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Healing Cambodia's Health Care | |||||||||
| MDGs |
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| 4 | Child Mortality |
| 5 | Maternal Health |
Cambodia’s poor, when they get sick, can be more likely to flee public health care workers than to seek advice or treatment. Many will selftreat or call in traditional healers before showing up at government-run clinics.
“I was afraid of injections. When I saw the health staff come to my village, I took my little baby with me and hid in the bushes behind the village,” relates one mother in the Memut District of Kampong Cham Province.
At an average age of 57 years, Cambodians die earlier than their Vietnamese or Thai neighbors, have more babies, die more often from malaria, and are more likely to die when giving birth according to the United Nations Development Programme. After 25 years of upheaval in the country, Cambodia’s health situation is among the world’s worst.
A government program that contracts private organizations to run and upgrade public health services is helping change that. It offers a unique way to achieve quick results and underscores the importance of innovation in working toward the Millennium Development Goals.
The widespread success of the program, started in 1998, has convinced officials to expand contracting from 5 to 10 of the country’s 76 districts.
The program is part of the Health Sector Support Project financed through a $20 million loan from ADB. The loan is also helping construct and renovate health centers and hospitals, and support diseasecontrol campaigns against HIV/AIDS, malaria, and other diseases.
Under the contracting system, use of public services has risen sharply, particularly among the poor. At the same time, average out-of-pocket health costs plunged, dropping by more than $30 per capita for the bottom half of the population in some project districts.
"Expenditure on health care is one of the main reasons people are pushed into poverty—they have to sell off assets to pay for services “
Indu BhushanPoor health comes at a high price in Cambodia. On average, Cambodians spend $33 per person each year to treat sickness, compared with government health expenditure of just $2 per person. They often pay ill-informed drug sellers, untrained healers, or freelancing government health workers for help—and the expense often destroys families, homes, and lives.
“Expenditure on health care is one of the main reasons people are pushed into poverty—they have to sell off assets to pay for services,” says Indu Bhushan, Principal Project Economist, ADB Mekong Department.
The contracted clinics are often more effective and offer treatment closer to home, which saves on transport.
By paying roughly $4 per person a year to contract health services, the government program can, in a short time, lift an enormous burden from thousands of the poorest people and provide more professional care. It underscores the importance of cooperation between ADB, government and, nongovernment organizations (NGOs) in designing projects.
MATERNAL
INSTINCT
Increased numbers of pregnant woman are seeking care
at Cambodia’s contracted clinics
Villagers are responding. The same mother who used to hide in the bushes says, “One day my baby had a high fever. The health worker in my village advised me to bring him to a hospital in Memut. There they showed me the importance of immunization and prevention of malaria. Now every month when the health worker or the midwife calls, I always take my baby.”
According to Save the Children Australia, which was contracted in the Memut district, “The wide level of community participation has led to an overall increase in the number of patients seeking care and number of pregnant women receiving iron supplements (currently 99%). All children in our area now receive vitamin A supplements and have access to measles immunization.”
NGOs entice people in need of care with clean clinics, professional and respectful services, and successful treatment. They use enforceable contracts, financial incentives, user fees, and achievable goals to motivate staff. Cambodia’s time under the Khmer Rouge and the years of civil conflict that followed ravaged its health system. New services had to be created from scratch, and development has been in progress for just over a decade.
Under the 1998 plan, contractors were chosen through competitive bidding to manage health services in five districts. In two, known as contracting-out areas, the contractor had full responsibility for delivering services—including hiring, firing, setting wages, and allocating resources.
Contracting-in, by contrast, provided private-sector management within a public sector setup. Contractors gave management support to civil service health staff and could not hire or fire, but could request transfers and receive a budget for incentives and operating expenses.
All five districts improved service coverage in a short time, the strongest being the contracted-out districts.
The use of health services among the poorest half of the population increased by nearly 30 percentage points in the contracted-out areas during the pilot program, as more and more people turned up at the clinics.
One villager, Khun Srean, came to the Memut Referral Hospital for delivery of her third child. “I prefer it because it costs less, the hospital is clean and close to my house, and the food and services are good.”
In the expansion to 10 districts, however, it was decided after consultation between ADB, NGOs, and the Government to use a hybrid system based mostly on the contracting-in model.
Contracts with NGOs are still at a fixed priced and based on performance, and the contractor retains complete flexibility in using whatever approaches and strategies are deemed effective.
Contracting-out created friction with civil servants and politicians concerned about losing control over health care. “The Government was reluctant to expand the program, and so relinquished control of the health services. The results convinced them,” says Mr. Bhushan.
Overall care improved for several reasons, says HealthNet International, one of the contracted NGOs. Of critical importance was an end to private practice among public workers.
Salaries were so low in the government clinics, at $10–$30 per month, that health workers had to seek other income. Many openly sold their services outside of the health centers and could earn 10 times more than their official salaries.
Payment was raised to levels high enough to get staff to dedicate 100% of their time to the public system. Doctors and district managers settled for salaries from $120–$180 per month.
“Existing district health managers have worked in an environment where it was unwise to make unpopular decisions. Many managers in charge are afraid to discipline staff as they fear dreadful repercussions,” says HealthNet.
An outsider is not hindered by longstanding relationships with staff and managers, and with reasonable incentives can get acceptance of new ideas.
“Civil servants expect life-long employment, and generally speaking, do not take risks that could jeopardize that position. The contract manager (by contrast) knows he has to score within the contract period,” says HealthNet. Failure to perform could mean no renewal.
By boosting salaries and putting in financial incentives, NGOs are getting clinic staff to stop private practice and ensure quality of care. Efficient and cleaner clinics are getting noticed, and patients are abandoning often more expensive outside treatment, and spreading the word.
Cambodia’s health care system remains rudimentary. But by building new facilities and contracting the management to private groups under ADB’s project, it is improving.
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