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1.1 Population and health
Cambodia has a population of more than 14 million and a per capita GDP of US$409 (2005). Approximately 85% of the population live in rural areas and are engaged mainly in subsistence agriculture. Approximately 35% of the population lives below the poverty line. Economic growth has averaged 7% per annum in recent years, and the structure of the economy is changing. Commercial agriculture, fishing and forestry account for a third of national income, and strong growth has been evident in industrial sectors including the garment and footwear industries and in tourism. This industrial growth has led to an increase in the number of formal-salaried and informal-sector workers in urban areas. Wages remain low, however, and the income tax system remains under-developed. The anticipated commencement of oil production and other mining activities may expand formal employment opportunities. It is a hope that anticipated revenues from oil production may provide resources for investment in the social sectors including health care. The National Strategic Development Plan 2006-2010 (NSDP) sets the main priorities for Cambodian strategic development, while the Cambodian MDGs set the indicators and targets to achieve by 2015. The aims of the HSP 2003-2007 was to strengthen health service delivery, improve access to health services for the poor, improve attitudes of health providers, improve the quality of services, ensure a regular and adequate flow of funds to facilities, strengthen staff skills and capacities, improve the drug supply and expand health information. While key health indicators have improved in recent years major concerns remain and key health indicators are weaker in Cambodia than in many neighboring countries. As Figure 1 indicates, results from the CDHS 2005 show a considerable improvement in life expectancy and infant and under-5 mortality rates. The maternal mortality rate remains unacceptably high, and child mortality rates are still high compared to other countries in the region. As noted in the CDHS 2005, 37% of children under 5 are stunted and 36% of children are underweight.
NSDP 2006-2010 Priorities in health and connected sectors Poverty reduction Access to basic education Gender equality
CMDG’s target by 2015 Halve the number of people living below the poverty line All children complete nine year basic schooling, gender disparities in primary education eliminated Reduce gender disparities in secondary and tertiary education, eliminate gender disparities in wage distribution and public institutions Halve by 2015 proportion of people without access to safe drinking water and sanitation Halve under-five mortality rates, improve DPT3 and measles immunization rates Reduce maternal mortality to 1/3 of baseline rate, improve access to deliveries assisted by trained birth attendants Decrease the spread of HIV/AIDS, malaria, dengue fever and TB: Reduce HIV/AIDS prevalence, TB and malaria case fatality rates, improve malaria treatment at facility and TB detection rates
Access to safe drinking water
Reduction of maternal mortality Combat HIV/AIDS, malaria and other diseases
Strategic Framework for Health Financing
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a minimum drug supply to public facilities guaranteed through the Central Medical Store and health staff placed in most facilities. In terms of health financing. traditional and religious healers and birth attendants attract 20. Now. 1.2 Achievements to date Indicator Life Expectancy (years) Female Male Infant mortality (per 100 live births) Under 5 Mortality (per 1000 live births) Maternal Mortality (per 1000 live births) CDHS 2000 57 50 95 124 437 CDHS 2005 65 60 66 83 472 Cambodia has made significant progress in the reconstruction of the health sector and the improved delivery of health services to the population in the last two decades.8% of patients. it is significant that demand-side initiatives to relieve the burden of OOP expenditures began with HEF (which is now available in almost half of all health districts) and CBHI (with Strategic Framework for Health Financing Page 2 of 15 . remains low. In the past decade. On the supply side. and in 1996 the Health Financing Charter authorized the collection of user fees at public facilities and helped to reduce the cost of services (by replacing more expensive under-the-table charges) and increasing utilization. By the mid-1990s Cambodia had already achieved much in developing national health policy and program priorities. the inability to provide good quality and affordable public health services created a vacuum that has been filled in different ways by private service delivery. strengthening national programs aimed at the principal communicable and preventable diseases.Department of Planning and Health Information Figure 1. The low utilization of public health services has been a chronic problem. however. re-establishing functioning primary health services through a district-based health system. In 1995 the Health Coverage Plan was adopted. Cambodia has been the site for experimentation with a range of new and interesting initiatives in health systems development. and raising the capacity of the health system overall to manage resources and perform basic functions efficiently. new initiatives have been piloted in health service coverage and in contracting to non-government providers. The different levels of success of these schemes have been well documented in terms of improved service-delivery management. Progress has been made towards the establishment of national health financing systems. The constraints on the delivery of quality public health services include inadequate management capacity. it accounts for 48. but have not achieved national coverage (with the exception of the HCP). low salary levels that in turn create an incentive for different forms of private practice and inadequate skill levels at most health centers and some hospitals. often supported by NGOs. with a variety of providers such as drug vendors. The quality of service delivery. The first truly national budget for health care was adopted in 1994 (until then health services were financed through allocations made to provincial governments).2% of treatment episodes. health equity funding and community based health insurance. the demand for public health services has often not responded: access to services has been restricted by financial and other barriers and levels of utilization of public services have remained low. On the demand side. Key health indicators in Cambodia Only 21. The private health care sector is largely unregulated and of unknown quality. where the quality of service delivery remains poor. In effect. a public health infrastructure has been provided across most of the country. Despite many supply-side reforms. under the HCP. increased quality of service and increased access to services. Most of the schemes have been local initiatives.6% of reported episodes of illness are treated in the public sector. The non-medical sector. or have been implemented locally in selected health districts. initiatives have been piloted in community co-financing.
