Cambodia: Greater Mekong Subregion Border Areas Health Project

Health / Disease control of communicable disease - Disease control of non-communicable diseases and other priority programs - Health care finance - Health insurance and subsidized health programs - Health system development - Mother and child health care

Health impacts of regional cooperation and integration. Strengthened regional cooperation and integration (RCI) in the Greater Mekong Subregion (GMS) has been a driver of the subregion's economic growth, leading to increased movement of people seeking economic opportunities offered by greater connectivity. Population movement facilitated by RCI has generated a unique set of health challenges driven by the dynamics of communicable disease spread, environmental and workplace determinants, and the health-seeking behaviors of individuals. Health challenges linked to mobility are most evident in border areas linked to major economic corridors that serve as both a transit point for departing and returning cross-border migrants and a destination for internal migrants seeking job opportunities in special economic zones (SEZs). Health systems in these border areas are often inadequately equipped to respond to mobility-linked health challenges, as illustrated during the coronavirus disease (COVID-19) pandemic when more than 260,000 Cambodian migrant workers returned to Cambodia. The majority re-entered through land borders with Thailand, overwhelming the capacity of the border area health systems for COVID-19 case detection, quarantine, and treatment. The GMS countries have collectively agreed on the need to enhance protection for vulnerable communities from the health impacts of regional integration, and strengthening health systems in border areas has been prioritized as an area for action.

Profile of Cambodian migrants. In 2018, more than 1.23 million Cambodian workers migrated, and 41% of these workers were female. Of this total, 1.15 million migrated to Thailand, which is the primary destination for Cambodia's migrant workers. The total number of Cambodians working in Thailand is considered to be far higher, with many individuals migrating through irregular channels. Internal migration is also widespread in Cambodia. About 1.2 million people migrated internally during 20152019. High rates of rural poverty combined with a lack of work opportunities act as catalysts for internal migration, with rural workers seeking employment opportunities in urban areas and the country's SEZs. Remittances from international and internal migrant workers, which totaled $1.5 billion in 2019, have been shown to reduce the poverty rate by 2% at the national level or 5% for recipient households. In 2020, remittances contracted by 13.5% because of the COVID-19 pandemic, highlighting the vulnerability of migrant workforces.

Migration in Banteay Meanchey province. Banteay Meanchey province is in Cambodia's far northwest, sharing a border with Thailand. Two international border crossings, both located in Poipet municipality, facilitate movement along the economic corridor between Phnom Penh and Bangkok. These border crossings are major transit hubs for both people and goods, with up to 30,000 individuals and 400 vehicles passing through daily. Cross-border movement of people into Thailand also occurs through the province's three local border gates. Banteay Meanchey is home to three SEZs, two of which are located in Poipet and employ more than 7,000 workers from across the country. An additional 27,000 Cambodian migrants are estimated to work in the province's informal employment sector, the majority in Poipet.

Hospital service capacity in Banteay Meanchey province. The dual demand for health services from local populations and migrants passing through the province creates unique challenges for local hospitals. The Poipet Referral Hospital is the closest hospital facility to the province's international border crossings and SEZs. In 2020, the hospital's bed occupancy rate was 124.8% and outpatient visits totaled 22,234 (67% female), of which at least 30% were estimated to be migrants. At the Mongkol Borei Provincial Hospital, the referral hospital for district facilities, the bed occupancy rate also exceeded 100% in 2019 and 2020. Supply-side constraints contribute to the pressures faced at each facility, compromising the quality of patient care. Both hospitals lack infrastructure and equipment to deliver the level and mix of inpatient and outpatient services in accordance with their designated facility levels. The hospitals are contracted by Cambodia's social health insurance (SHI) programs.

Health-challenges of cross-border migrants. Vulnerabilities throughout the migration cycle increase a migrant's susceptibility to health threats. Despite efforts of GMS countries to expand universal health coverage for their populations, migrant workers are increasingly neglected by health systems both at home and abroad. Individuals deciding to migrate through regular channels face complex predeparture requirements for health screening. These requirements contribute to people opting out of regular migration channels and migrating through irregular channels instead, increasing their vulnerability in the destination country. A lack of dedicated migration health services at predeparture, particularly with respect to sexual and reproductive health and rights (SRHR), maternal and child health (MCH), occupational safety, and social issues including gender-based violence (GBV), leaves both women and men ill-equipped to manage their health throughout the migration cycle. Migrants' inability to access their personal medical and treatment history while in destination countries is a barrier to the quality of care. High rates of smartphone use among migrants (in a sample of returning female migrants, 89% owned a smartphone) create opportunities for the innovative use of enabling technologies to ensure continuity of care. On return to Cambodia, failure to provide systematic access to essential screening and treatment services at the point of arrival jeopardizes the well-being of both migrants and host communities.

Health challenges of internal migrants. Internal migrants working both in Cambodia's SEZs and in informal sector employment are susceptible to health risks. Environmental issues such as airborne emissions, water, and noise pollution, coupled with workers being inadequately equipped for workplace safety, create occupational injury risks. Lifestyle factors, including lack of access to safe water and nutritional foods, contribute to poor health status of migrant workers. A survey of Cambodian factory workers, the majority of whom were female, found high prevalence of anemia and being underweight. Inadequate support for reproductive health issues and access to services leaves female factory workers, particularly those under 30 years of age, susceptible to sexual and reproductive health conditions. Absence of on-site medical services in SEZs, coupled with rigorous working conditions and long working hours, results in workers using pharmacies for medical assistance instead of going to a health center or hospital.

