HEALTH POLICY AND OUTCOMES OF POLICY INTERVENTIONS

Transcription

1 Country Report HEALTH POLICY AND OUTCOMES OF POLICY INTERVENTIONS TO SUPPORT TO CHILDREN AND WOMEN AND THE POOR The Report prepared for The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society August 28-31, 2006 Tokyo, Japan Prof. Sann Chan Soeung, Deputy Director General for Health Lo Veasnakiry. MD., MA(HMPP) Director, Department of Planning and Health Information MINISTRY OF HEALTH CAMBODIA Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 1

2 CAMBODIA Socio-demographic & Economic Indicators Demographic Population 13.1Millions Urban 15% Rural 85% Males 48.3% Females 51.7% Sex Ratio (number of males for 100 females) 93.5% Distribution of population by age group (1) 0 _ 4 years 11.0% 0-14 years 39.0% 5-14years 27.0% 15_49 years (women in reproductive age only) 26.0% Annual Population Growth Rate 1.8% M ale Life expectancy at birth 60 Female Life expectancy at birth 65 Number of regular households 2,530,000 Average households size 5.1 Density per km2 74 Health Total Fertility Rate (TFR) 3.31 Infant Mortality Rate (IM R) 66 per 1,000 live births 1 Under 5 Mortality Ratio (U5MR) 83 per 1,000 live births 1 Matemal Mortality Ratio (MMR) 437 per 100,000 live births 2 Crude Birth Rate (CBR) 27.7 per 1,000 population Contraceptive Prevalence rate (any method) (CPR) 24% Percentage of households with access to safe drinking water (total) 44% 1 - Urban 72% - Rural 40% Percentage of households with toilets facility within premise (total) 22% - Urban 55% - Rural 16% Education Adult literacy age 15 and over (total) 74% 1 - Male 85% - Female 64% - Urban (both sexes) 84% - Rural (both sexes) 72% Economic Government expenditures on health care per capita per year (USD) Household expenditures on health care US$ 24 Sources: (1) National Institute, Ministry of Planning,Cambodia Intercensal Population Survey 2004, general report (2) Ministry of Health, Ministry of Planning, Cambodia Demographic and Health Survey 2000 (3) Ministry of Health, DPHI, Joint Annual Performance Review 2005 Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 2

3 HEALTH POLICY AND POLICY INTERVENTION TO SUPPORT TO CHILDREN AND WOMEN Article 72 of the National Constitution of the Kingdom of Cambodia expresses clearly the responsibility of the Ministry of Health. It reads: The health of the people shall be guaranteed. The State shall give full consideration to disease prevention and medical treatment. Poor citizens shall receive free medical consultation in public hospitals, infirmaries and maternities. The State shall establish infirmaries and maternities in rural areas. This vision is reflected in the Ministry of Health's Mission Statement: ". is commitment to ensure sector wide equitable, quality health care for all the people of Cambodia through targeting resources, especially to the poor and to areas in greatest need." 1. The National Strategic Development Plan The Royal Government of Cambodia has established a strategic framework for a broadbased approach to poverty reduction in Cambodia. This framework is laid out in the Government s Rectangular Strategy and the National Strategic Development Plan (NSDP). The NSDP's MDGs-related goals and targets will be operationalised and implemented through the Royal Government of Cambodia's Rectangular Strategy. "Capacity Building and Human Resource Development" is the fourth rectangular of the strategy, and "improving health services" is one of the elements of this fourth rectangular. In this context the Ministry of Health has formulated four health goals in the NSDP. Goal 1: Reduce infant and child mortality (Child Survival Strategy formulated by the Ministry of Health in March 2005) Goal 2: Reduce maternal mortality (Reproductive Health Strategic Plan) Goal 3: Reduce prevalence and fatality case of infectious diseases including HIV/AIDS, malaria, tuberculosis (HIV/AIDS Strategic Plan) Goal 4: Improve health system performance focusing on equity, efficiency, quality and accountability (revised Social Health Insurance Master Plan 2005; Guidelines for Community Based Health Insurance 2006; National Policy for Quality in Health 2005) 2 Health Sector Strategic Plan As part of its commitment to this strategic vision, the Ministry of Health is continuing implementation of its own strategic plans, to provide leadership and strategic management for activities across the health sector. The Health Strategic Plan (HSP), the first of its kind for Cambodia, was launched in August 2002, with the endorsement from the Prime Minister. The strategic plan provides a common framework for all partners in the sector, both government and external for the period The document outlines strategies of the six key areas of work: health service delivery (HSD), behavioral change and communication (BCC), quality improvement (QI), human resource development (HRD), health care financing (HF) and institutional development (ID) for the key purpose of effective and efficient health services development that improves health for all Cambodians especially the poor and marginalized population. As identified by the Joint Annual Performance Review 2006, the overarching priority for 2007 remains the same as for , this being: Develop linked Child Survival and Reproductive Health interventions, including HIV/AIDS. This is to be accomplished through Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 3