1. There is therefore an over-riding need for a national framework for health financing. While considerable improvements have been made in health indicators and access to services (including for the poor) in the past five years. April 2007.Department of Planning and Health Information more limited coverage) initiatives and only more recently have plans to implement SHI arrangements been developed.3 Health financing Government budget. Disbursements tend to be low in the early months of the year.3. particularly at the provincial level. because of the weak taxation system. by Christopher Lane. The proportion of public funding reaching the service delivery level is relatively low.1 National health budget The national health budget is increasing. national programs and national drug fund) and to 8090% for provincial budgets during 2005-06. these results have largely been achieved with the support of substantial donor input and technical assistance. actual expenditure rose to 95% for the central health budget (including national hospitals. and the 2007 budget targeted health spending equivalent to 12% of government recurrent spending and 1. As a proportion of budget. However. In the future. 1. it is likely that a national coverage of social health insurance and social health protection will be difficult to organize and fund. this fragmented approach is likely to be both ineffective and unsustainable.10 per capita in 2000 to US$5.70 per capita in the 2007 budget. a large proportion of transfers to provincial health departments are still paid in-kind. including part of essential drugs and medical supplies. but the allocation of resources between these is not optimal. Following a sharp drop in 2004 the budget has since recovered. and only about one third of the government health budget reaches the primary service delivery level according to 2004 estimates. A comprehensive discussion of health financing issues in the period to 2015 is contained in Scaling Up for Better Health in Cambodia: A Country Case Study for the Royal Government of Cambodia / World Health Organization / Post-High Level Forum on Health Millennium Development Goals. As in most countries of similar socio-economic status. These increases are broadly in line with NSDP objectives. The budget mainly finances salaries and recurrent costs. starting with government current and capital budget in priority social areas such as health and education sectors. In nominal terms. 1 It is estimated that district hospitals and health centers receive about 18% of the gross health budget and 36% of resources when donor transfers are included. Page Strategic Framework for Health Financing 3 of 15 . The burden of social protection measures has therefore fallen on localized and independent schemes.2% of GDP. donor funding and household spending are the principal sources of financing for health care. US$19. The Public Financial Management Reform Program (PFM) which has been implementing by MEF. although it is not clear if this is own financed or donor on-budget financed expenditures. Consequently. Budget disbursement has also improved. In 2007. budget spending increased from US$2. constraints on government funding and the dependence on donor resources. 1 The low level of public resources reaching the primary health care service delivery level explains both the high level of out-of-pocket payments and the widespread prevalence of private providers.5 million of the budget was allocated to the health Public Investment Plan for capital costs. making health services work effectively to meet MOH goals may require substantial increase in health expenditures on service delivery. will ensure higher standards of management and accountability of public resources for health. and the back-loading of spending remains a significant problem.
00% 100.939 401.312 158.966 21.332.065.340 7.7220.127.116.110 5.000 37.000 50.12% 100.194 34.24% 76.00% YEAR 2005 Chapter GRAND TOTAL Sub Central 10 11 31 32 12 PAP13 Sub Province 10 11 Approved Budget 240.009.00% 100.600 4.026 17.043.000.228.970 25.000.000.403.564.668.000 70.340 7.968.437.29% 14.663 31.00% 100.37% 85.858.879.706.77% Expenditure 185.747.00% 100.461 397.000 73.34% 91.000.390.000.398.000 7.000.05% 83.872.06% 92.000 17.000.516.00% 100.000.245.255 17.000 25.448.090.58% 100.166 21.000.650 6.609 58.038.00% 100.76% 95.575.016.000 25.194 34.389.58% 32.52% 84.526.792 23.856.Department of Planning and Health Information GOVERNMENT HEALTH EXPEDITURE YEAR 2003 Chapter GRAND TOTAL Sub Central 10 11 31 32 12 PAP13 Sub Province 10 11 31 Add13 PAP13 YEAR 2004 Chapter GRAND TOTAL Sub Central 10 11 31 32 12 PAP13 Sub Province 10 11 31 Add13 PAP13 Approved Budget 226.62% 100.626.745 Page % 97.817.000 7.79% 85.000 350.000 78.415 101.806.93% 77.045.182.15% 97.198.330 19.00% 100.090.000 7.420.081.70% 99.000 5.33% 31.044.000 15.747.095.393 71.38% 100.485.162.397.388.00% 100.122.941 73.901.000 Mandate 230.748 103.604.700 % 96.05% 75.700 37.928.855.188.950.664 4.000.901.000 23.302.46% 80.000 1.272.000.000 240.104.437.671.000.623 55.318.57% 87.000 Mandate 191.095.370.77% 17.516.792 23.448.600 4.941 73.788 35.084.000.000 200.604.970 25.000 132.415.458 35.323 58.000 25.206.743 401.919 109.280.228.21% 96.48% 100.983 6.733.000.32% 81.000.32% 91.498.045.384.000.42% 80.200.000 6.000 50.022.136.000.322.79% 63.68% 99.030 27.368.466.825.554.060 5.000 24.080.575.000 1.672.24% 95.368.458 36.000.332.00% 100.807.62% 7.00% 100.95% 81.730 19.461 397.060 5.46% Expenditure 157.081.92% 72.676 6.788 35.000.000.289.00% Strategic Framework for Health Financing 4 of 15 .152.497.950.471.043.951 18.403.41% 100.000.366.188.317.000 Mandate 167.668.100 % 84.000.093.610.57% 92.000 31.000.11% 83.000 17.000 15.650 6.106.860.397.130.657 58.964 4.20% 91.472 88.100.000 7.85% 100.974.000 108.292.437.022.000.877.507.510.06% 94.000 21.960.564.288 5.700 71.113.628.000.198.000.752.49% 87.000 15.15% 81.000.671.638.398.03% 85.201.000 34.20% 95.44% 99.745 % 94.825.540 5.951 18.13% 83.440.62% Expenditure 224.000.237.930.94% 405.411.472 88.00% 100.700 37.00% 100.663 25.493.00% 70.336 5.030 19.00% 99.398.26% 424.18% 100.565 38.000.446.000.80% 80.225 159.00% 100.026 19.00% 97.897.02% 100.859.994.000.370.00% 80.890.633.000.398.302.475.245.000.287 132.000.00% 92.863.668.152.390.000 23.950.451 17.946 % 82.60% Approved Budget 202.197.283.307.769.498.324.283.239 126.090.575.000.254.000.307.565 38.000 103.00% 100.000.946 % 93.564.00% 88.52% 100.900.990.27% 100.098.733.000 153.748 103.290.890.000 87.000 6.000.554.605.000 6.000 160.000 15.605.358.272.752.196.800 20.084.098.800 20.
