20.06.2014 Health Care in Cambodia – More Than Money and Medicine Prof. Dr. Steffen Fleßa Universität Greifswald Contents 1. Country profile 2. Social and Health Care Sector 1. Health Care Provision 2. Epidemiology 3. Service Provision 3. Health Care Financing 1. Overview 2. Health Financing Policy Draft 4. Health-oriented Development Work 1. Linkage Schemes 2. NCDs 3. Current Problems 5. Future Developments Health Care in Cambodia 1 20.06.2014 Contents 1. Country Profile 2. 3. 4. 5. 1. 2. 3. 4. Geography History Religion Economy Social and Health Care Sector 1. 2. 3. Demography Epidemiology Service Provision 1. 2. Overview Health Financing Policy Draft 1. 2. 3. Linkage Schemes NCDs Current Problems Central foundation of health care is not medicine, but historical pathway, population, culture and economy. Health Care Financing Health-oriented Development Work Future Developments Health Care in Cambodia Cambodia Nation – Religion - King Health Care in Cambodia 2 20.06.2014 Cambodia • Size: 180,000 sqkm • • • (=1/2 Germany) Population: 14 Million (= 76 p. sqkm) Tribes: 90% Khmer, 5% Vietnamese, 1% Chinese The “micracle of Tonle Sap” Health Care in Cambodia 1.2 History: A proud nation • Angkor – from 802 to 1471 AD mightiest kingdom in S.E. Asia – Tonle Sap and Rice-Planting Culture – destroyed by Siam – but the pride is still there. – Hindu-Temple World Heritage Health Care in Cambodia 3 20.06.2014 Angkor Wat Health Care in Cambodia French Indochina • 1859: French protectorate • • • • to avoid Thai and Vietnamese invasion 1887: “Union of Indochina” (Vietnam, Laos, Cambodia) Little colonial interest (except for some farmers, e.g. pepper) Japanese invasion, unrest Independence 1954 1886 Health Care in Cambodia 4 20.06.2014 Vietnam War • Vietnam war: 1965-1975 • Ho-Chi-Minh-Path and camps of Vietminh: – “Secret bombing” – Ground incursion: 1970 – U.S. air operations continued in Cambodian into 1973. President Richard Nixon explained the April 1970 incursion of U.S. ground forces into Cambodia in terms of a future withdrawal from SEA. • 1970: USA support revolution against Sihanouk – Start of „Tragedy of Cambodia“ Health Care in Cambodia Khmer Rouge • 1975-1979: Communist rulers – Leader: Pol Pot – Backing: China • 15-30% of population died (killed, starved) – “Cleaning” of towns – “Cleaning” of intellectuals • Civil war until 1998 Health Care in Cambodia 5 20.06.2014 Further Development • 1975-1989: Vietnam invasion, occupation – – – – Khmer attacks on Vietnamese in border areas Vietnam: Russia-backed Khmer Rouge: China-backed Guerrilla action: Khmer Rouge took refuge in the jungle along the Thai border • 1989-1991: Civil war, fighting until 1998 • 1991-1993: Ceasefire and “United Nations • Transitional Authority” (UNTAC) Since 1993: stepwise development towards democracy and market economy Health Care in Cambodia Consequences • At the end of wars Cambodia had lost about half of its population. • The country is plotted with land mines. – 35,000 lost disabled – 500-800 casualties annually – Several thousand victims annually • There was nobody who was no victim or deliquent – Younger population: there is nobody who has lost a close relative • Cambodia is a play-ground for different countries – E.g. Khmer-Soviet Friendship hospital – E.g. Bank of China – … Health Care in Cambodia 6 20.06.2014 Current System • Constitutional Monarchy – God-King Norodom Sihamon – Prime Minister Hun Sen • Cambodian People's Party • Market Economy: – strongly China-driven King Norodom Sihamon Prime Minister Hun Sen Health Care in Cambodia 1.3 Religion • Buddhism Health Care in Cambodia 7 20.06.2014 