CDC - Speech by Hong Sun Huot

CAMBODIA PUBLIC HEALTH DILEMMA DURING HIV/AIDS ERA SPEECH ADDRESSED BY H.E. DR. HONG SUN HUOT Senior Minister, Minister of Health and Chairman of the National AIDS Authority AT THE CONSULTATIVE GROUP MEETING *PHNOM PENH, 19 JUNE 2002*

Respected Samdech Hun Sen Samdech, Princes, Princesses, Excellencies, Ladies and Gentlemen, and Distinguished National and International Guests On behalf of the Ministry of Health and the National AIDS Authority, I am indeed honored and privileged to be able to address the Consultative Group Meeting in Phnom Penh. I would like to take this opportunity to present the recent developments in health in Cambodia during the HIV/AIDS era. Respected Samdech Hun Sen Samdech, Princes, Princesses, Excellencies, Ladies and Gentlemen At the onset of the new millennium, the health sector in Cambodia has made substantial progress in recovery, development and change. However the country’s efforts and achievements in the sector were not immune from insufficiency of actions, weaknesses and challenges. Significant progress has been made over the past decade, and major frameworks for health sector development are already in place. However, Cambodia remains one of the poorest in the region with a high Infant Mortality Rate and Maternal Mortality Ratio. Many public health challenges in particular communicable diseases remain to be tackled along with the new formidable tasks of fighting HIV/AIDS. The process of economic liberalization and the open-door policy, which have deepened and widened since the signing of the Paris Peace Accord in 1991, have to consider the widespread occurrence of HIV/AIDS. The trend indicates a rapid epidemic increase of AIDS among some population groups, together with a spread of infection out to the population in general. HIV prevalence among blood donors had increased from 0.1% in 1991 to 4% in 1998. The sero-prevalence rates for adults within the sexually active group reached almost 4% in 1998. Although the prevalence has decrease from 3.8% in 1998 to 2.8% in 2000, there is no room for complacency. The rate is among the highest in Asia. The burden of AIDS on the society remains extremely heavy. HIV/AIDS has put the Royal Government’ s efforts to deal with other public health priorities in a tough dilemma. If only 5% of all people in Cambodia living with HIV/AIDS were to be hospitalized this would require more hospital beds than currently exist in the country. Thus, there would be no space for our sick children, pregnant women and other seriously ill patients. If all AIDS patients were treated with anti-retroviral drugs for only three months, there would be no single cent left in the budget for the Ministry of Health to buy medicine for other patients. This has been on of the tough challenges for us in developing a well prioritized health strategy. As you may know the infant mortality rate and maternal mortality ratio in Cambodia remain relatively high in comparison with our neighboring countries. If we pay too much attention to vertical program for HIV/AIDS, tuberculosis and malaria, how can we assure that all our children enjoy their right to access to full immunization, treatment of deadly meningitis, diarrhea and acute respiratory infection? We must also assure that all mothers can exercise their right to prenatal care, safe delivery and post-natal care. All of these demands for control of disease and provision of basic and referral health services need to be balanced. Samdech, Princes, Princesses, Excellencies, Ladies and Gentlemen In response to the above mention issues, the MOH has undergone a reorganization of the public health services based on the Health Coverage Plan (HCP) initiated in 1996 to extend services to the population, the majority of whom are situated in rural areas. This was the major attempt to lower the barriers of geographical access. As the result, the public health infrastructure has been reorganized through a shift from the administrative district/commune system to a system based on criteria of population and accessibility of services. The system is based on the formation of a network of health centers (HC) and referral hospitals (RH) grouped into “Operational Districts “ (OD), the basic units of health care, so that the population has a rational and equitable access to basic health and referral services. Under the planned allocations, which covered the whole population leaving neither gaps nor overlaps, 941 HCs and 67 RHs are being developed in 73 ODs. Currently, around 84% of the total planned health centers are providing minimum package of activities, a package of services carefully designed to focus on the priority health problems. All the 67 planned Referral Hospitals are in different stages of development towards fully offering the complementary package of activities. Today, fourteen Former District Hospitals converted into referral hospitals are able to provide major surgical operations as an important component of CPA. Complementing the organizational reforms is better targeting of health spending for the poor and official establishment of cost recovery systems including a safety net for the poor through an exemption mechanism. There was a strong message in the National Health Financing Charter to build in exemption procedures wherever user fees were introduced with a particular reference towards enabling the poor to gain access to priority health services. Health financing schemes introduced at health centers and referral hospitals under the National Health Financing Charter added approximately US$1.5 million to funds available at these facilities in 2001. This constituted a positive reallocation of resources from unregulated private