222 7.00% 100.433.05% 97.28% 517.222 76.210.000.563.000.207 51.059.56% 100.000 8.190 94.842.82% 96.91% 100.413.000.839.803 69.228.282 8.001 93.000 20.400 97.065 28.054.894.727.000 517.600.21% 256.747.264.558.075.50% Approved Budget Mandate % Expenditure % Chapter Approved Budget GRAND TOTAL Sub Central 10 11 31 32 12 PAP13 Sub Province 10 11 31 Add13 261.000 7.15% 89.000 186.102.000 8.000.752.714.803 69.269.222 5.07% 89.747.378.514 82.413.264.000.000.48% 98.457.356.00% 100.000 8.948 8.631 8.800 802.207.013.391.00% 84.13% 99.78% 97.57% 100.813 40.209.000.00% 100.840.840.000.000.000 105.001 93.742.209.000.317.592 179.000 1.000 176.00% 106.875.000 50.00% 100.000 88.000.000.000.000.000.00% 93.000.806.000.713.68% 117.29% 39.75% 105.456.000.960.000.000 276.000 100.000 49.460.752.996.210.793 44.013 179.989.32% 96.800 680.514 39.133.00% 100.000 21.791.000 20.000 31.845 41.606.000 89.06% 83.261.032.578.000 96.677.028.657.988.735.914.805.317.00% 100.842.000 84.378.043.606.965.059.644 27.000 48.000 100.713.791.34% 91.108.00% 99.00% 100.000 26.96% 100.60% 91.Department of Planning and Health Information 31 Add13 PAP13 YEAR 2006 Chapter 1.000 1.533.000 50.875.000.563.45% 109.563 7.00% 100.000.407 100.000.240.000 7.996.000.00% 100.948 8.804.000.000 5.563 39.00% 63.426.000 71.965.000.45% 97.812.727.222 5.000 71.00% 100.000 9.845 41.897.31% 116.00% 100.52% 91.00% 105.912.000.960.805.14% 261.35% 101.422.912.90% Strategic Framework for Health Financing Page 5 of 15 .
000 99.051 102.430.167.350.7% 26.000.8% 7.5% 4.3% 98.130.764 92.3% 95.167.000.0% 10.5% 247.330.051 102.000 99.135.000.4% 5.734.000 13.0% 18.120 97.776 92.143.000.6% 9.9% 100.317.633.956.0% 5.776 92.8% 10.000.000 3.4% 83.992.060.518.1% 14.862.000 27.483.120.403.9% 451.658.000 28.635.048.000 20.317.0% 91.000 94.794 82.860.3% 10.081.000.881.8% 100.4% 100.733 94.628.405 94.000 11.000 99.3% 341.468 94.0% 100.000 96.100 72.207 95.9% 100.Program Budget 218.000 59.000.247.0% 11.688 83.870 97.000.3% 2.040.430.800.273.338.6% 100.000 27.909.628.000 27.0% 11.628.8% 347.3% 58.6% 96.375.783 96.840.307.958.775.9% 5.633.000 11.9% 15.000 21.005.8% 15.000 96.1% 99.000.2% 83.8% 9.266.9% 98.895.3% 96.0% 100.5% 96.000 123.0% 97.963 77.719 93.275.Department of Planning and Health Information Government health budget Vs Expenditure 2007 Approved Charpter Budget by Assembly 1 Grand total Adjusted Requested for commitment Commit ed budget budget Amount % Amount % 3 361.9% 100.0% 140.7% 99.9% 99.715.177.002.612.451.021.141.660.000.980.963.0% 97.000 16.6% 99.468 94.888 91.0% 26.130.1% 96.639.000.162 92.7% 100.5% 3.4% 96.0% 100.100 72.400 97.8% 26.000 28.953.521.000 4 5=4/3 6 7=6/3 349.165.963.0% 98.954.358 96.060.2% 234.506.000 27.478.000 91.0% 11.600.718.000 242.721.273.165.327.000 262.0% 26.963.274.3% 100.0% 94.000.033 98.786.869.5% 540.9% 58.400.105.000 21.0% 228.000 6.3% 4.9% 100.000 99.330.000 86.822.476.000.167.079.141.493.888 91.963 77.048.136 98.000 38.338.786.344 79.721.231.410.152.660.000.289.544 76.0% 83.612.236.422 91.000.973.0% Strategic Framework for Health Financing Page 6 of 15 .0% 37.576.141.120 96.002.961.6% 10.6% 39.1% 100.275.000 581.240.0% 100.9% 11.660.345.166.468 94.788.0% 83.410.000 2.190.476.953.4% 451.000 9.000.861 89.0% 4.954.7% 99.630 93.000 56.746.0% 39.7% 9.034.558.600.2% 83.000 86.8% 18.223.8% 100.842.146 95.9% 99.0% 9.344 79.240.000.556 83.855 98.6% 100.963 77.733 94.794 82.000 96.786.6% 58.463 93.295.983.060.081.2% 11.0% Program Budget 20.421.518.024 95.000 91.130.663.661 89.033 98.8% 247.081.0% 5.975.610.029 94.0% 140.021.384.0% 96.000.344 79.100 72.656.794 82.107.307.4% 99.000 96.120 97.000 236.661 89.000.0% 39.000 99.017.661.0% 2.660.4% 100.000 11.375.879.103 92.0% 2.113.000.1% 15.4% 100.3% 92.350.4% 100.375.338.063 90.000.000.221.9% 100.6% 79.497.638.9% 11.483.338.002.000 16.000 Requested mandate Mandated budget Cash disbursed Amount 14 Amount 8 % % 9=8/3 10=8/4 Amount 11 % % 