Cambodian-German Development Cooperation Strategy Paper for the Priority Area Health (2014-2018) Social Protection in Health for the Poor and Vulnerable July 2014
Table of contents 1. The main challenges, risks and opportunities; potential for and obstacles to development within the priority area 1 2. Outline and assessment of RGC's national sectoral strategy and of the capacity of its systems within the priority area 2 3. Development partners and partner country s own activities in the priority area 4 4. The German contribution in terms of goals, indicative financial planning, approaches and guidelines for the preparation of programme proposals 5
List of acronyms AFD Agence Française de Développement AOP Annual Operational Plans BTC Belgium Technical Cooperation CARD Council for Agricultural and Rural Development CCC Cambodian Country Coordinating Committee (GFATM) CD Communicable Diseases CHC Cambodian Health Committee CMDGs Cambodian Millennium Development Goals CRPD UN Convention on the Rights of Persons with Disabilities DFID Department for International Development DP Development Partner GAVI Global Alliance for Vaccines and Immunisation GFATM Global Fund to Fight Aids, Tuberculosis and Malaria (Global Fund) GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit mbh HCD Human Capacity Development HEF Health Equity Fund HP Health Partners HSP Health Strategic Plan HSSP Health Sector Support Programme ID Poor Identification of Poor Households Programme IHP+ International Health Partnership + JICA Japan International Cooperation Agency KfW Kreditanstalt für Wiederaufbau (German Development Bank) KOICA Korea International Cooperation Agency MDGs Millennium Development Goals MoH Ministry of Health MoLVT Ministry of Labour and Vocational Training NCDs Non-Communicable Diseases NGO Non-Governmental Organisation NSDP National Strategic Development Plan NSHPF National Social Health Protection Fund NSSF National Social Security Fund P4H Providing for Health Initiative PBA Programme-Based Approach RGC Royal Government of Cambodia SHPP Social Health Protection Programme SHP Social Health Protection SNDD Sub-national Democratic Development SWiM Sector Wide Management TWG Technical Working Group UHC Universal Health Coverage UN United Nations UNAIDS United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNICEF United Nations Children s Fund UNOPS United Nations Offices for Project Services USAID U.S. Agency for International Development USG U.S. Government UXO Unexploded Ordnance WB World Bank WHO World Health Organization
1. The main challenges, risks and opportunities; potential for and obstacles to development within the priority area Starting from a post-conflict situation, Cambodia has achieved significant gains in poverty reduction and health outcomes during the past 20 years. It is very likely most of the Cambodian Millennium Development Goals (CMDGs) will be achieved in 2015. In areas such as maternal and child health Cambodia can present impressive results. The country can also show encouraging progress in controlling communicable diseases such as HIV/AIDS and tuberculosis. Still, there is a long way to go. Compared to other countries in the region, Cambodia ranks rather low and significant challenges remain, e.g. as regards accepting modern family planning methods, reducing neonatal mortality, improving nutrition and malaria control. Non-communicable and chronic diseases such as respiratory disease, diabetes and hypertension are on the rise and pose a severe challenge to the country s health system and beyond. More than 50% of deaths each year can be linked to health issues in this area and demographic transition will further increase the challenge posed by such diseases. Physical disability, cognitive disease and mental illness are certainly an issue in Cambodia with its long history of civil war and unrest. In 2013, another 111 Cambodians were injured or killed by mines or unexploded ordnance (UXO) and the psychological consequences of the Khmer rouge regime have only been studied selectively. The Cambodian national poverty rate has dropped significantly, from 53% in 2004 to 19.8% in 2011. This is an extraordinary achievement. However, income variation among the poorest 40% of the population remains modest, making a clear-cutting definition of poverty difficult and leaving the majority of those lifted out of poverty near-poor and highly vulnerable to slipping back into poverty at the slightest crisis. 1 Expenses for health care are a major cause of impoverishment. Consequently, the Royal Government of Cambodia (RGC) envisages a health system with the eventual goal of universal coverage. For the time being the government has put an emphasis on the poor population, who benefit from free health care services through the Health Equity Fund (HEF). The near-poor population in the formal and informal sectors, including households with elderly, disabled or chronically ill members, does not currently benefit from HEFs or any other government-subsidized health protection scheme. Service quality at public health facilities is generally low in Cambodia at all levels due to low qualifications among staff, poor infrastructure and also low salaries and insufficient maintenance of the facilities. Utilization rates of public