4 focusing activities and resources throughout the health sector on the following 5 priorities requiring urgent attention: - Emergency Obstetric Care - Attendance at Delivery by Trained Health Providers - Implementation of the 11 Child Survival Scorecard Interventions - Full MPA Status at Health Centers - Reproductive Health including Birth Spacing Services These 5 priorities are to be supported by activities within each of the 6 Key Areas of Work, either directly, or through health sector strengthening activities. Achievement of the priorities is an essential step toward the strategic goals for the health sector set forward in the Health Sector Strategic Plan and the four health related strategic goals of the National Strategic Development Plan (infant and child mortality, maternal mortality, tackling communicable diseases, and an effective health system). 3. Medical Services for children and women 3.1 Health Service Delivery System The reformed health system is composed of three levels: the first level, the most peripheral is made up of operational district serving about 100, ,000 populations, and composing of a referral hospital and a network of health centres. Each health centre covered the population of 8,000 to 12,000. The second level or intermediate level is made up of a provincial hospital and provincial health department. The third or central level consists of the Central Ministry of Health, national institutes, national hospitals, national programs, and training institutions and other central health institutions. As of 2005, the national health coverage plan consists of 8 national hospitals, 77 operational districts, 69 referral hospitals, 968 health centres and 77 health posts. The institutional structure reform clearly defines the role and functions of each level within the health system, in particular at health service delivery level. Health center, closest point of contact with the community population, provides Minimum Packages of Activity, mainly basic essential services and referral hospital provides Complementary Package of Activity including specialised services. 3.2 Health Service Utilization o Antenatal Care Antenatal care consultations have shown a steadily increasing trend, along with outpatient consultations as described previously. The national average for a minimum of 2 visits was 52% in 2005 with the predominant number of such consultations taking place at provincial health facilities, as opposed to the national hospitals. As expected, coverage tends to decline as the number of ANC visits increase, from 73% for the first visit to 52% for the second. While the target of 50% for women receiving Vitamin A within 8 weeks of delivery was met, the Vitamin A targets for children were not (MoH Annual Statistics Report 2005). o Emergency Obstetric Care Well staffed and well equipped hospitals providing high quality care, a well functioning referral system, and access to safe blood are all essential to the provision of Emergency Obstetric Care. Progress has been made in each of these areas. Just under half of all referral hospitals are now equipped to perform Caesarian Sections, Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 4