12=11/3 13=11/6 % % 15=14/36=14/11 2 336.0% 94.000.693.300 98.000 27.040.000 93.6% 7.166 94.0% 7.483.295.000.557.000 98.1% 338.492 94.4% 5.4% 97.472 74.7% 39.4% 99.6% 99.733 97.371.0% 3.7% 99.000 12.240.9% 98.527.7% 58.000.048.1% 98.000.152.6% 99.029 94.453.9% 96.0% None.1% 253.000 3.294.307.183.4% 146.0% 11.1% Sub Central srbu 60 61 62 63 64 65 srbu 60 61 62 65 238.527.633.271 102.191.103 99.7% 100.729.0% 2.022 75.625 96.6% 99.5% 99.0% 140.000.862.789.345.478.7% 2.0% 94.000 8.307.815.0% 100.307.000 13.8% 18.338.218.104.22.168% 100.7% 26.953.000 11.3% 100.745.6% 341.473.000 6.000 18.564.000 91.0% 58.223.051 102.704.3% 228.000.453.8% 100.405 94.000 38.000 93.000.029 94.320.6% 99.8% 3.063 90.000 92.646.990 96.776 92.492 94.1% 10.834.660.338.033 98.6% 83.721.000.734.000.554.862.142.0% 4.909.144 80.405 94.748.6% 15.850.000 96.676 85.0% 7.709.330.926.907.000 15.000.276.105.2% 11.885 99.5% 97.860.1% 11.318.4% 3.6% 100.229.219.000.021.181.1% 228.430.047.024 95.000 581.958.5% 100.0% 18.063 90.273.130.0% Sub Province 60 61 62 64 65 63 98.000 148.100.9% 4.5% 247.000.850.303.448.478.273.8% 11.318.909.7% 7.5% 98.311 96.219.2% 8.557.000 255.518.661 89.746.000 22.214.171.124% 147.311 97.953.0% 568.154.9% 3.414 99.661 89.291.7% 99.472 91.453.0% 451.709.888 91.701.860.369.
Strategic Framework for Health Financing Page 7 of 15 . NSDP: Priority Action Plan for Health 2003-05 (percent of total) Primary health care coverage Scale up equity funds Contracting in remote areas Health education (incl HIV aids) Public private partnership in basic health Communicable diseases HIV Aids Communicable diseases ( non-HIV aids) Staff incentives in remote areas Pilot health insurance 0 10 20 30 40 50 Donor disbursements for Health by Purpose 2003-05 (percent of total) STD control including HIV/AIDS Infectious disease control Health policy & admin. harmonization and alignment are critical issues. there was a further increase in 2005 particularly from the Global Fund. according to the 2006 OECD harmonization and alignment baseline survey. management Basic health care Reproductive health care & family planning Medical services. Donor funding comes from a diverse range of multi-lateral and bi-lateral sources and a large number of international NGOs and is delivered mainly through a project approach. In recent years the financial level of donor funding for health has been increasing (partly due to the depreciating value of the US dollar). mgmt Basic health infrastructure Basic nutrition Health personnel development Health education 0 10 20 30 40 50 Source: 2002 NSDP Source: OECD. which identified at least nine different ‘project implementation units’ in the health sector. CRS database. equivalent to about $8 per capita compared to public current health spending of $4 per capita).2 Donor funding Donor finance exceeds the government budget for health (a total of $114 million in 2005. Donor coordination. but a number of donors have supported a program-based approach in health sector through SWiM and in the implementation of HIV/Aids assistance. Japan. There was a sharp increase in donor funds in 2002-04 from the US. training and research Population policy and admin. as envisaged in the second Platform of the PFM reform (200709) will in turn set the stage for channeling donor finance through the budget and addressing harmonization and alignment problems with donor finance.Department of Planning and Health Information 1. Better tracking and accountability. Donor financing is not closely aligned with national priorities as set out in the HSP. By devolving budget control and management closer to service delivery public-sector reforms supporting deconcentration and public finance management reform will address transparency and accountability issues. UK and the Global Fund.3. There has so far been only limited alignment of donor programs with Cambodian institutions and procedures.