health facilities are thus low. Other barriers that prevent patients from using public facilities are high transaction costs and also socio-cultural aspects, including gender, age and cultural health-seeking behaviour. A 2010 health facility survey drew attention to significant differences in the utilization of health services by both geographical area and level of income, emphasizing that there is a significant gap between wealthier and poorer households as well as between urban and rural areas. Various factors including low salaries for public servants lead to low motivation, low performance, absenteeism, and widespread dual practice. Perceived care in private facilities is better, as illustrated by the preferential use of them by the general population (70% of all treatment takes place in the private sector). However, studies have demonstrated substandard clinical quality and practice among many private providers as well. Sufficient financing for the health sector through the RGC s own resources is certainly an issue in a country where nearly half of total health sector spending is financed by development partners (DP). Growing fiscal space allows for greater spending on health to be financed from government resources but at the same time there are severe inefficiencies at 1 A recent WB assessment revealed that an average loss of US$0.30 or 1,600 Riel in income per day would push three million near-poor Cambodians back into poverty, doubling the country s current poverty rate from about 20 percent to about 40 percent. 1
all levels and there is little clarity about how the budget is spent. Deconcentration in the health sector has been delayed and the lion s share of public spending is still managed at the central level, mainly in order to purchase drugs and medical equipment. Findings from the last Public Expenditure Review (2011) suggest that more than US$50 million per year (=1/4 of the RGC health budget in 2012) could be saved if a more efficient procurement system was put in place. Compared with other sectors, there are relatively few rent-capturing opportunities in the Cambodian health sector but two areas can be identified where resistance to reform prevails because of self-motivated interest: the (non-) regulation of private service providers and the procurement of drugs and medical equipment. Change agents can be identified at all levels of public health administration, but their sphere of influence is limited as most health policy decisions are taken at the highest levels of government, in the MoH or elsewhere. It is widely agreed that the ongoing decentralization reform process could be used as one entry point to address existing governance challenges through the empowerment of the service users. 2. Outline and assessment of RGC's national sectoral strategy and of the capacity of its systems within the priority area The Health Strategic Plan 2 (HSP2) 2008-2015 is the main tool for strategic sector management to which most Health Partners (HP) align their support. Its vision is to enhance sustainable development of the health sector for better health and well-being of all Cambodians, especially of the poor, women and children, thereby contributing to poverty alleviation and socio-economic development. HSP2 builds on the National Strategic Development Plan (NSDP) and identifies the main challenges of the Cambodian health sector by framing three programme areas for action: 1) Reduce maternal, new born and child morbidity and mortality, and improve reproductive health, 2) Reduce morbidity and mortality of HIV/Aids, malaria, TB, and other CDs, 3) Reduce the burden of non-communicable diseases and other health problems. These outcomes are to be achieved through the implementation of strategies for improved Health Service Delivery, Health Care Financing, Human Resources for Health, Health Information System and Health System Governance. Medium-term goals, objectives and indicators are defined for measuring sector performance. What is lacking however is the alignment of financial flows with sector priorities, as well as the sequencing of objectives within and across areas, given the limited financial resources available (prioritizing the priorities). HSP2 underlines equity and the right to health for all Cambodians. Social health protection, especially for poor and vulnerable groups, is thus one out of five working principles 2 that is outlined and which links up with the broader efforts of government in the area of social protection. With the National Social Protection Strategy for the Poor and Vulnerable (2011-2015) the RGC has underlined its willingness to address the social and economic situation of the poor and vulnerable more effectively. Affordable quality health care and financial protection in the case of illness for vulnerable groups, including persons with disabilities and the elderly, are priority areas in this strategy. The most important targeting mechanism of the strategy is the identification of poor households programme (ID Poor), which was rolled out in rural areas starting in 2007. ID Poor is also used for identifying the HEF target group and has improved in quality over the years. Yet, in order to maintain its prominent role, data accuracy needs to be improved and the latest poverty and migration trends must be reflected in the programme so as to better address the needs of those vulnerable to poverty, including the urban poor. The RGC ratified the UN Convention on the Rights of Persons with Disabilities (CRPD) in 2012. The draft National Disability Strategic Plan 2014-2018 for the 2 The remaining principles are: (2) client-focused approach to health service delivery; (3) integrated approach to high-quality health service delivery and public health interventions; (4) human resources management as the cornerstone for the health system; and (5) good governance and accountability. 2
