme. This accounted for 40% of deliveries among the poor, thus enabling women who previously delivered at home with the assistance of an unskilled traditional birth attendant, deliver under the care of a skilled birth attendant in a health facility (Annear, 2008).
The health coverage policy resulted in the development of the district based health care system with the reconstruction of health facilities, which were distributed according to population coverage resulting in increased geographical access to health facilities especially in the rural areas(Couwenberg, 2008).
However, due to the poor remuneration and wages of health workers, most of the health facilities in the remote areas remain understaffed and under-utilized. This makes patients seek health services from traditional healers and unqualified private service providers despite the availability of funds and health facilities leading to high private spending and poor health status of the populate (Grundy, 2006).
External donor-aid plays a significant role in financing health care services, accounting for about 50% of the total health expenditure. Donor's support has contributed significantly in enhancing health sector development leading to an improvement of the health of people of Cambodia especially mothers and children, evidenced in a reduced maternal and child mortality rates, reduced total fertility rates, improved nutritional status among women and children and a more effective health system(Annear,2008).
However, this support has been provided in a disintegrated manner which is poorly aligned with government priorities despite efforts made with the Sector wide management (Swim) process. Furthermore donor agencies tend to work independently of each other, resulting in disintegrated funding of the health sector which is controlled by the donor's priorities: which focuses on four main areas-HIV/AIDS,Tuberculosis,Maternal and Child health. Consequently poorly targeting the needs of the risk population and thus neglecting other aspects of the health system where it is also needed (Grundy, 2006).
The health sector of Cambodia is highly dependent on donor funding, resulting in non-governmental organizations playing a significant role in policy making and implementation, influencing the priorities of the heath sector which are cure-based with less emphasis on public health practices and preventive medicine. This leads to preventable diseases such as diarrhoea, dengue fever and vaccine preventable diseases being the major causes of death in Cambodia (Annear, 2008).
Strategies for improving Governance Arrangement:
The governance and management capacity at the provincial level should be improved through health system strengthening and capacity building. This would increase the capacity of the provincial directors to issue, design and monitor the activities of the various respective districts. This should be implemented through building effective co-ordination and collaboration process between the provincial directors and private providers for effective delivery of health care services through regulatory mechanisms (MOH, 2008).
Increased managerial capacity at the operational district level should be developed, with stronger regulation and stewardship of the private sector by the provincial directors. Effective private-public partnership should be promoted to improve the quality, affordability and accessibility of health services through the reinforcement of regulations. The regulatory capacity of the provincial level should be strengthen through reinforcing health legislation, professional ethnics and code of conducts resulting in effective and efficient delivery of health services (MOH, 2009).
Furthermore, a communication mechanism should be developed between the public sector and non-governmental organisations, thus providing a medium for future gains in terms of integration and quality control measure for the delivery of health care services (MOH, 2008).
Strategies for improving Financing and Human Resource Generation, Allocation and Management:
The allocation and management of financial resources to provincial and district levels should be improved through decentralization of budgets and strengthening the system for tracking budgets and expenditures. The decentralization of budgets would result in the reduction of the number of approval steps thus decreasing the time taken for the budget to be allocated to the provincial and district levels. Scrupulous management of financial resources should be done through the formation of an efficient budgeting and auditing system thus making health facilities accountable for their use of resources (MOH, 2008).
According to Grundy and Annear (2009),the distribution of health professionals should be improved through deploying health professionals especially midwives and nurses to remote areas on contracts basis with incentives and improving staff remuneration through rural allowances and facility based salary supplementation from user fees. In the long run, the number of health professionals in remote areas can be increased by admitting more students from rural areas into schools and universities and deploying them to serve in remote areas as a prerequisite to being permanently registered. This strategy has worked with good results in Nigeria with the national youth service scheme.
The professional expertise and proficiency of health care workers especially midwives and nurses should be improved through pre-service and in-service training which should be done quarterly with more emphasis on clinical and public health practices. This would result in improved performance and distribution of health care workers thus reducing the inequalities in the health status of the people of Cambodia (Bloom, 2006).
Strategies for addressing National and International influences and their effects on equity:
The co-ordination of donor's support should be improved through the sector wide approach process (SWAP) by aligning the donor's priorities and funding with the health sector priorities and strengthening the co-ordination of donors funding and activities through pooling arrangement. Thus resulting in efficient use of resources towards achieving the National health sector's targets. However, strong government leadership, political commitment, efficient management body and making a policy to its effect is essential in making the strategy achievable (MOH, 2003).
The sector wide approach process would be implemented by integrating it as a component of the Health sector strategic plan, which would be compulsorily endorsed by all external donors. This would include a set of indicators which would be used for evaluating the implementation of the policy and the health sector's progress, establishing a code of conduct which would be signed by the government and development partners and forming a sector co-ordination committee. The committee would recommend and inform the external donors of key decisions related to the policies and priorities of the health sector. This approach is of an immense success in Mozambique; who have a similar context to Cambodia in post-conflict situation, fragmented funding and heavy reliance on external donors (MOH, 2008).
The poor remuneration and wages of health care workers especially in remote areas should be improved through the use of equity funds and user fees to supplement the salaries of health workers. This would be implemented through the allocation of 60% of the funds to be used in supplementing the wages of health workers with conditions attached: which would include performance and number of hours worked. This approach has been piloted with significant success in Vietnam resulting in health workers earning more money by working in public rural health facilities and an increase in the number of health workers in rural areas (MOH, 2008).
The health status of the Cambodians has improved significantly since the post-war period. Two of the indicators used for defining the quality of the health system: Infant and Child mortality rates have improved significantly. Although maternal mortality rates still remain high. Strengthening the health system in Cambodia is important if the health status of the people of Cambodia is to be improved as well as the efficiency and effectiveness of health service delivery (MOH, 2008).