5 with 28 referral hospitals offering Complimentary Package of Activities (CPA) Level 2 services, and 16 RH s offering CPA3 level services. 16 surgeons from 11 RHs have been trained with the Basic Surgical Training (BST) course, 20 nurses with the Operating Theatre Nurse (OTN) course, and 20 nurses will finish the ISAR anesthesiology course in March Around 9 additional RHs are expected to have staff with similar training in CPA guidelines are under revision, and guidelines for referral have now been completed. 32 referral hospitals now have blood banks, and 8 referral hospitals are now implementing the Provider Behavior Change Intervention to improve quality of services. In partnership with RACHA, Life Saving Skills (LSS) courses have been provided to123midwives. o Attendance at Delivery by Trained Health Providers The nationwide percentage of deliveries attended by trained professionals such as doctors, nurses or midwives was 41% in 2005, again showing a steady increase over recent years. Deliveries at health centers (7.98%), hospitals (16.16%) and homes attended by trained professionals (16.43%) comprised this proportion. Across the provinces, the highest percents were recorded at 66.7%, and lowest at 12%. The training and deployment of midwives is a key element for this priority area, as is ante-natal care, an effective referral system, and improved community awareness of the importance of seeking proper care. Multi-sectoral issues relating to recruitment and salaries continue to pose significant challenges, however progress can be reported for The Council for Administrative Reform of the RGC has allocated 360 new posts for the Ministry of Health, including 100 new midwifery posts. 63 midwives have now been recruited to these posts. There were 17 graduates from the Post-Basic Midwifery Training and 61 graduates from Primary Midwifery Training. Of these, 35 are now primary midwives in the public sector. Continuing education for midwives was provided for a total of 193 Health Center staff from 153 HC s, and a draft personnel policy has been discussed to address the misdistribution of staff and attract staff to remote geographical areas. o Integrated Management of Childhood Illnesses 322 Health Centers now have at least one IMCI trained staff member, nearly doubling from 164 in For children under 5 years, new case consultations per year rose to 0.92, and hospital admissions rose to 57/1000. Eighty six percent (86%) of children under the age of 1 year now receive DTP3, and the program for deworming school children continues to expand its success, now covering over 2/3 of all children. Fifty percent (50%) of women received Vitamin A within 8 weeks of delivery, and TV spots on breastfeeding have been developed and broadcasted. The Sub-decree on Marketing of Infant and Young Child Feeding Products has now been signed by The Prime Minister. o Birth Spacing Services In 2005, the percentage of married women using modern contraceptive methods supplied by the public health service continued to rise to over 22%, and many women are also seeking these services from the MoH s partners in the private sector. The effectiveness of birth spacing programs in Cambodia is now becoming apparent with the drop in Total Fertility Rate to 3.3 as reported in the 2004 Cambodian Intercensal Population Survey. 3.3 Human Resource Development The three strategies related to HRD of the Health Strategic Plan were set for meeting the shortage of staff working at lower level of health services and to equip existing with appropriate skill for better service delivery. These are: Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 5