6 0. 2003 and 2005 (US$ millions) Donors Multilateral UN UNFPA UNICEF WFP support to MCH WHO UNDP UNAIDS ADB WB EC Global Health Partnerships GAVI GFATM 2003* 2005** 25.Department of Planning and Health Information Estimated Donor Disbursements for Health. in practice the proportion of patients receiving exemptions remained very low.5 2005** 114. Out-of-pocket payments are made as user fees to public and private providers.3 2. Official fees were set at a level considered affordable to most people.9 3.8 2. While the official user fees system also introduced a process of exemptions for the very poor. This occurred mainly because the costrecovery policy did not foresee that the absence of any mechanism to fund the exemptions would lead to a Strategic Framework for Health Financing Page 8 of 15 . The introduction of official user fees at public facilities in 1996 was an attempt to regulate unofficial charges in a situation where under-the-table payments were common and expensive and to provide additional revenue to facilities to supplement low government salaries.8 4.1 1.1 4.2 6.3 1. this dependence on private services reflects distrust in the public health system.1 1.2 2.7 3.7 0.2 0 0 2.1 1. ** Source: Cambodia Center for Development Cooperation. payments to government staff working privately and the direct purchase of medicines from pharmacies and drug sellers.4 23 16. about 30% went to public health services and about 70% to private providers. OECD DAC Creditor Reporting System and GAVI and Global Fund websites 1.4 7.5 3.9 Total 2003* 83.6 11.1 1.8 Donors Bilateral Australia Belgium Canada UK France Germany Japan Korea Netherlands Norway Switzerland US NGO 2003* 46.2 3. Much of the private spending on health care comes from higher-income groups while poorer households either rely on government services or are excluded from care because of cost.8 5 3.6 1.7 12. In 2006. and the introduction of official fees effectively lowered the costs of access to health services and increased utilization at most government health centers and some referral hospitals. borrowing and asset sales.3. But expenditure figures must be disaggregated against income levels to reveal a truer picture.1 6.9 1. To some extent. out of the total household OOP expenditure on health care.5 18. Approximately three-quarters of this OOP health expenditure is financed by cash in hand and savings and one-quarter by gifts.7 0.6 2005** 65. It was also estimated that.3 Household health spending It is estimated that 67% of total health spending in 2005 came from households in the form of OOP payments.2 7.3 0.6 1.1 1.7 2.4 1 6 1 1.2 27. the distribution of these gains was not uniform across income groups. However.7 21 1.6 3.3 26.1 0.8 4.9 15. a study by Catherine Michaud (for the Macroeconomics and Health initiative) estimated that little more than 40% of total health expenditure flowed into the public sector with almost 60% to private providers.2 * Source Michaud (2005).
the Cambodian MDG for U5M (65 deaths per 1.4. Page Strategic Framework for Health Financing 9 of 15 .4 Institutional framework 1. (iii) Provide services where needed.000 live births) has already been achieved by the richest quintile while the remainder of the population remain far away from it. 2 An Oxfam study in 2000 showed that 60% of households who sold productive land did so to cover for health care costs. A survey among garment factory workers (GRET 2007) also shows health care as a cause of debt. A consequence of high OOP expenditures and limited riskpooling is considerable inequality in health outcomes by income level. (iv) Be transparent and accountable. The effects of OOP on impoverishment of households are demonstrated in several studies on debt for health and landlessness 2 .2 Policy on Public Service Delivery The Policy on Public Service Delivery applies to services of social affairs that include health and sanitation. A case study among urban poor population (Center for Advanced Studies 2006 ) analyze indebtness as a result of health care costs. particularly for the poor. The PFM reform is sequenced in 4 platforms: (i) A more credible budget. there is a crucial need for social health protection measures. For example. Platform 1 is being currently implemented with the following activities: • • • • • • • • • Improve comprehensiveness of and integration of budget formulation and execution Improve realism and sustainability of budget Streamline ability of budget holders to spend in line with budget Avoid re-accumulation of payment arrears Improve process for post-budget supplementary expenditure credit approval Develop revised procurement procedures Capacity development measures Motivational measures within MEF and line ministries Integration of functions within MEF 1. Similarly. making the poor particularly vulnerable to the expenses incurred during ill health. efficiency and effectiveness of services. (iii) Affordable and prioritized policy agenda. (ii) effective financial accountability.4. (v) Ensure quality. community-based health insurance emerged at the same time as a pre-payment mechanism designed to protect the not so poor from impoverishment due to health costs. (iv) Managers fully accountable for program performance. Consequently. The policy prescribes that public administration has to (i) Ensure accessibility to services. user fees remained a major barrier for the poor. Consequently.1 Public Financial Management Reform Program The Public Financial Management Reform Program (PFM) implemented by MEF aims “to install much higher standards of management and accountability in the mobilization of all government current and capital resources and effectiveness and efficiency in the use of resources in their application […]”. 1. particularly catastrophic health expenditures. Health equity funding emerged in 2000 in response to this situation as a means to fund fee exemptions at public facilities for the identified poor. In fact. (ii) Focus on the real needs of consumers. the under-five mortality rate for the bottom two wealth quintiles is three times the rate for the highest quintile. Private spending on health care exhibits very limited risk pooling.Department of Planning and Health Information situation in which few exemptions were actually granted.