providers to the public health system. Human Resource Management is being improved through implementation of the Workforce Development Plan and the Functional Analysis for health personnel. To address the low level of health worker salaries, the National Health Financing Charter provided a legal framework for generating extra resources for staff incentives. It also provided extra funds for operational costs thereby improving quality of care. It was envisaged that motivating staff through supplementing salaries would eliminate unofficial charges to consumers. This has largely happened where the system is working well. Samdech, Princes, Princesses, Excellencies, Ladies and Gentlemen Another milestone, the pilot tests on a number of alternative mechanisms for improving management and health financing of health service delivery brought fruitful lessons learned in targeting the poor. For instance, the evaluation of a mechanism for service delivery through contracting-in and contracting-out of health services found that the out-of-pocket expenditures by the lowest 50% socio-economic group declined significantly in all the contracting districts. In the contracting-in district with user fees and additional enforcement of the limitation on private practice, the evaluation showed lower health care expenditures and higher utilization by the poor. Since the above-mentioned reform initiatives are not sufficient to protect the consumers, the Ministry of Health for its part has paid also special attention to the regulation of private medical services as an essential element of the national health system. Since 1995, the Ministry of Health has made available a number of health-related regulatory mechanisms such as the law on pharmaceutical management, the law on abortion, the law on the Management of Private Medical and Paramedical Profession, the Royal Decree on Medical Council of Cambodia and various circulars and instructions on pharmaceuticals and the medical profession. Currently, another major milestone in improvement of the management of the health sector is the development of the Health Sector Strategic Plan 2003-2007. The first draft of the Plan is being circulated for stakeholder comment and it is expected that it will be finalized by July 2002. Furthermore, it will be accompanied by a Medium-Term Expenditure Framework and a series of annual operational plans accordingly. This and other initiatives are designed to lead the health sector towards a future Sector Wide Management (SWIM) approach and promise to fill the gap left by the previous absence of a comprehensive national health plan. Samdech, Princes, Princesses, Excellencies, Ladies and Gentlemen Another good sign: the Royal Government of Cambodia considers that health is a priority sector for improving the people’s welfare and one of the foundations for the socio-economic development of Cambodia. The proportion of government revenue that is allocated to the health sector is relatively quite large compared to other Asian countries. However, although the proportionate allocation is high, the overall government revenue base is relatively narrow because Cambodia is a low-income country with limited local economic activity and export income. Although the Government Expenditure on Health has increased tremendously - by 175% - during the period 1998-2001, an adequate level of the government expenditure seems a long way off. The basic package of publicly funded health services is estimated to cost between US$12 and US$24 per capita per year. This is well above the current level of RGC budget allocation to health, which is approximately US$2-3 per capita. Given this gap in funding, the health sector is dependent on donor contributions in both the short and medium terms to develop adequate capacity to deliver appropriate services. This reliance on international assistance is likely to persist for at least the next decade. Estimates point to the RGC being able to finance primary care at US$12 per capita by 2013 - based on the Cambodian economy’s continued growth rate of over 5%, increased budget allocation for health in real terms, estimated reduction in donor spending once primary health infrastructure is upgraded, and better more equitable allocation of household expenditure on health. Samdech, Princes, Princesses, Excellencies, Ladies and Gentlemen I have outlined briefly today the measures undertaken by the Ministry of Health to develop a health system that covers the whole population in an equitable manner and gives highest priority to the health problems affecting the most vulnerable populations. As I have cast these efforts in the context of HIV/AIDS era let me reassure you that while striving to build our health system, we are also investing considerable effort in confronting, with our colleagues in others sectors, this epidemic that threatens not only our health system but also the whole development of this country. We have made progress but we cannot afford to reduce efforts. I am confident that at the next CG meeting we will be able to report positive progress in the development of the health system but also in the battle against HIV/AIDS. Samdech, Princes, Princesses, Excellencies, Ladies and Gentlemen Before ending, I would like again to thank Samdech Hun Sen for spending part of his precious time to attend this Meeting and to wish him long life so he may continue to lead the Kingdom of Cambodia in its march toward prosperity and progress. Finally, I would like also to thank your Excellencies, Ladies and Gentlemen, and to wish you Ayouk Vannak Sokha Pollak forever. In addition, for all the delegates, I wish you a nice and fruitful stay in Cambodia during the CG Meeting 2002. Thank you