implementation of the CRPD addresses challenges relating to the social protection of persons with disabilities and their access to health services including early detection and interventions. 3 The draft Health Financing Policy, currently under consultation within the government, outlines the path to universal health coverage (UHC) in Cambodia by broadly defining the goals and objectives, strategies and implementation framework, and by identifying six areas of intervention 4. The Ministry of Health (MoH) is responsible for the SHP scheme for the poor (and the envisaged National Social Health Protection Fund, NSHPF) and shares responsibility for other vulnerable groups with the Ministry of Labour and Vocational Training (MoLVT), which is responsible for the National Social Security Fund (NSSF) for workers in the formal sector. Provided that all relevant government entities show the necessary ownership, the policy has the potential to spur structural governance reforms and to improve transparency and efficiency in health financing and in the sector as a whole. The establishment of an institutional home for the envisaged National Social Health Protection Fund (for the poor and vulnerable), the expansion of coverage to include the near-poor and vulnerable groups other than the poor, and the adequacy of funding remain key challenges to be addressed. The National Strategic Plan for the Prevention and Control of Non-Communicable Diseases (2013-2020) outlines the Royal Government s response to the growing burden of disease (e.g. heart disease, cancer, diabetes, and chronic respiratory disease). Given the limited resources for NCDs to date (1.5% of the RGC health budget, 15% of total health funding), this strategic plan identifies priority areas for intervention on the basis of certain selection criteria and defines short-, medium- and long-term strategies to achieve its vision where non-communicable diseases are effectively and equitably prevented and controlled for people in Cambodia, and the burden of non-communicable diseases on households and society is minimised. Finally, the Fast Track Initiative Road Map for Reducing Maternal & Newborn Mortality (2010-2015) was launched in 2010 after the Royal Government realized that the country would most probably fail to achieve its health-related MDGs in 2015 without extra efforts. The initiative has been very successful in terms of achieving results and clearly demonstrates the potential of a concerted approach by government and HP. The HSP2 mid-term review has found a modest increase in sector stewardship by the MoH, but more progress is needed in particular with a view to strengthening management capacities and speeding up reforms. Moreover, the mutual efforts of the RGC and development partners are often fragmented and not always implemented in a coordinated way by the various stakeholders, including NGOs. Therefore, further attention needs to be given to the ownership and accountability of the RGC for achieving its objectives regarding social protection in health, to structural reforms and to inter-ministerial dialogue. Horizontal and inter-sectoral coordination is essential, in particular when it comes to cross-cutting issues such as social protection, decentralization, gender, inclusion of people with disabilities and NCDs. Indeed, the Council for Agricultural and Rural Development (CARD) is responsible for coordinating the implementation of the National Social Protection Strategy for the Poor and Vulnerable (NSPS), which also encompasses social health protection schemes for the formal sector. 5 Yet, there is currently no coordination committee for harmonizing and aligning the social health protection efforts by the various ministries. The draft Health Financing Policy foresees a Social Health Protection Committee with representatives from various ministries for this role. The Providing for Health (P4H) network is stimulating 3 Strategy No. 5 Develop and strengthen social protection systems and service delivery to persons with disabilities including women and children with disabilities. 4 Universal population coverage, benefits, purchasing services, institutions, sources of funds and regulation. 5 Whereas the NSPS puts a focus on the informal sector poor and vulnerable, the Joint Monitoring Indicators 2014-2018 acknowledge that vulnerability also exists in the formal sector. 3