3 In fact the quality of private health providers has never been assessed and is not monitored. but fee-exemption schemes at health facilities have not worked adequately to protect the poor or provide sufficient access to services. income from user fees at facilities has been allocated 60% to the facility for staff incentives. Contracting is commonly associated with user fees for service and often with health equity funding schemes. 22 CPA1. The situation is aggravated by health workers dual public and private practice. Among other forms of contracting of services used in Cambodia are performance-based contracts used by bilateral and multilateral donors and other donors with various health units (such as a Provincial Health Department or OD Office).4. and deconcentration and decentralization of public services. mainly because these fee-exemptions have not been funded. 1. in line with the strategic framework on decentralization and deconcentration reform adopted in 2005. and allowances to staff. there are 76 ODs. In 2004.5 Contracting The contracting of public health service delivery to non-government providers (generally international NGOs) began with pilot schemes in 1999. An Inter-Ministerial Prakas in 2006 allows government funds to be used within the framework of MOH credit budgets for paying user fees on behalf of poor patients. Until now there are 67 Referral Hospitals.Department of Planning and Health Information Implementation mechanisms for the policy rely on One-Window Office. 3 1. and once a user-fee scheme is approved and put into operation all other forms of user fees previously implemented shall be stopped. Regulations provide that user fees will be implemented in consultation with the community and local authorities by taking into account consumer needs and affordability. Health seeking behavior is determined by a lack of trust in public facilities and perceived higher quality of private providers. 39% for operating costs and 1% paid as tax to the treasury. drug. User fees remain a minor proportion of facility revenues but play a significant role in financing additional incentives for staff and non-salary operational costs of health facilities. Referral hospital are classified into three categories in providing CPA services (CPA1.4. In 2004 the MOH introduced a second phase of Contracting in 11 ODs under the Health Sector Support Project (HSSP). CPA2 and CPA3) while HCs are mandated to provide MPA service. 793 HCs. in particular ‘under-the table payment’.4 Health Financing Charter Since 1996 the HFC has authorized the collection of user fees for services provided through public health facilities. 32 CPA2 and 18 CPA3 and 877 MPA HCs are functioning and also 95 Health Posts have been established to provide basic health care in remote areas. 6 Natinoal Hospitals and 3 Health Institutes are officially implementing user fee. user fees accounted for 13% of HC and 22% RH operational expenses. Until now there are 77 ODs. Contracting has strengthened facility management in these districts and helped to increase facility utilization. User fees are implemented and administered by the health facilities themselves following approval by the MOH. 1.4. Following a 2005 the MOH and the MOEF’s Inter-Ministerial Prakas. Contracting is not strictly a form of health financing but aims at better management of services. According to the AOP 2007. supplies and equipment costs.3 Health Coverage Plan According to the 1996 HCP. Contracting arrangements have recently been reviewed under the HSP Review process. Page Strategic Framework for Health Financing 10 of 15 . Contracting contributes to better staff remuneration and incentives and works to improve access to services and key service delivery indicators (like immunization levels). user fees will finance up to US$5 million out of planned MOH recurrent spending (including loan funds and NGO contributions) of US$80 million. most public health facilities remain underutilized by a public that often prefers the formal and informal private sector where quality of services is perceived as being higher than in public facilities. However. 69 Referral Hospitals and 966 HCs across Cambodia.
20 April 1.299. and provided a needed subsidy to facilities. reduced the impact of health costs on impoverishment.00 $1. Since their beginning in Cambodia in 2000.60 $2.70 $302.239.456.551 $11. Contracting ODs by Provinces No Province 1 Kampong Cham OD Memut OD Ponhea Krek-Dambe 2 Prey Veng OD Pearaing OD Preah Sdach 3 Mondulkiri OD Sen Monorom 4 Takeo OD Kirivong OD Ang Rokar 5 Rattanakiri OD Banlong 6 Koh Kong OD Smach Meanchey OD Sre Ambel Sub Total 7 Preah Vihear OD Thbeng Meanchey Grand Total Effective date contract National Budget End date contract Source of fund HSSP/ADB/DFID Contract amount $2.780.40 $204. successfully targeted the poor.00 $208.00 April 1.500.658.506. HEFs are decentralized schemes commonly based in a single OD.539.785. the MOH adopted the National Equity Fund Implementation and Monitoring Framework to coordinate the work of the various independent HEFs.440.850.00 October 1.80 $157.958.270.4. HEFs on average fund exemptions for approximately a third of referral-hospital patients where a scheme is available. the number of HEF schemes has grown rapidly to cover now almost half of all health ODs.00 1. implementation and management of HEF schemes. and it reimburses poor patients for the costs of transport and food during hospitalization.262.573. roughly the same level as the proportion living below the poverty line on average.00 $82. provided access for the poor who previously could not attend due to cost. 2004 December 31. The MOH intends to accept greater responsibility for the funding.061. 2007 HSSP/ADB/DFID December 31.00 extimate per year April 1.048. In 2005.995.600.6 HEF national framework Health Equity Funds are an informal social-transfer mechanism designed to subsidize health facilities for the costs of user-fee exemptions provided to the poor. 2007 HSSP/ADB/DFID $1. Poor patients receive free or discounted care at public facilities.00 $120. 2005 December 31.00 $346. 2007 HSSP/ADB/DFID $2. with guidelines for pre-identification of beneficiaries and a common schedule of benefits. 2004 December 31. While conditions vary widely between ODs.543.337.569.360.392.Department of Planning and Health Information Recent positions of the MOH indicate phasing out of contracting in its current form and shifting to internal contracting.848. they are donor-funded and mostly implemented through international and local NGOs (in a few cases the HEF is implemented through local community organizations.20 $2. 2004 December 31.046. 2004 May 1. The poor are identified according to eligibility criteria and the HEF reimburses the public health care providers for the cost of services provided.066. Pagodas or Hospital-based committees).60 $401. 