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Health |
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(i)
Introduction The
average annual income of Cambodian people is as low as US$258 per capita.
However, household expenditure for health care is as high as US$29 per
person, most of which comes from savings and borrowed money. Health care
remains a serious factor of impoverishment in Cambodia (where 36% of the
people live below the poverty line of $0.5 per day). Yet, less costly
household expenditures for health care would boost investment and
consumption, two factors that contribute to economic development. Healthy
workers are physically and mentally more productive and have a higher
income. Also, a healthy workforce creates incentives for foreign companies
to make long-term investments in the country.
Still, the OECD recently noted, “While health is widely understood to be
an important outcome of development, the role of good health in promoting
economic development and poverty reduction has been much less appreciated. In Cambodia, the Ministry of Health has made
consistent efforts to develop the public health sector, but structural
obstacles have prevented it from reaching health-related poverty reduction
goals established in the first Socio Economic Development Plan. As a
matter of fact, the population health status remains very low and most
health care consumers do not perceive changes from policy reforms.
Medical, representing 110 health organizations, urges the Royal Government
of Cambodia, Donors and Development Banks to show their commitment in
addressing these structural issues. At the same time, Medicam would like
to recommend that the Ministry of Health priorities intermediary measures,
which will increase access to affordable and high quality health services
thus contributing to poverty alleviation. Consistent
Achievements in the Health Sector Drug
supplies: In year 2001, as a result of the Ministry of Health’s
efforts, drug supplies have greatly improved. Community
participation: More feedback committees and health centre management
committees have been established, which provide an opportunity to both
health centre staff and local communities to better link with each other
and improve the quality of existing health services. Outreach
activities: A guideline for outreach activities, as well as an
allowance of 8,000 Riels has been established to encourage health centre
staff to implement outreach activities. Construction
and renovation: Construction and renovation of health facilities have
allowed the 1996 revised health coverage plan to be implemented at 81%,
although new facilities are not always operational. Priority
Action Program (PAP): Though chaotic for a first year, the PAP,
implemented in seven provinces, is also a positive step toward modernising
the health financing system. However, reserves from the Ministry of
Economy and Finance to expand this post-audit system to additional
provinces and to possibly modify its scope have created uncertainties for
the future. Planning
exercises: Planning exercises have also been better coordinated and
implemented both at provincial and national levels, which is a crucial
step in improving health service delivery. In particular, the on-going
development of the Health Sector Strategic Plan, which should be finalized
by the end of August 2002, has the potential of being a significant tool
for management of the health sector if strategies and activities are
prioritized in a realistic way. (ii)
Key Issues and Structural Obstacles Low
wages: All
these positive developments, which show the willingness of the Ministry of
Health to develop the public health sector, are however jeopardized by a
number of structural obstacles, which are beyond the Ministry of
Health’s authority but need to be addressed at a higher level. Thus, the
problem of low salaries, which discourages public health workers,
jeopardises the quality and availability of public health services. Senior
consultants who are supporting the Ministry of Health in building the
national Health Sector Strategic Plan noted that the issue was not
selected during the national workshop organised to establish the health
sector priorities for 2003-2007. When participants were questioned
informally about this, the response usually was that this issue “has come
up time and time again and no one seems to be able to address it so we
have given up..." Medicam joins other partners who strongly
recommend an increase in salaries to
the level of a living wage. The recently established “Position
allowance” and the “Priority Mission Group” strategy adopted by the
Council for Administrative Reform are two positive steps forward, but the
salary increase they generate is so meager for field health workers that
they still do not address the low wage problem. Still, access to
affordable quality health services in the public sector is a crucial
factor of poverty reduction, and this can only happen if health workers
are able to perform without the recurrent worry about insufficient income. So
far, the government has argued that it does not have the financial
capacity to increase salaries. Medicam joins other partners who recommend
that the government assess strategies that will better balance its
budget between running costs and Public staff compensations.
A much higher budget should be provided to the Ministry of Health to allow
the latter to provide public health workers with specific significant
allowances, in particular 1) to encourage health workers who are ready to
work in remote areas, and 2) to motivate health workers to provide quality
services. It has to be noted here that only experiences of bonus provision
that have linked bonus payment to performance have been successful.
As such, local independent monitoring and evaluation bodies need to be
established to monitor performance and encourage public health workers to
perform well. Budget
Release and Access to Budget: Current
cash flow procedures are another structural obstacle that prevents the
public health system developing as they dramatically delay budget release
and access to budget. As a result, only 3% of the health section of the
PAP budget (against 25% after three months in 2001) and close to 0%
of the health section of Chapter 11 were released during the first four
months of 2002. This deep structural macro-economic problem worsens year
after year and paralyses the whole public health sector. The NGO community
would appreciate being briefed on plans and progress being made at that
level to address this crucial issue. (iii)
Recommendations for Intermediary Measures Equity
Funds In
this difficult structural context, some intermediary priority measures can
be taken to improve the health status of the population and contribute to
poverty alleviation. Exemption status for the poor has already been
established, which is a positive step towards improving access to public
health care for the poor. It is recommended that the financial burden of
the exemption for the poor be not borne completely by the health
facilities and the health workers. Thus, equity funds could be established
in all Operational Districts where quality of care and management are
present to support them. To avoid conflict of interest, it is highly
recommended that a third party with a good understanding of the
local communities, manages these equity funds. Nutrition,
Outreach Activities and Behavior Change Improvement
of the nutrition status and prevention of disease, particularly for poor
people, would help them cut their expenditures for curative health
services. Thus, outreach activities could be promoted and
monitored. Also, promotion of behavioral change at consumer level,
as well as at practitioner level, could be undertaken on a large scale.
Firstly, at consumer level, this would require studies in health
behaviors, particularly health behaviors relating to the poor. Medicam
congratulates the Ministry of Health for considering the inclusion of
behavior change in the coming five-year Health Sector Strategic Plan, and
would stress that the ministry give this a high priority in its annual
plans. CONCLUSION Improving
the population’s health status is a necessary pre-requisite to other
poverty reduction and human development objectives. The booming private
sector presents itself as an alternative to the public health sector
affected by the structural weaknesses and financial difficulties. However,
in an environment notorious for its reluctance to accept regulation,
commercial health care provision with its high prices, will not lead to
improved access to the poor. Strengthening the public health sector and regulating the private sector will remove threats to the health status of the people and obstacles to economic development. |
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