constructive dialogue amongst the development partners and alignment of activities for social health protection. Experience from the past has also shown that programme objectives are often defined with the assumption of wider reform progress in related areas such as human resources, public financial management, good governance, regulation of private practice by public sector health staff, compensation reform for civil servants and the decentralization process. These complex government reforms materialize slower than planned, which needs to be taken into account in future programmes. It needs to be acknowledged that HP can support by their engagement in these areas but cannot drive core reform processes and that a long-term engagement and perspective is needed to achieve results. SHP requires a long-term engagement and perspective, too. No one should expect quick wins. 3. Development partners and partner country s own activities in the priority area The Cambodian health sector is supported by a large number of bi- and multilateral development partners, known as health partners. Within the UN family the World Bank, WHO, UNAIDS, UNFPA, UNICEF and UNOPS are present. Vertical initiatives such as the Global Fund and GAVI play an important role in fighting communicable diseases. Bilateral donors include JICA, the U.S. government (USG), the Australian government and KOICA. Cooperation with non-traditional donors such as Viet Nam and China is on the rise, although little is known about their activities and modalities. Among the EU partners, France is providing support in the health sector, since 2013 mainly in the form of loans. The Czech Republic is also engaged in various small-scale health projects. In addition to bi- und multilateral donors, a large number of national and international NGOs are active throughout the country, and while many of them play a crucial role in delivering health services to the population and in operating social health protection schemes, the high number of actors is one of the reasons why the Cambodian health sector is perceived as being highly fragmented. Coordination between the RGC and DPs takes place in an elaborate and multi-level dialogue structure with technical working groups (TWGs) as the main body for coordination and sector dialogue. The TWG Health meets on a monthly basis and is chaired by the MoH with the WHO as lead donor facilitator. Coordination among DPs takes place in the monthly HP meetings, chaired by the WHO with a bilateral co-chair, currently the Australian government. Cambodia is a member of the International Health Partnership Plus (IHP+) and the WB / WHO serve as facilitators in this connection. Within the EU, Germany is lead donor for health and in 2014 is a member of the TWG Health Secretariat, representing bilateral donors there. In the Global Fund country coordinating mechanism (CCC), Germany (with France as alternate) and USG represent bilateral donors. A 2012 review on the functioning of the TWG Health notes that, while it is an effective mechanism for information exchange, there is scope for enhancing its role to encourage more substantive, strategic and open debate on policy, strategy and problem solving, underpinned with evidence. Although the MoH supports the aid effectiveness agenda, it has a preference for engaging bilaterally with HPs, making the development of an effective and efficient sector-wide approach difficult to achieve. In 2010 the RGC initiated a Programme-Based Approach (PBA) as a tool for enhancing development effectiveness that encourages all partners and all modalities to ensure that their support falls within the policy framework, work plan and budget. The existing Sector Wide Management (SWiM) in the health sector is in line with this approach, but has not achieved its full potential. It is defined only vaguely and does not contain clear implementation principles. The latest HSP2 mid-term review (2011) underlines that compared to earlier years more HP funds have been channelled through government planning mechanisms 4
like the annual operational plans (AOPs) 6, and some of them have been pooled. However, most external funding remains outside or vertical, and imposes multiple fund management and reporting requirements, thereby increasing the administrative burden and making it more difficult for the MoH to fulfil its sector stewardship role. The Health Sector Support Programme (HSSP) was created in 2003 by a number of HPs as a tool for greater harmonization and increased aid effectiveness. Its second phase, the HSSP2 (2007-2013, extended to 2015), is supported inter alia by the World Bank, the Australian government, UNICEF, UNFPA, BTC (until 2012), DFID (until the end of 2013), AFD (until 2014) and KOICA (since 2014), and allows for partners to provide funds through a pooled fund and/or through discrete funds. HSSP2 has created a joint partnership agreement that includes common planning and budgeting mechanisms and a joint review process based on a single set of programme indicators. German development cooperation is well aligned with the main partner strategies and this support is closely coordinated with that of other HPs at the central and the provincial level, as well as within the framework of P4H. Germany also ensures that its cooperation activities and resources are integrated into the MoH AOP on the national, provincial, district and even local levels in a transparent manner. Still, German cooperation has so far not been part of joint aid modalities in the health sector and using country systems more stringently is a challenge where further efforts by HPs and the government are needed. The ongoing discussion on the prolongation of HSSP2 and on a potential successor provides an ideal window of opportunity for Germany to analyse whether and how to get more engaged in this regard. 