2007 $10.468.757. increase the proportion of health Strategic Framework for Health Financing Page 11 of 15 .10 $325. 2007 HSSP/ADB/DFID December 31. Currently. 2005 December 31. The Framework was supplemented with an HEF reporting and monitoring system developed in 2007 by the Bureau of Health Economics and Financing of the DPHI. 2007 HSSP/WB/DFID $1.00 $215.400. reduced debt and interest payments for health care.263.00 $2. AusAID and RMIT University) found that HEF significantly increased utilization of facilities.90 April 1. The MOH regards HEF as a primary initiative to help the poor population with access to quality public health services. WHO. It proposed to increase HEF coverage of the poor. 2004 January 1. The Implementation and Monitoring Framework offers a partnership with donors and NGOs to establish a uniform monitoring and reporting process.00 $208. The JAPR 2006 proposed that the number of HEF schemes be increased from 16 to 35 in non-Contracting ODs and continue in all 11 Contracting ODs through the HSSP (reaching a total of 46 out of all 77 ODs). The 2006 Study of Financial Access to Health Services for the Poor in Cambodia Phase 1 (for the Ministry of Health. 2007 HSSP/ADB/DFID $947.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Province Health Operational District Facility Donor INGO LNGO HEF began At RH IPD y/n OPD y/n At HC HEF schemes supported by NGOs Banteay Meanchey Mongkul Borei Banteay Meanchey Battambang Battambang Kampong Cham Kampong Cham Kampong Cham Kampong Cham Kampong Thom Kratie Kratie Mondulkiri Odar Meanchey Phnom Penh Preah Vihear Prey Veng Prey Veng Pursat Rattanakiri Siem Reap Siem Reap Siem Reap Sihanoukville Stung Treng Svay Rieng Takeo Takeo Takeo Takeo Thmar Pouk Mung Russei Sampov Luon Chamkar Leu-S.08 7/2002 7/2002 7/2003 12/2004 2/2005 9/2000 4/2006 7/2006 1/2005 7/2002 4/2005 1/2005 5/2003 5/2005 6/2007 6/2007 6/2007 11/2006 6/2007 6/2007 6/2007 6/2007 6/2007 6/2007 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No No Yes Yes Yes Yes No No No Yes Yes Yes No No Yes No Yes Yes Yes Yes Yes Yes No No No Yes No No No No No No No No No Yes Yes Yes No Yes No No No No Yes No No No No No No Yes No Districts supported by MOH Kampong Chhnang Kampong Chhnang Kampong Speu Kampot Kampot Kandal Kandal Prey Veng Svay Rieng Takeo Pailin Kampong Speu Angkor Chey Kampong Trach Ksach Kandal Takhmao Kampong Trabek Romeas Hek Daun Keo Pailin Strategic Framework for Health Financing 12 of 15 . Health Equity Fund Schemes by Operational District # of OD and Hosp.Treng Cheung Prey-Batheay K. Expansion of HEF coverage was endorsed by the 2006 HSSP Mid-Term Review The actual impact of HEF on overall out of pocket spending may however be limited for the following reasons: 1) many HEF cover only referral hospital care.Department of Planning and Health Information facilities offering HEF and improve HEF information systems. 2) post-identification mechanism in place in many ODs is not very effective in informing the population about their entitlements and 3) a large proportion of the population still prefers private health services not covered by HEF. Cham-K. Siem Prey Chhour-Kong Meas Kampong Thom Chhlong Kratie Sen Monorom Samrong/Anlong Veng Municipality (4 ODs) Thbeng Meanchey Peareang Preah Sdach Sampeov Meas Rattanakiri-Banlong Siem Reap PH Sotnikum Kralanh Sihanouk Stung Treng Svay Rieng PH Ang Roka Kirivong Kirivong Takeo PH (Daun Keo) Provincial Hospital Referral Hospital Referral Hospital Referral Hospital Referral Hospital Referral Hospital Provincial Hospital Referral Hospital Referral Hospital Referral Hospital Referral Hospital Provincial Hospital PH and HC Municipal RH Referral Hospital Referral Hospital Referral Hospital Provincial Hospital Provincial Hospital Provincial Hospital RH and HC RH Referral Hospital Provincial Hospital Provincial Hospital Referral Hospital Referral Hospital Health Centers Provincial Hospital USAID CIDA USAID USAID BTC BTC BTC BTC HSSP USAID USAID HSSP BTC USAID HSSP HSSP HSSP USAID HSSP BTC BTC BTC USAID VSO UNICEF EU EU CIDA SRC RGOC RGOC RGOC RGOC RGOC RGOC RGOC RGOC RGOC RGOC URC MSF/HNI URC URC BTC BTC BTC BTC GTZ URC URC HNI BTC URC HU HNI HNI URC HNI BTC BTC BTC URC VSO UNICEF SRC/HNI SRC/HNI EED/SRC SRC MOH MOH MOH MOH MOH MOH MOH MOH MOH MOH CFDS CAAFW AFH AFH AHRDHE AFH AFH AFH AFH AFH AFH CFDS CHHRA USG AFH AFH/RHAC CFDS AFH CHHRA CFDS/CHHRA CHHRA RHAC Hospital EFS Cttee AFH BFH Pagodas CFDS ODO ODO ODO ODO ODO ODO ODO ODO ODO ODO Page 6/2003 5/2000 7/2004 8/2006 12/2005 11/2005 9/2005 1/2006 10/2005 6/2004 8/2006 10/2002 1/2005 8/2000 2006.
CBHI is a private.000 beneficiaries. All companies and NGOs who want to implement CBHI must register with MOEF by submitting a financial plan they have obtained a Certificate of Recognition for the CBHI scheme from the MOH. All the schemes are supported by external premium subsidies or funding for administration provided by the sponsoring NGOs and other donors.7 CBHI guidelines A number of community-based health insurance schemes have been introduced in various parts of the country by a range of international and local NGOs. CBHI is based on the principle of risk pooling and pre-payment for health care. and portability between different CBHI schemes. Strategic Framework for Health Financing Page 13 of 15 . The CBHI scheme pays the contracted facility for the cost of services delivered to its members. nonprofit.4. basic benefit package. The JAPR 2006 proposes to expand the number of CBHI schemes and to increase the membership of existing schemes. with a total of approximately 30. The Guidelines provide for a common approach to the administrative and technical requirements. voluntary insurance mechanism based on the sale of low-cost insurance premiums that provide the purchaser and their family with coverage for health charges for a stated list of medical benefits delivered at contracted public health facilities (generally health centers and referral hospitals). CBHI coverage is currently offered through six schemes by five international and local NGOs working in seven ODs nationally. the MOH produced guidelines for CBHI implementers. Formal regulations for CBHI implementation are to be introduced through the Draft Sub-Decree on Micro Insurance prepared by the MOEF. Following the formulation and launch of the Social Health Insurance Master Plan in 2005 (see next section). The MOH has adopted Guidelines for Implementing CBHI prepared by the DPHI in 2006.Department of Planning and Health Information 40 41 42 43 44 45 National hospitals supported by MOH National Hospital Ang Doung National Hospital National Hospital National Hospital National Hospital National Hospital MCH Calmette Preah Kossamak National Paediatric Kampuchea-Soviet RGOC RGOC RGOC RGOC RGOC RGOC MOH MOH MOH MOH MOH MOH Hospital Hospital Hospital Hospital Hospital Hospital 2007 2007 2007 2007 2007 2007 1.