6 (1) To increase the number of midwives and strengthening their skills through continuing education contribute to the quality improvement of health service delivery. Increase the number of midwives: o Post basic midwifery graduates: There were only 17 midwife graduates in 2005 from 2 Regional Training Centers (TRC). No applicants at Technical School for Medical in Phnom Penh and Kampong Cham RTC. o Primary midwifery graduates: This program has been expanding to the other three RTCs with the total intakes of 303 (194 are primary midwife students) against the target of 200 intakes (120 primary midwifery students). o Revitalization of the 3 year program of Midwifery pre service training: The production of primary staff with basic midwifery skills could not fulfill the number of midwives needed at the HC level. The quality of midwifery service remains a big concern of the MoH and health development partners. Therefore it is necessarily to revitalize the three midwifery program to bridge the gap between the post basic and primary programs. The implementation of training will be started in Provision of midwifery skills o There are two packages of continuing education for midwives. One package is set for the ones who are working at the HC level and another one is for midwives working at the RH level. The 4 month midwifery course was conducted at the five schools with 60 participants (12 participants per school). In addition to this, LSS course areprovided to midwives. In total, 193 HC staff from 153 HCs was equipped with midwifery skills in o In 2005, JICA supported 20 participants for training for the RH level (CPA midwifery course). It is planned to support 40 midwives of 2 classes every year for 2006 and (2) To Strengthen human resource planning to reduce mal-distribution o Identification of staff needed for each level of health service: to identify the Standard Staffing Level (SSL) for the different levels of health services. To assist managers in the staff management and training decision, SSL was approved and disseminated as nation wide for implementation. The SSL will be then incorporated to the HR database for staff management. o In order to have midwives working at the front line of the health services, all of 63 midwives who applied for MoH were recruited to work at 52 HCs against the approved post of 100 from the Government. Among them, 100% of primary midwives from the first batch of the primary course have been allocated to the HCs of the four provinces. In 2006 and 2007, at least 70% of new MoH posts will be kept for midwives. o Provision of appropriate skills and knowledge to staff for better service delivery: the MoH training policy aims at equipping staff with appropriate skills according to their job description and service package to be provided at each level of health service. As result, at the MPA service level, staff from 153 HCs has been equipped with midwifery skills and 52 HCs received primary and secondary midwives from 2005 staff recruitment. At the CPA service level, 16 surgeons from 11 RHs have been trained with the Basic Surgical Training (BST) course, 20 nurses with the Operating Theatre Nurse (OTN) course, and 20 nurses will finish the ISAR course in March In addition, 25 staff was trained with the 3 rd batch of the X Ray 4 month course which is under JICA support. The same number of staff will be trained in 2006 with HSSP budget if needed. Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 6

7 (3) Enhance management and technical skills for all health workforces o MPA Training for HC staff: only 1,757 of HC staff received MPA module 8 in In 2005, MPA will be based on the results of a training need assessment (TNA). In addition, MPA module 7 is expected to be providing to 5,500 HC staff in o Management skills of health managers, 44 managers attended the health service management course (HSMT). No hospital management (HMT) course has been conducted due to lack of resource person for training implementation in hospitals managers will be targeted to receive HMT every year for 2006 and o Due to the growth in private training institutions for health, MoH officers are developing a committee for establishing standards/criteria for training for health to be used by the Accreditation Certificate Committee, in collaboration with relevant partners, including Council of Ministers, ACC, Ministry of Education Youth &Sport, as well as private training institutions. Successful implementation of these strategies will lead to the improvement of maternal and child morbidity and mortality. 4. Challenges for Health Service delivery for Children and Women and Action for Future While there have been notable improvements in health care delivery to children and women in 2005, the major constraints remain unchanged since last year. Those are: o Mal-distribution of sufficient and qualified staff continues to hamper the functioning of referral hospitals and health centers. In particular, shortages of midwives and other staff at the health center level remains a serious constraint to providing Full MPA services and ensuring attendance at deliveries by trained health providers. o Access issues (distance, time, transport costs), quality issues (either real or perceived low quality of services), lack of knowledge about availability of health services, provider attitudes and behavior, and competition from the private sector further aggravate this. o Malnutrition among children and micronutrient deficiencies among women and children remain high. o Weaknesses in the referral system, low levels of awareness in communities continue to be serious constraints to improving health service delivery o The primary training program could not address the MoH goal of having midwife staff for the health services, which is important for the reduction of Maternal Mortality Rate and Infant Mortality Rate in Cambodia. Therefore, effort will be focused on the revitalization to the midwifery pre service program. o In keeping with the adoption of the Child Survival Strategy in 2005, it is recommended that the IMCI priority be expanded to include the interventions in the Child Survival Scorecard. This will allow for easier targeting and monitoring, as well as for a strengthened emphasis on the key areas of nutrition. Attendance at Delivery, Full MPA, Emergency Obstetric Care and Birth Spacing Services will remain priorities. 5. COLLABORATION 5.1 Collaboration of Social Welfare and Health Medical Services Social Health Insurance is a new concept in Cambodia. Therefore, it is critically important to create good guide for awareness, understanding and commitment among policy makers and other relevant line ministries such as the Ministry of Health, the Ministry of Labour (MoL), the Ministry of Social Affairs, Vocational Training & Youth Rehabilitation (MoSAVY), and the Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 7