Theravada Buddhism • Oldest form of Buddhism – relatively conservative • Features in Cambodia – – – – – – Animism and syncretism Importance of God-King and monks Importance of “spirits” Prevention and “spirits” Insurance and “spirits” Fate and punishment Health Care in Cambodia 1.4 Economy • GDP (2012, PPP): – $36.59 billion – Country comparison: No. 108 • GDP - real growth rate: – +6.5% – Country comparison: No. 31 • GDP p.c. (PPP): – $2,400 – Country comparison: No. 184 – Least Developed Country Health Care in Cambodia 8 20.06.2014 Sectors GDP Labour Agriculture 35% 58% Industry 24% 16% Services 41% 27% Health Care in Cambodia Health Care in Cambodia 9 20.06.2014 Current Situation • Garment factories and the fight for “fair” salaries • Influence of China • Cash crops or food crops? Health Care in Cambodia Poverty Health Care in Cambodia 10 20.06.2014 Poverty Health Care in Cambodia Poverty 100 90 80 Income [%] 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 80 90 100 Population [%] Health Care in Cambodia 11 20.06.2014 Development of Poverty Health Care in Cambodia Summary • The historical pathway, its culture and economy are unique. • Every health care system or development aid that does not take this uniqueness into account is due to fail. Health Care in Cambodia 12 20.06.2014 Contents 1. Country profile 2. Social and Health Care Sector 1. Demography 2. Epidemiology 3. Service Provision 3. Health Care Financing 1. 2. Overview Health Financing Policy Draft 1. 2. 3. Linkage Schemes NCDs Current Problems 4. Health-oriented Development Work 5. Future Developments Health Care in Cambodia 2.1 Demography • Median age: 23.3 yrs. • Life expectancy: 63 yrs. • Population growth: 1.7% • Birth rate: 25/1000 • Total fertility rate: 2.8 children/woman • Death rate: 8.0/1000 • Migration: -0.33/1000 • Urbanisation: 20% • Prime City: Phnom Penh (1.5 mio.) Health Care in Cambodia 13 20.06.2014 Population Density Health Care in Cambodia Health Care in Cambodia 14 20.06.2014 Health Care in Cambodia Health Care in Cambodia 15 20.06.2014 Health Care in Cambodia 2.2 Epidemiology Burden of Disease in Cambodia (2004) Condition Death [‘000] DALYs [‘000] Communicable, maternal, perinatal and nutritional conditions 83 2903 Noncommunicable diseases 58 1724 Malignant neoplasms Diabetes mellitus 11 3 169 39 Neuropsychiatric conditions 3 451 Cardiovascular diseases 24 361 Ischemic heart disease 8 121 Cerebrovascular disease 7 91 6 5 132 122 150 5003 Respiratory diseases Digestive diseases Other Total Health Care in Cambodia 16 20.06.2014 Cancer in Cambodia Health Care in Cambodia Under 5 mortality down sharply, neonatal mortality only modestly 140 Malnutrition persists, despite strong economic gains 50 45 120 40 100 35 30 80 25 60 20 40 15 10 20 5 0 Neonatal mortality 2000 Infant Mortality 2005 Under-Five mortality 2010 0 Stunted Source: CDHS 2000, 2005, 2010 2005 Wasted Underweight 2010 Source: CDHS 2000, 2010 Health Care in Cambodia 17 20.06.2014 Continued inequalities in infant and child mortality within Cambodia 180 160 140 120 100 80 60 40 20 0 Source: CDHS 2010 child MR Health Care in Cambodia infant MR 2.3 Service Provision • Health Centre – no beds – Staffing: 3-6 – Population: 5-10,000 Health Care in Cambodia 18 20.06.2014 Health Facility Health Care in Cambodia Hospitals • Hospital (Level II) – 80-200 beds – Staffing: 100-200, incl. doctors – Population: 50250.000 – NB: • 1 hospital bed for 10.000 • 1 doctor for 5000 Health Care in Cambodia 19 20.06.2014 Hospitals • National Hospital (Level III) – Only in Phnom Penh – Training Institutions – Highly specialised • Kantha Bopha (Beat Richner) Health Care in Cambodia Private providers are most frequently consulted for health care 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Source: CSES 2009 Urban Rural Health Care in Cambodia 20 20.06.2014 Health Equity Funds • Content – Input-Based Financing of Government Health Care Facilities • Problem: no incentive • Solution: User-Fees 1996 • Disadvantage: How to exempt the poor? – HEF: 2000 Ir, P. et al. (2010):Translating knowledge into policy and action to promote health equity: The Health Equity Fund policy process in Cambodia 2000–2008, Health Policy Health Care in Cambodia Financing Alternatives HEALTH CARE FINANCING Output-Based Financing Input-Based Financing Needs Combination Financing Admissions Buildings Grants Population Beddays Equipment Beds DRGs Materials Services Rebates Staff Other 21 20.06.2014 Input-based Financing Client Service Provider service Complete input MoH HEF Client Present certificate Service Provider service ID-Poor claim Reimburse ment according to services MoH Donors 22 20.06.2014 HEF Health Care in Cambodia Main problems of Cambodian health care system • Quality of staff – Training of doctors! • Availability of drugs • Transport • No quality control of private providers • Traditional medicine: mainly lost Health Care in Cambodia 23 20.06.2014 Contents 1. Country profile 2. Social and Health Care Sector 1. 2. 3. Demography Epidemiology Service Provision 3. Health Care Financing 1. Overview 2. Health Financing Policy Draft 4. Health-oriented Development Work 1. 2. 3. Linkage Schemes NCDs Current Problems 5. Future Developments Health Care in Cambodia 9 Most health spending is out-ofpocket; catastrophic expenditures have declined, but remain high 8 % catastrophic expenditure 7 6 5 4 3 2 1 0 1 2 3 4 5 Wealth Quintile 2004 2009 Source: CSES 2004, 2009 Health Care in Cambodia 24 20.06.2014 Government and donor health spending have increased sharply in nominal terms 250.000 US $000 200.000 150.000 100.000 50.000 0 2000 2001 2002 2003 ODA 2004 2005 2006 2007 2008 2009 Government Source: CDC 2010, MEF TOFE provisional data 2009Health Care in Cambodia Government health spending is increasing per capita and as % of GDP and % of budget 12% 10 9 10% 8 US $, per capita 7 8% 6 6% 5 4 4% 3 2 2% 1 0% 0 2000 2001 2002 2003 Health spending per capita 2004 2005 2006 % of GDP 2007 2008 2009 % of budget Source: MEF & World Bank Estimates Health Care in Cambodia 25 20.06.2014 Budget allocations to hospitals are linked to beds, but not to outputs 800 700 600 US $ 500 400 300 200 100 0 Ang Daung Calmette Khmer-Soviet Kossamak Gov't Budget/bed per month National Pediatric KBH/Javav. 7 Gov't Budget/discharge Health Care in Cambodia Spending on drugs & medical supplies is more than double wage outlays 140 120 100 80 60 40 20 0 2004 2005 2006 2007 2008 2009 Drugs and medical supplies Programmes of action (ADD & PAP) Operating costs (excluding drugs) Salaries Health Care in Cambodia 26 20.06.2014 Pharmaceutical spending continues to increase, but drug stockouts persist 90 14 12 70 10 60 50 8 40 6 30 4 Stockout percentage Expenditure USD million 80 20 2 10 0 0 2001 2002 2003 2004 2005 Expenditure 2006 2007 2008 2009 2010 2011 Reported stock-out at facilities Source: MEF budget data; MOH HIS Health Care in Cambodia 3.2 Health Financing Policy • NSSF: National Social Security Fund – For Wage-earners – Start 2014? • NSSF-C: National Social Security Fund for Public Servants – For public servants – Rejected by Government • Informal sector – Voluntary Health Insurance? • Political process? Health Care in Cambodia 27 20.06.2014 Political Process • 4-K framework Health Care in Cambodia Contents 1. Country profile 2. Social and Health Care Sector 1. 