Health care policy and administration

A quality and effective healthcare system that provides equal access to services is critical to ensure the well-being of any population. Both developed and developing countries strive to bring improvements to their healthcare systems. Cambodia, in particular, has undergone significant transformations in terms of healthcare as a result of its recent rapid economic expansion1  Since the 1990s, Cambodia has taken critical steps and strategies towards improving its healthcare systems and policies to ensure the well-being of its citizens2 Nevertheless, despite notable changes in the overall health status of the population over the last few decades, significant disparities and challenges remain. As a response, Cambodia has been implementing new health policies to improve service delivery.

Health financing has experienced significant changes in its role of improving healthcare delivery in Cambodia. The Cambodian Government was able to increase health financing from 1057 million dollar in 2014 (due to the country’s economic expansion) to 1207 million dollars in 2017.3

This number was more than 7% of Cambodia’s GDP and was made possible through diversified sources of finance, including taxation, external donors, out-of-pocket, and health insurance, as indicated in Figure 1.4

                                                                                                             According to figure 1 , the out-of-pocket expenditure accounted for most of the revenue (61.3 percent), followed by official development assistance (20.2 percent), government budget (19.3 percent) and then health insurance (0.2 percent). On the other hand, Figure 2 presents the main expenditure components for the spending. Figure 2 show that significant proportion of the budget was spent on Pharmaceuticals and other health care services (41.8%), staff salaries and incentive accounted for 25.2%. followed by operating cost (18.8%) and lastly, capital expenditure (13.7%).

                                                                                                                   Increased resources devoted to healthcare have also helped in rebuilding healthcare infrastructure and human resources – after the Khmer Rouge period, Cambodia was left with only 25 doctors 5. Cambodia has implemented two health workforce plans to increase the medical workforce through recruitment and training programs, given that the number of professionals is insufficient to cover its 16 million population.  Cambodia expressed the need to attain 32,000 health workers by 20206. By 2018, Cambodia had over 29,000 healthcare workers, thus making tremendous progress towards its 2020 target.7 

The healthcare system reform that started in the 1980s resulted in the establishment of the current three-tier structure in 1996, allocating responsibilities at the central, provincial and district level 8 These tiers are mandated with different responsibilities and must work together to ensure better healthcare delivery. At the top is the central tier, which comprises the Ministry of Health (MOH) and national institutes that help to formulate policies, legislation, and strategies. The intermediate level is the second tier comprising provincial health departments and hospitals, which link the central level to operational districts, and operationalizes national policies. The lowest level consists of operational districts, referral hospitals, health centers, and health posts9. The development of these tiers is instrumental in decentralizing administration delivery, hence enhancing quality in service delivery and advancing viable public-private collaborations to provide services at the community level.

Currently, the Cambodian Government, in collaboration with development partners, is implementing its Third Health Strategic Plan 2016–2020 (HSP3).10 This strategic management tool by the MoH guides the country’s health sector in mobilizing available resources and using them judiciously for the realization of improved healthcare outcomes. The plan is also an indication of the Government’s determination to strengthen operations in healthcare provision, prioritize key services, and harmonize laid-down strategies for various programs. This plan outlines the framework for tracking implementation alongside other goals such as mobilizing financial resources, guiding revenue allocation, and guiding development assistance in the country’s health sector 11

The Government, through the MoH, has also deployed fundamental mechanisms for notifications concerning disease outbreaks. Cambodia has a Health Management Information System (HMIS) to conduct surveillance operations and monitor disease outbreaks, providing the MoH with critical information to mount timely preparations.12

A nurse is checking up on an ill infant in a local health center, Preah Vihea province. Photo by Chhor Sokunthea / World Bank, taken on 30 January 2013. Licensed under CC BY-NC-ND 2.0.

Cambodia is sometimes affected by infectious diseases due to poor sanitary conditions in some locations. Waterborne infections like dysentery (and on very rare occasions, cholera) affect some people as a result of limited hygienic facilities and unsafe drinking water. These infections have motivated the Cambodian government to develop surveillance systems to help in managing healthcare delivery by detecting disease outbreaks through data collection from national hospitals and health centers. Innovations in ICT have led to the applications of camEWARS, thus improving efficiencies and timeliness when collecting data concerning disease outbreaks. Like poor water quality, poor air quality can also cause problems. Most households, especially in rural locations, use biomass fuels for cooking, resulting in high cases of respiratory infections, particularly among children.

Cambodia has a health financing charter that provides a framework and exempts poor people from health fees. This is critical in allowing healthcare service delivery to income disadvantaged populations in attempts to enhance healthcare delivery in Cambodia.13 Approximately 18% of patients visiting healthcare facilities are from poor backgrounds. Health Equity Fund (HEF) schemes, in particular, provide an effective means to cater to the poor population due to extensive donor support channeled towards delivering health service to financially disadvantaged individuals. HEF schemes cover over 50% of Cambodian health districts, serving a significant portion of the income-disadvantaged population.14

The Government has also introduced social security schemes including injury programs and old-age pensions. Cambodian demographic composition is rapidly changing due to the increasing elderly population who require long-term care services. The vulnerability of this age group to non-communicable diseases (NCDs) increases mortality rates in Cambodia. Mortality from NCDs increased from 32% to 52% between 2000 and 2013, severely affecting older persons.15 Social health insurance (SHI) was also developed to promote equal healthcare access, rationalize household expenses on healthcare, and improve healthcare delivery in Cambodia.

In summary, Cambodia has taken significant initiatives to ensure better health delivery by reforming its healthcare policy and administration. The Government has boosted health financing through multiple channels like taxation and donations to provide necessary health equipment and services. As for human resources, more health professionals are being trained to ensure there are enough medical personnel to cater for Cambodia’s growing population. Cambodia has also implemented two health strategic plans to improve healthcare delivery and effectiveness a different levels. Surveillance operations directed towards detecting disease outbreaks, especially waterborne infections like cholera, are pivotal in realizing better and equal health access. The health financing charter has further enhanced health delivery in Cambodia by increasing access to healthcare among the poor population.

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