8 Ministry of Economy and Finance (MoEF). This collaboration has been done through the establishment of a Social Health Insurance Committee (SHIC) with fairly broad representation. The SHIC is chaired by a Secretary of State for Health and comprises of Senior Officials of the the MoH, the MoSAVY, the MoL, the Ministry of Planning, the MEF and the Council of Minister. In addition the Committee includes representatives of the Cambodia National Insurance Company (CAMINCO), WHO, GRET (French NGO) MEDICAM (the association of NGOs in Cambodia), GTZ and ILO. The Health Insurance Committee is required to meet quarterly to monitor the progress of and provide strategic direction for SHI development process, as well as to promote inter-ministerial collaboration in social protection aspect. Both the Ministry of Health and the MoSAVY are interested in collaborating to reach the inclusion of health care and extension of coverage to the public salaried sector in the Social Security Law passed in The MoSAVY is accelerating the development of the NSSF and to draft the Regulations for the Law. The next step would be dialogue between the relevant Ministries, and with the Ministry of Economics and Finance. To facilitate the dialogue, a proposed draft of the necessary Sub-Decree to include health care. To date, there is a need for the development of legal framework (sub decree) for Community Based Health Insurance (CBHI) by taking the existing legislation into account such as Social Security Act ( MoL), Legislation on private for-profit insurance companies and Micro-insurance sub-decree (draft, MoEF). As agreed in the most recent meeting of the SHIC, a legal framework for CBHI needs to be developed and this would be integrated with the Micro-Insurance sub-decree drafted by the Ministry of Economy and Finance. It was agreed that the sub decree will address clearly the definition of CBHI, capital requirement and taxation issue as well as provisions to ensure protection of members and fraud control in the implementation of CBHI schemes. 5.2 Public and Private Sector (NGOs) There are currently more 100 local and international NGOs (non-for profit organizations) actively working in the health sector. Almost of them are working closely with the public health system in supporting various health program activities and social services at community level. These community-based NGOs are coordinated by Medicam, who is the primary networking agency that seeks to link all stakeholders in the health sector by representing voices of civil society, facilitating policy advocacy, building capacity of Medicam s members and health partners, and sharing relevant quality information. Medicam has 4 important mandates: (i) information exchange; (2) capacity building especially for local NGOs; (3) facilitate advocacy; and (4) represent the voice of civil society. The coordination and collaboration between the health sector and NGos community is done through the formal mechanism recommended in the Royal Government of Cambodia's Harmonization and Alignment Action Plan adopted last year. That is the establishment and functioning of the Technical Working for Health chaired by the Minister of Health with representations of all stakeholders including Medicam and Provincial Technical Working Group for Health chaired by Director of Provincial Health Department at provincial level. 5.3 Role of Community and Local Authority o Community Participation and the Public Health System Village Health Support Group (VHSG) or Health Volunteers are an important link between communities and the public health system, in particular the health center. Numerous Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 8

