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Healing Cambodia’s Health System
NGOs are being tapped as new partners to deliver services for better health care

By Marcia R. Samson (csamson@adb.org)
Editorial Coordinator

BETTER CARE: Seriously ill Tharin receives professional, immediate attention at the new health center in Cheung Prey.

For nearly two weeks, 13-year-old Tharin's fever was so high she could not go to school. Her mother, Ya, took her to a nearby private doctor for an injection. But Tharin continued to suffer from high fever and severe headaches. She became weaker.

Worried that Tharin could have malaria or dengue fever, Ya brought her youngest daughter to the new health center in Cheung Prey, Kampong Cham Province, one of 48 newly constructed health centers providing treatment, immunization, family planning services, and prenatal care.

Through a US$20 million concessional loan from the Asian Development Bank (ADB), the Basic Health Services Project is funding civil works to upgrade facilities and services in district health centers and hospitals, training district health workers for capacity building and decentralized management, and implementing an innovative pilot program for contracting health services.

Ya says she regrets that she has delayed taking her daughter to the health center, which is nearer than the closest hospital; yet from their home, the health center is still more than an hour's ride in an ox cart. "It was easier to see the private doctor, but he just kept giving Tharin injections every three days that cost riel (KS)20,000 each." Equivalent to US$5 per injection, the sum is a huge amount in a country where the average family lives on only about US$260 per year, one of the lowest in Asia.

The health center's doctor diagnosed Tharin's condition: advanced typhoid fever. Immediately she received medical attention and free medicine.

Also at the health center on that day was Thy On, who rode on a borrowed bicycle to get a shot of an injectable contraceptive that will be effective for three months. This was her second dose; the first injection was from a private paramedic.

HEALTHIER MOTHERS AND BABIES: Centers are providing low-cost prenatal care.

"We are poor and cannot afford to have many children," says 28-year old Thy, who has a 10-year-old daughter and a 4-year-old son. "I want to be able to send my children to school so they can be factory workers when they are older instead of farmers like us." She provides an accounting: child delivery at home through a trained traditional birth attendant costs about KR10,000 (US$2.50), as does 500 grams of infant formula.

An Innovative Partnership

The Project was designed to improve the management of Cambodia's long-neglected health centers and hospitals and test innovative approaches for delivering health services.

As a part of this effort, the Government has been tapping nongovernment organizations (NGOs) as a new partner to deliver improved health services. Under a contracting-out scheme for services, contractors have full authority and funds for staffing, management, and operational costs. Under the contracting-in approach, contractors provide technical support to the operational districts, and the Ministry of Health remains responsible for the operational costs for health services and staff salaries. So far, the approach has been tested in five operational districts and has been working well.

The Australian NGO Save the Children (SCA) is the contractor for the referral hospital in Cheung Prey District. SCA's Dr. Som Chit Bungnasiri, who is managing the Project there, says that the number of patients has increased considerably. Some have come from far away towns after hearing that health care delivery has improved and free meals are provided. Overcrowding is a problem, with some patients occupying beds in the corridors and front lobby.

Dr. Un Sok Run, Cheung Prey's Health District Manager, says that aside from hospital care, staff are sent out for community outreach activities to increase awareness of health services and provide basic education to promote preventive health care. To avert the loss of hospital supplies and essential drugs, staff discipline is being emphasized. Staff are being given incentives under the contracting-in scheme through budget supplements.

Dr. Wan Azmin, ADB Health Specialist and Project Officer, describes the relationship between NGO contractors and the provincial, district, and local health officials as "generally healthy." This is essential in strengthening the health care system at the community and district levels to deliver preventive and curative services to the rural poor.

The health centers and referral hospitals are being fully used despite a lack of medical equipment and supplies. Health center consultations range from about 116 to 1,144 per month, with longer queues in centers with better-trained staff.

WILLING BUT UNABLE: Few Cambodians can afford to pay for health care; the project provides medicine and services at affordable fees, particularly for the rural poor.

Cost-sharing schemes have also been implemented, with most health centers now collecting user fees of KR100–500 (2–12 US cents) per outpatient visit. Willingness and the ability to pay are still issues. Most Cambodians cannot afford to pay for health care, and health insurance is unheard of.

Health Workers Need Help

In addition to inadequate infrastructure and equipment, Cambodia faces a serious shortage of trained health personnel, as many were killed or had fled during the Pol Pot regime. On top of this, extremely low salaries adversely affect staff morale and receptivity to supervision. Government health workers, like other civil servants, earn very little: a nurse earns about KR30,000 (US$8) a month and a doctor KR40,000 (US$10).

To make ends meet for their own families, government health workers often work only part time so they can also engage in private practice. This situation is being tolerated because the Government cannot afford to pay them decent wages, admits Dr. Nguon Sim An, Provincial Health Director for Kampong Cham. "We cannot expect good performance from our health workers if they are underpaid and worried about their families' survival. If we try to stop their private practice, they may resign."

Although costs were underestimated and the original project scope reduced, the Project is well on its way to reaching its revised goal of constructing 177 new health centers, and renovating 20 existing health centers and 13 referral hospitals by June 2002. This step is helping heal Cambodia's health system, but the country has a long way to go before its health system makes a full recovery.

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