835 25. including the provision of a work injury program and old age pensions. AusAID. MOSVY is also looking into development of a sub-decree on medical benefits to provide a legal basis for a pilot scheme in social health insurance for Ministry employees in Phnom Penh. 2006. 1.942 102. following the establishment of the National Social Security Fund.621 290.443 153.792 129. Phnom Penh: MOH. The Master Plan covers compulsory social health insurance through the social security framework for public and private sector salaried workers and their dependents.341 CBHI 565 CBHI 565 CBHI 2.774 CBHI 1. MOEF and the Council of Ministers.694 296. occupational injury and other benefits including maternity and sick leave. local NGOs and health care providers for the informal employment sector and social assistance schemes including health equity funds and other funds proposed by government for the poor.Department of Planning and Health Information Operational District with Community Based Health Insurance (CBHI) PHD_C ode PHD_Name OD_Name Thma Puok Kampong Thom Koh Thom Municiplity Sampov Meas Ang Rokar Kirivong Kirivong Samraong OD Pupulation Type Starting population Covered 130.806 Source Implementers CAAFW GRET/SKY GRET/SKY GRET/SKY RACHA GRET/SKY BFH GRET/SKY CHHRA Health Facility Types 1 RH & 8HCs RH HC Rolous RH 1RH and 1 HC 2 RHs & 9HCs 2 RH and 8HCs RH &HC 2 HCs Benefit OPD & IPD IPD OPD IPD OPD & IPD OPD & IPD OPD & IPD OPD & IPD OPD Payment Mechnism Case based payment Capitation Capitation Capitation Capitation Capitation Capitation Capitation Case based payment 1 Banteay MeanCheay 2 Kampong Thom 3 Kandal 4 Phnom Penh 5 Pursat 6 Takeo 7 Takeo 8 Takeo 9 Ordor Mean Cheay Total Feb-05 2007 GTZ/GRET 1998 2005 Aug-06 2001 AFD/GRET Apr-06 SRC/GRET 2003 Aug-05 Abbreviations: Con Contracting HEF Health Equity Fund CBHI Community Based Health Insurance CAAFW Cambodian Association for Assistance to Families and Widows CFDS CHHRA CIDA EFS EU GRET Cambodian Family Development Services Cambodian Health and Human Rights Alliance Canadian International Development Agency Equity Fund Steering committee European Union Groupe de Recherche et d'Echanges Technologiques HSSP Health Sector Support Project. Study of Financial Access to Health Services for the Poor in Cambodia – Phase 1: Scope. voluntary insurance through the development of CBHI schemes sponsored by different development partners. MOP. 1.257 CBHI 5. the MOH adopted the Master Plan for Development of Social Health Insurance and an interministerial Social Health Insurance Committee was established between the MOH.166 CBHI 1. Annear et al. WB and DFID SKY Soka Pheap Kruosa Yeung BTC Belgian Technical Cooperation GTZ HNI URC SRC UNICEF VSO HU German Technical Cooperation Health Net International University Research Company Swiss Red Cross United Nation Volunteer Services Overseas Health Unlimited Source: Based on MOH. health care will be added in the next phase (after 2009).8 SHI Master plan In 2005. MOLVT.466 221.335 CBHI 1.5 Lessons learned and challenges From the situation analysis a number of lessons can be drawn: Strategic Framework for Health Financing Page 14 of 15 . RMIT University (Melbourne). funded by the ADB.417 CBHI 1. The MOLVT is responsible for the development of compulsory social security and health insurance for private-sector salaried workers under the Social Security Law of 2002 (which authorized the establishment of the Social Security Organization). Bureau of Health Economics.386 CBHI 39. MOSVY. The MOSVY is responsible for the development of social security for civil servants and is developing a sub-decree on the provision of pensions. Design and Data Analysis.4. WHO.
• Important issues relating to the economic allocation of existing resources and their efficient use remain unresolved. strengthening government taxation and revenue collection is essential. There is a need to move aggregate resources from inefficient and ineffective private providers to an efficient public health system.Department of Planning and Health Information • While the health status of the population is improving key health indicators are weaker than in neighboring countries. Better donor-government coordination. • The provision of health care mainly through the private sector funded through private out-ofpocket payments by households will continue until 2015 even though the quality of care obtained through private providers is generally low. harmonization and alignment are crucial. Strategic Framework for Health Financing Page 15 of 15 . • The relatively low proportion of public funding reaching the service delivery level largely explains the high level of out-of-pocket payments which in turn leads to considerable inequality in access to services and health outcomes. external aid for health is highly fragmented and not closely aligned with national health priorities. • Because service quality is poor only one in five illness episodes are treated in the public sector. • Because per capita total national health expenditure is very high compared to all other developing countries the total quantity of health financing does not appear to be the central impediment to achieving improved health outcomes. Strengthening Contracting. HEF. • While government funding for health care is a significant proportion of the national budget the health budget remains low in absolute terms. CBHI and integrating them in a coherent plan are an immediate need. While it is substantial. • Different health financing schemes are in place but they are not consistent and not integrated into a single plan. Strengthening the efficient allocation of appropriate levels of resources to the service delivery level is a priority. The dependence on OOP spending for health care means that the implementation of social health protection measures is crucial.