Health financial protection. In Cambodia, out-of-pocket payments accounted for 64% of health expenditure in 2019. For more than 17.0% of households, 10% of their annual expenditure was on health, while for 5.1% of households, 25% of their expenditure was on health. Self-financing of health care leads to an increase in household debt and delays in accessing care. Options for social health insurance (SHI) coverage for both female and male internal migrant workers, the majority of whom are employed in the informal sector, are limited. While Cambodia's National Social Security Fund is accessible to informal sector workers, uptake is low. The operational procedures of the fund, which are based on a formal employment model, are not well-suited to the needs of informal sector workers. The current eligibility criteria, registration procedures, and contribution arrangements are obstacles to uptake. Cross-border migrants, particularly women, face similar obstacles in accessing social protection. Enrollment in Thailand's Social Security Fund (SSF), which is intended to provide cover for migrants employed through regular employment channels, is estimated to be 40% for regular female migrants. Regular migrants in domestic labor and part-time agriculture and construction roles (positions disproportionately filled by female migrants) are ineligible for SSF cover. Even for those migrants in SFF-eligible employment, barriers to enrollment exist. On returning to Cambodia, female migrants are significantly more likely than males to forgo health care because of financial barriers. Cambodia's National Social Protection Council (NSPC) recognizes the risk of internal migrants in informal sector roles and cross-border migrants slipping through the SHI safety net. Programming response is hampered by the lack of gender-disaggregated data on the health-seeking behaviors of these migrant groups, and the barriers to enrollment and access to benefits that contribute to low SHI coverage. Effective tools to extend SHI coverage to these vulnerable segments of the populationboth in Cambodia and across bordersare needed.

Protection of vulnerable communities from the health impacts of regional integration strengthened

Access to quality health services for populations residing in, and migrating through, selected border areas improved

Health service delivery in selected border areas strengthened

Health financial protection for migrant populations improved

Systems for integrated and gender-responsive delivery of health services within and across borders enhanced

Participatory approaches and project activities that will strengthen inclusiveness in project implementation. The project will improve the quality of health care available to migrant workers and to poor and marginalized populations in target areas. In addition, it will improve the interpersonal counselling skills of health staff at target facilities to ensure that (i) every contact with a health professional by migrant workers and local people is respectful; and (ii) information provided is useful, accurate, and communicated in a way that is understood. The project will support the rollout of operational standards for health facilities, which include standards for ensuring feedback from migrant workers and local patients concerning health services and measuring patient and migrant worker satisfaction.

CSO participation. CSOs dealing with migrant workers' rights (Center for Alliance of Labor and Human Rights) and women's health issues (Cambodian Women's Crisis Center) were consulted during project design on the health needs of migrants.

All consultants will be recruited according to ADB's Procurement Policy (2017) and Procurement Regulations for ADB Borrowers (2017), as amended from time to time.

The Ministry of Health (MOH) will engage two international consultants (9 person/months) and twelve national consultants (363 person/months). Rationale for using individual consultant selection include: (i) the consultants will provide their inputs individually without the need of a firm's support; (ii) the MOH, under the ongoing project, had successfully hired individual consultants during past and current similar projects; (iii) to ensure consultant flexibility and timely recruiting of consultants; and (iv) to guarantee strong executing agency ownership over consultants' output. The international travel restriction during the COVID-19 outbreak will be considered in the commencement date of the services if required.

A strategic procurement analysis was undertaken to achieve value for money, effectiveness of procurement; and mitigate risks around supply chain volatility, security and quality of the supply, and the requirements on local access to technical support for specialized equipment. The analysis assessed the executing and implementing agencies' capacity to undertake procurement, current market options, existing suppliers in the ongoing GMS Health Security Project, and other recently undertaken projects funded by ADB and the World Bank in relation to government priorities, lesson learnt, and good practices from similar procurement in the region. Given the uncertainty and restrictions in the current circumstance, it was assessed that the diversified procurement arrangement will help mitigate procurement risks in the context of COVID-19.

All procurement of goods will be undertaken in accordance with ADB's Procurement Policy (2017) and Procurement Regulations for ADB Borrowers (2017), as amended from time to time.

The main areas for procurement will be civil works for the Mongkol Borei Provincial Hospital and Poipet Referral Hospital and the delivery of medical and non-medical equipment. The project includes a substantial amount for cross-border and sub-regional cooperation as well as regional health financing which will be funded from the grant component. The following are the main packages to be procured under the project:

a.Civil works for:

-Mongkol Borei Referral Hospital, including (i) a new 3-storey hospital building for outpatient and inpatient services, and (ii) renovation of existing laboratory buildings.

-Poipet Referral Hospital, including (i) a new 3-storey hospital building for outpatient and inpatient services, (ii) a new wastewater treatment plant, and (iii) relocating the TB ward.

b.Provision of medical, non-medical and IT equipment for the two project hospitals.

c.Consulting services through Firms for (i) detailed design and construction supervision, (ii) capacity building and training, (iii) design and implementation support for a UHI/ePHR pilot, and (iv) analytical work on social health insurance

d.Individual consultants in the PMU to support project implementation.

Before the start of any procurement, ADB and the government will review the public procurement laws of the government to ensure consistency with ADB Procurement Policy (2017), as amended from time to time. All procurement through open competitive bidding (national advertisement) will follow the applicable public procurement laws in that country, subject to the modifications to the laws described in the relevant Procurement Plan.