9 community-based structures that support VHSG/community health volunteers have been implemented throughout Cambodia in the goal of increasing the communities involvement in primary health care. Role of VHSG/health volunteers as described in the Policy on Community Participation and the Primary Health Care Implementation Guidelines: - Provide health education/promotion and distribute IEC materials in the village - Communication channel between the HC and the villages - Collection of health statistics - Community mobilization during HC outreach - Community DOTS - Pre-Identification of the poor - Promote utilization of HC services - Immediate reporting of suspected outbreaks - Emergency referral to health structures Impact in Community: VHSG/Health volunteers help to empower rural areas, through building a sense of community ownership and developing collective problem solving skills. They can help to mold projects to meet the real needs of target beneficiaries, leading to increased customer satisfaction. Because they are sourced locally, VHSG/health volunteers maximize local capacity and resources through sharing and transferring knowledge to their neighbors. Impact on Health Center: Health center staff during interviews said that they could noticeably see the increase of HC clients after the VHSGs were set up. They attributed this to referral systems - while informal, still help to convince villagers to use HC services in serious cases. Through the VHSG mechanism village health reports are available for HCs, increasing the HC staff s awareness of the health situation in villages including emergency reports from villages and highlighting specific cases for follow up during outreach. Similarly, health volunteers can disseminate health messages and information from HCs to the communities in a timely manner. o Commune Councils and the Public Health System In 2002, the first elections in Cambodia were held for the Commune Councils through an electoral system The Law on Administration and Management of Commune/Sangkat, states that Communes may take a lead role in service delivery, but does not provide guidance for specific roles and responsibilities. Currently, the main involvement in health service provision by the Commune Councils is through the Health Center Management Committee where the Chief of the Commune or the Second Deputy chief in Charge of Social Affairs acts as the chairperson of the committee. An annual fund of approximately $8000 USD/year is allocated to each Commune/Sangkat in order to provide services identified through a local planning process entitled the Commune Investment Plan (CIP). Most of these funds go toward small infrastructure projects, although some may be earmarked for social service delivery in the future. CC members are positively inclined toward allocating some of their budget (especially if it is increased) for aspects of health service delivery. In some Communes, CC members are involved, usually in partnership with the village chief, in the pre-identification of the poor. Some Commune Committees such as the Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 9

10 Commune Committee for Women and Children (CCWP) have been specifically established in order for social services to be included in the CIP. The Commune-based Planning and Budgeting Committee (PBC) is also active in helping social services get into Commune plans. 6. Assistance in Medical Expenses especially for Low-income Family 6.1 Health and Poverty Like in many other developing countries, Cambodian health financing is dominated by out-of-pocket spending. Compared to neighboring countries however, a very large proportion of Cambodia s health expenditures come from private households. The total expenditure on health per capita in 2002 was US$ 33 of which 72% (US$ 24) was out of pocket, while 19% was from donor organizations and only 9% from the MoH, representing a relatively high (10-12%) government budget allocation. Despite rapid economic growth rates in recent years (GDP growth 5-6% annually), per capita income is only US$ 280, and at least 36% of the population lives under the poverty line of US$ income per day. Recent estimates show that average poverty levels are lower than before, but that the gap is widening (WB recent poverty assessment). Poor households cannot afford health expenditures. Many households not officially under the poverty line are still lacking cash. Health expenditures can tip them into poverty. Ill-health and poverty are closely related in Cambodia. In many cases, poor families simply cannot afford qualified health care and resort instead to a range of traditional healers and other unqualified (and often dangerous) private service providers. Treatment rates vary significantly depending on the patient s location and socio-economic status. 6.2 The Current Health Financing Schemes The Ministry of Health introduced the Health Financing Charter in 1996 in order to provide a legal framework for developing and testing various alternative financing schemes such as user fees, contracting, social health insurance including community pre-payment scheme in the sector with systematic monitoring and evaluation of the impact of the schemes. o User Fees User charges are most common financing schemes implemented in public health facilities (hospitals and health center). The objectives of the implementation of user charges are (i) promote equity; (2) improve quality of services; and (3) increase staff motivation. In order to protect the poor and vulnerable group from financial barrier for access to and utilization of health care services, the exemption mechanisms are strongly recommended by the Charter and revenue collected are maintained and managed at facility level based on the formula 1% (being transferred to the National Treasury), 39% (being used for quality improvement); and the rest 60% (for incentives for staff). As long as equity is concerned, the evaluation of impact of user fees on equity, access, quality and efficiency conducted in 2000 reported that the exemption practices are not consistent across the facilities and fees remain a barrier for the poor to use health services in particular hospital services, which are costly, but at primary level health center the exemption seem to be work well. In this context, the Ministry of Health and its health partners have initiated health equity funds. Key features of user fees: - Fee level is set based on economic status of geographical areas where Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 10