4. The German contribution in terms of goals, indicative financial planning, approaches and guidelines for the preparation of programme proposals German development cooperation activities are to be found in the context of social protection for the poor and vulnerable with a focus on social protection in health. Overall, Germany is supporting the efforts of the RGC to further develop a health system that provides universal access to an essential package of quality health services based on equity in access and fairness in financial contributions. In line with the social protection strategy and the Cambodian MDGs, Germany s development cooperation focuses specifically on the inclusion of poor and vulnerable groups, including in the formal sector. The current reform dynamics in the health sector provide momentum for expanding German support from providing access to specific health services in the area of reproductive health to a comprehensive approach of providing access to an essential package of quality health services through social health protection schemes, in particular HEF, thereby stimulating demand. A thematic focus will be kept on improving access to quality reproductive, maternal and neonatal health care services to support the Royal Government s Fast Track Initiative, which is a direct contribution to the G8 Muskoka Commitment. Improving access to quality health care services in the area of non-communicable diseases and chronic conditions (including for persons with disabilities) will be given greater emphasis in Germany s cooperation with Cambodia, given the growing demand and challenges in this area that Cambodia is likely to face in the years to come. The specific needs of persons with disabilities will be considered whilst improving access to quality health services for vulnerable groups. Relevant measures are to be selected according to the twin-track approach of German development cooperation. 7 These measures will directly contribute to the implementation of the UN Convention on the Rights of Persons with Disabilities ratified by the RGC and Germany. 6 AOPs are the MoH s core bottom-up planning tool, also in order to negotiate the health budget with the Treasury. 7 Action Plan for the Inclusion of Persons with Disabilities, BMZ Strategy Paper 1 (2013). 5
All measures under German development cooperation are aligned with partner policies and strategies, and are geared towards partners goals, objectives and indicators to the greatest extent possible; the RGC and HPs will be informed about any exceptions and the reasons for them. The goal of German development cooperation in the health sector is thus that the poor and vulnerable population in Cambodia is healthier and faces less financial burden by using quality health care services. The following indicators will be used to measure progress, while these indicators will be further defined (Wertbestückung) in the joint GIZ-KfW programme proposal, part A: (1) By 2018 the incidence of catastrophic health expenditure for the poor and vulnerable has decreased in Cambodia. (2) By 2018 the use of services by members of one form of a social health protection scheme has increased in Cambodia. (3) By 2018 maternal and neonatal mortality of the poor and vulnerable has decreased in Cambodia. (4) By 2018 an increasing number of public and private health facilities in Cambodia provide quality health services according to national standards and are recognized by the Ministry of Health or a national accreditation body. (5) By 2018 the numbers of screenings and treatments / early interventions regarding two chronic conditions (to be specified) have increased in Cambodia. 8 The strategic approach of German development cooperation in the Cambodian health sector is aimed at achieving social protection in health and strengthening the health system, thereby addressing both the supply and the demand side. Acknowledging the current reform dynamics and having in mind German priorities and experience to date, German cooperation will focus on the following areas of intervention: Health Care Financing o Supporting the MoH and other entities of the government responsible for Social Health Protection in further developing and rolling out a comprehensive and uniform social health protection system, inclusive of the poor and vulnerable. o Financing essential quality health care services by co-funding (integrated) social health protection schemes for the poor and vulnerable, preferably by joint financing approaches through pooled funds. Health Service Delivery o Supporting the MoH at all levels and other institutions in establishing and implementing a national system of quality improvement and accreditation for public and private service providers. o Improving physical infrastructure and human capacity at different levels of the health system. Health System Governance o Supporting inclusive dialogue and planning mechanisms to improve transparency and accountability in the health sector as well as strengthening clients rights. 8 Given that addressing NCDs/ chronic conditions/ disability in Cambodia is a relatively new area for German cooperation, this output indicator was identified as sufficient and appropriate (plausible/realistic) for the time being. 6