2. 3. Demography Epidemiology Service Provision 1. 2. Overview Health Financing Policy Draft 3. Health Care Financing 4. Health-oriented Development Work 1. Linkage Schemes 2. NCDs 3. Current Problems 5. Future Developments Health Care in Cambodia 28 20.06.2014 Aid Aid Humanitarian Development Individual Capacity Infrastructure Organisational Development Systems Development Health Care in Cambodia - Health MoH + Poverty + - Standardisation vs. fragmentation + Quality of Care + Utilization - Lower friction between operators - - Discrimination - Foundation for comprehensive social protection system Management of Provider + - Concentration on one operator + - Members Household Costs Quality Incentives + + + + Linkage + Pay-forperformance HEF CBHI + - Efficiency - + Health Care in Cambodia Administrative Cost 29 20.06.2014 Developments of Linkages 30000 Kampot No. of members 25000 20000 15000 10000 5000 0 Jan 12 Apr 12 Jul 12 Okt 12 Apr 12 Jul 12 Okt 12 Okt 11 Jul 11 Apr 11 Jan 11 Oct‐10 Jul‐10 Apr‐10 Jan‐10 Oct 09 Jul 09 Apr 09 Jan 09 Jan 12 Time Health Care in Cambodia Voluntary members Subsidized (HEF) members 90000 Total members Kampong Thom 80000 70000 No. of members 60000 50000 40000 30000 20000 10000 0 Jan 09 Apr 09 Jul 09 Oct 09 Jan‐10 Apr‐10 Jul‐10 Oct‐10 Jan 11 Apr 11 Jul 11 Okt 11 Time Health Care in Cambodia Voluntary members Subsidized (HEF) members Total members 30 20.06.2014 Relative coverage of population of operational district 25% Kampot 20% 15% 10% 5% 0% Jan 09 Apr 09 Jul 09 Oct 09 Jan‐10 Apr‐10 Jul‐10 Oct‐10 Jan 11 Apr 11 Jul 11 Okt 11 Jan 12 Apr 12 Jul 12 Okt 12 Time Voluntary members Subsidized (HEF) members Total members Health Care in Cambodia Coverage of Population of Operations District 35% Kampong Thom 30% 25% 20% 15% 10% 5% 0% Time Voluntary members Subsidized (HEF) members Total members Health Care in Cambodia 31 20.06.2014 4.2 NCDs • Disease Management Standard Risk Factor Analysis Risk Group Laboratory Testing Urine Sugar Screening Second-Line Treatment Blood Sugar Screening First-Line Treatment Treatment of Complications Drugs Insulin Health Care in Cambodia - VIAScreening + Pre-cancerios lesion Surgery + Pap-SmearScreening Cancer Radiotherapy successful Not successful Target Population Cryotherapy - Chemotherapy Health Care in Cambodia 32 20.06.2014 Current Problems Planning and Implementation of Pilots Operational Research Scientific Research Report Scientific • Convince Government GIZ report, Technical Brief Development Policy Brief Political Provide Policy Advise Political and Personal Health Care in Cambodia Improved Concept New Concept Operational Evidence Operational … Feed in Policy Process Implement Scientific pilot Feed in Policy Process Improve Scientific pilot Rejection Scientific Develop pilot Adaption Scientific Need to adopt Health Care in Cambodia 33 20.06.2014 5. Future Development • Economic development: “young tiger” • But: “much more than money”: absorption capacity is very limited • “Much more than medicine”: – traditional believes make insurances and prevention difficult • “A tortured nation with strong inequality”: Revolutionary potential? Health Care in Cambodia • “„If we, as health workers, or teachers, or students, or civil servants do not feel that we, and the groups or organisations we belong to, have some power to alter policy that affects our lives, or the lives of those around us, why get up in the morning?“ (Gill Walt 1994). Health Care in Cambodia 34
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