11 health facilities are located, in consultation with community. - Revenue collected is retained at and managed by collecting facilities - Facility based identification of the poor o Health Equity Fund More recently, several development partners have proposed Equity Funds as an interim measure to cover health care expenditures for indigent households. As of 2005, HEF are currently implemented in 21 districts. The number of poor patients with assistance from equity funds has increased from 5,234 to 99,801 patients against. Poor patients exempted from user fees made up 16% (of total IPD), and 3% (of total OPD). This number includes the national hospitals. HEF seem to be a powerful tool to channel funding for the poor and have promising potential for direct service delivery to the most vulnerable population. They may also help avoiding catastrophic health expenditure. They are seen as a poverty reduction strategy and support achieving MDGs. If successfully developed and implemented, they may become one of the most important strategies for Health Financing in Cambodia. They will improve both access to health care and the quality of services. There is growing concerned of long term sustainability of equity funds implementation since the current equity funds implementation are mainly funded from external sources. Only one scheme is domestically funded through community mobilization. It is interesting to note that the Ministry of Economy & Finance strongly supports equity funds schemes. As a result, the MEF has agreed in principle to allocate the national budget for equity funds. By taking long term sustainability of equity funds into consideration, social health insurance has emerged on health financing agenda of the Ministry of Health. Key features of Equity Funds: - Payment for fees of services - Managed by a third party, mainly non-for profit local NGOs, through contractual arrangement (Tri-parties contract: funding agency, equity fund operator and health service providers) - Community based pre-identification of the poor, most accurately targeting the poor - Currently, external funding sources - Small scale implementation- need scaling up. o Social Health Insurance The recognition of the potential of social health insurance as a major health care financing method for Cambodia in the future comes after a decade of health sector reform and development. It is essential to recognize multiple objectives in the establishment of social health insurance in Cambodia. This method can serve to bring additional financing to the health care system, through fair and affordable contributions from families. It can thereby provide social protection and reduce the risk of poverty due to high and unpredictable costs of health care. The Cambodian Master Plan for Social Health insurance recognizes the multiple objectives of developing social health insurance for Cambodia as the implementation of a stable financing mechanism, the promotion of equity in access to health care, facilitating rational household expenditure on health through regular prepayment rather than Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 11

12 unpredictable payment at the time of illness and as a means of promoting improvement in the health care delivery system. To reach universal health insurance coverage in Cambodia, a parallel and pluralistic approach is recommended. This approach comprises: - Compulsory social health insurance through a social security framework for the public and private salaried sector workers and their dependents, through addition of health care to the Social Security Law passed in 2002 and administered by the National Social Security Fund. - Voluntary insurance through the development of community based health insurance (CBHI) schemes sponsored by different development partners, national non-government organizations in the initial stage and health care providers for non-salaried workers' families that can contribute on a regular basis. Social health insurance for this population sector should include all family members registered in the Cambodian Family Book. o Community Based Health Insurance Community Based Health Insurance (CBHI) is the health insurance scheme for the Cambodia population in the informal sector (e.g. the self-employed and the farmers). The members can go to the hospital and receive treatment free of charge at the time of use, with all costs covered by the CBHI scheme. The insured families prepay regularly a small amount to the scheme to avoid payment of large fees at the time of use. The CBHI is voluntary and nonprofit Scheme. Families can become members on a voluntary basis. The scheme has no saving fund. The contributed amount collected from the members is paid to the health centres and the hospital as capitation for the members. The CBHI scheme is situated in the community, which has a non profit organization to monitor and administers the scheme, under technical support and supervision of the Health Economics Unit, Department of Planning and Health Information of the Ministry of Health. The only social health insurance experience to date in Cambodia is the micro health insurance pilot. These pilots are designed within the framework of voluntary and community based health insurance (CBHI), with primary health care and hospital-based benefits, and using existing public health facilities for the provision of these benefits. All family members registered in the Family Book are included in the family unit. Payment to providers is based on capitation contracts with health centers and district hospitals, while insured persons receive small cash benefits in specific approved cases (mainly as funeral grants). Prior to the finalization of capitation contracts, the insured were reimbursed for payment to hospitals according to the type of service. There are only 6 Community Based Health Insurance schemes in Cambodia. The total number of insured who received a CBHI card were 12,398 (2,655 households), and the number of insured with assistance reimbursement from CBHI were 28,293 for OPD, IPD were 764 against target 6,000. However the achievements of the implementation of CBHI have been improved more than expected. Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 12