o Developing the capacity of health care providers, civil society and local authorities in the context of the national programme on Sub-national Democratic Development (SNDD). Provided that the SNDD reform is progressing, Germany is prepared to deepen its current development cooperation engagement, in particular with a view to the transfer of functions, budget and personnel from central government to sub-national authorities with the aim of improving service delivery and promoting local accountability. The area of communicable diseases will be supported by means of vertical initiatives such as the Global Fund and GAVI. As bilateral donor representative in the CCC for the period 2013-2014, Germany is committed to and will lobby for close alignment between bi- and multilateral activities, in particular in the area of strengthening the health system. Germany is currently actively engaged in development cooperation activities in seven provinces: Kep, Kampot, Kampong Thom, Kampong Speu, Kampong Cham 9, Prey Veng and Svay Rieng. These geographic target areas will be reconsidered along with the transition to co-funding SHP schemes for the poor and vulnerable. Those identified as poor and those who are vulnerable to poverty are the target group of German development cooperation. In line with the social protection strategy of the RGC the latter includes the near-poor in the formal and informal sector, women of reproductive age and children under 5, as well as persons with disabilities and the elderly. The main partner of German development cooperation is the Ministry of Health and subordinate bodies. The Ministry of Labour and Vocational Training, which is responsible for formal sector employees, is another German cooperation partner. A third important partner for German cooperation activities is the Council for Agriculture and Rural Development, responsible for coordinating RGC social protection efforts overall. The following approaches and requirements are obligatory for the design of new programme proposals under Technical Cooperation and Financial Cooperation: Approaches Application of the Multi-Level Approach (Mehrebenenansatz); Application of all instruments of German development cooperation (financial contributions, development advisors, integrated experts and HCD); Cooperation within the framework of P4H and IHP+ as appropriate; Capacity development of core actors, organizations and networks as well as facilitation of inter-ministerial dialogue in the area of social protection in health. Requirements Alignment with partner strategies, policies and plans including respective goals, objectives and indicators as well as priorities to the greatest extent possible; Use of country systems in planning, reporting, monitoring, procurement and financial management with the aim of strengthening development effectiveness. In areas where the use of country systems is not yet feasible, accompanying capacity development will be offered with a view to achieving internationally accepted standards; Financial cooperation through joint financing approaches and pooled funds is to be given priority; 9 One development advisor (Preceptor Training Programme) is based in Kampong Cham. 7
Close collaboration between Financial and Technical Cooperation and the use of common steering structures with partners; Strengthening synergies and increasing cooperation with German cooperation programmes and projects in the cross-cutting area Good Governance; In order to increase the sustainability of interventions, the following criteria should be applied: o Increasing counterpart funding and feasibility of financial take-over by the RGC; o Potential for scaling up; o Ensuring that demand-side interventions are met by the supply side; o Principles for the selection of NCDs/chronic conditions according to the relevant strategies, in particular 1) Priority based on burden of disease, 2) Step-wise approach based on feasibility and 3) Prioritizing cost-effective interventions. 10 Application of a rights-based approach and the principles of good governance: o Distinct focus on the poor and vulnerable and their empowerment as well as on participatory approaches; o If diagnosis of diseases is financed, adequate treatment must be ensured; o Mainstreaming the specific needs of persons with disability; o Gender sensitivity; o Conflict sensitivity. This strategy paper contains the strategic approach and implementing arrangements for German development cooperation in the priority area health. It is based on the joint European Development Cooperation Strategy for Cambodia and aligned with the forthcoming NSDP 2014-2018. If necessary the strategy will be reviewed in 2016 after the launch of the next Health Strategic Plan, Phase 3. The German government will strive to maintain current commitments for the priority area health. Indicative financial spending for the period 2014 to 2018 is 50 million euros; the funding will be provided through bilateral grants for financial and technical cooperation. 10 National Strategic Plan for the Prevention and Control of NCDs 2013-2020, p.19. 8