13 o New Initiative: Integration of a Safe Motherhood Component in CBHI Cambodia is faced with high MMR at 437 per 100,000 live births (year 2000) and high IMR at 66 per 1,000 live births. Maternal mortality is still the leading cause of death among women of reproductive age. Based on WPRO Report in 2002, these rates are very high compared with other countries in Asia and Pacific. As one of the approaches to respond to this, it was proposed to integrate a Safe Motherhood Program with well-baby component to social health insurance. From a gender perspective, this is an indication of a well-designed scheme that is responsive to priorities in the health sector. This approach will be piloted in the GRET Urban SKY SHI scheme at the Phnom Penh Municipal Referral Hospital which targets informal economy workers in the urban setting. The proposed Safe Motherhood Program within the CBHI scheme will cover antenatal care, referral of high risk pregnancies to obstetric-gynecologic specialist, coverage of medicallynecessary abortions and post-abortion care, coverage of normal and caesarean section deliveries, referral to family planning/birth spacing services, referral to the VCCTs for HIV testing and to the PMTCT services (if positive), provision of essential drugs, provision of micronutrients and advice on nutrition relevant to safe pregnancy, post-natal care (at least 2 examinations of the mother), referral of the newborn to immunization services and provision of cash Maternity Grant of $15 per month for 3 months post-delivery. The grant serves as an incentive for full participation in the protocol of Safe Motherhood Program for insured families in the Urban SKY. Initially, the cash grant is financed by GTZ to start the pilot implementation, and later on, to be incorporated in the computation of the applicable premium contribution. 7. CONCLUSIONS This brief summary has presented only a few highlights of the many achievements across all six Key Areas of Work in 2005, contributing to improvement of children and women's health status. What is evident from these is that the Cambodia is making significant progress toward better health for all, both in terms of delivery of services as well as the fundamental institutional reforms that support these services. However, challenges and constraints still facing Cambodia's health system and may continue to be for some time. These include institutional challenges, such as low public sector salaries, maldistribution of staff, weak budgetary management, and the need for increased harmonization and alignment of partners activities with national priorities. They also include the cross-sectoral challenges of poverty, such as low incomes, low educational attainment, insufficient rural infrastructure, and high levels of malnutrition, all of which have serious impacts on health outcomes. While the health system can have a more direct impact on challenges such as malnutrition, others remain outside its influence Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 13

14 References: The Ministry of Health.Cambodia: Health Sector Strategic Plan The Ministry of Health.Cambodia: The Guidelines for Community Based Health insurance The Ministry of Health.Cambodia, BTC, WHO: Equity Forum Report.2006 Kristina. M: Joint Assessment of Community Health Volunteers Final Repor 2006.Non-published The Ministry of Health.Cambodia: Joint Annual Performance Review The Ministry of Health.Cambodia: Revised Mater Plan for Social Health Insurance The Ministry of Health.Cambodia: National Equity Funds Implementation & Monitoring Framework The Ministry of Health.Cambodia: Annual Statistics Report.2005 Medicam: Medicam Briefing Note Personal communication The Ministry of Health.Cambodia: Policy on Community Participation in development of Health Center The Ministry of Health.Cambodia:The National Health Financing Charter.1996 Cambodia Country Report: The 4 th Japan & ASEAN High Level Officials Meeting on Caring Society 14