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NGO Statement, 2000 Consultative Group Meeting On Cambodia


 HEALTH

TABLE OF CONTENTS


NGO Statement to the 2000 Consultative Group Meeting on Cambodia

- Home.................................
- About us.............................
- Message.............................

- Introduction........................
- Progress.............................
- Good Governance................
- Human Resource 
- Development
......................
- Reaching the Poor...............
- Conclusion..........................

Sectoral Papers..................

- Agriculture..........................
- Child’s Rights....................
- Commune Administration 
- and Decentralization
............
- Commune Elections..........
- Disability and Rehabilitation..
- Education............................
- Fisheries.............................
- Forestry Reform..................
- Gender and Development.....
- Good Governance................
- Health...............................
- HIV/AIDS...........................
- Human Rights......................
- Landmines..........................
- Land Reform.......................
- Microfinance........................
- Weapons Reduction.............

General NGO Information...

References.........................

 

 

 

 

 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


INTRODUCTION

NGOs are active at all levels of the health system, from the central ministry level down to the village and community level. They are working with all populations throughout the country - from hill tribe populations to rural peasants, to urban squatters. NGOs are therefore well placed to observe the impact of health care delivery on the Cambodian population. NGOs active in the health sector seek to use this knowledge and experience to provide feedback from the field straight to the central policymakers, thanks to the openness of the Ministry of Health (MoH) and to the MEDiCAM network. NGOs note a genuine will from the MoH to respond to well-recognized priorities such as maternal mortality, immunization, malaria, tuberculosis etc. Since the last Consultative Group (CG) meeting in 1999 NGOs also have noted an improvement in the level of funding available for delivery of health services. Pilot programs such as the Basic Health Services project funded by the ADB appear to be providing valuable lessons for the future direction of the health sector in Cambodia. Since 1996, the Royal Cambodian Government embarked on a Health Sector Reform program that is widely supported by external donors. Much has been accomplished since then. Yet, access by the poor to quality health care still remains a major challenge to meet, in a public sector where health professionals still receive a salary so meager that it does not even cover their families' basic cost of living.

As detailed in the 1999 MEDiCAM Position Paper, health services are one of the main causes of indebtedness of the poor and vulnerable in Cambodia; this indebtedness often leads to irreversible poverty. One year on MEDiCAM observes a continued boom of unregulated private clinics, but only very limited progress towards the goal of "equal access to quality health care". MEDiCAM also observes an urgent need to deal with the growing crisis in the public health system.

KEY ISSUES

Transparency
MEDiCAM notes a significant improvement in the relationship between the Ministry of Health (MoH) and the Ministry of Economy and Finance (MoEF) over the last twelve months. We also note some improvement in financial transparency by the MoH. However, no progress on transparency within the MoEF was observed. Specific concerns on transparency include:

  • The MoEF still does not share with the MoH the monthly decree on the amount of funds allocated per province, despite last year's commitment to do so. This lack of information makes it more difficult for the Health Managers to access these budget chapters, managed by civil servants from MoEF. This problem continues to dominate the credit available for Chapters 10 (salaries) and 11 (running costs, including patient food)
    n Health managers are asked to sign receipts for amounts higher than actually received,

  • Despite last year's Reform promises, the greatest part of the health budget, even operational expenditures, is managed and spent by civil servants from the MoEF instead of MoH.

  • Under-the-table payments reportedly continue (even where official user-fee schemes operate),

  • Drug procurement remains non-transparent; the private monopoly provider may be charging the government up to 60% more than international market prices.

Under-funding of the health sector
Present trends on RGC expenditure indicate there was no significant shift from the defense/security budget to the social sector, with the percentage of GDP expended on health decreasing. In May 1999 health staff were granted a 30% rise of salary, but given the already unacceptably low salary a 300% increase is actually required. Concerns on under-funding of the health sector are linked to transparency. In other words, more funding needs to go hand in hand with real reform. The one and only exception to this is the Chapter 13 (ADD), managed by the MoH itself, which is cut systematically by up to 3 percent by civil servants from the MoEF.

Ethics and Standards
Unethical practice and poor standard of care is a serious issue in the health sector in Cambodia, often with life-threatening implications. 
Concerns include:

  • Under-the-table "registration fee" students reportedly have to pay to enter the faculty of medicine and the subsequent reimbursement of this "loan"

  • Institutionalized corruption and private practice by public health staff, arising from unrealistic low salaries, leading to unethical practices

Such practices occur in a general context of low skills, lack of laws and regulations, bad prescribing practices, lack of political will from the MoH to seriously investigate reported unethical practices, absence of any self-regulatory medical council, and absence of good role models at the highest level.

User fees & equity of access
MEDiCAM believes that in general user fee schemes are almost always seriously flawed, with ineffective exemption schemes resulting in an even reduced access to health care by those who cannot afford to pay. First hand observations in the field indicate that equity of access has not improved with the introduction of user fees, indeed to the contrary. 

Laws and regulations in the health sector
MEDiCAM supports the current government's initiatives to establish a supreme council of doctors ("Ordre des Médecins"). However, MEDiCAM has additional concerns, which include:

  • Current lack of enforcement of existing laws and regulations on drug safety, quality control and on the serious problem of fake drugs

  • Licensing of pharmacies is not enforced and the taxes levied from them are not related to any health authorities control

  • No control of the private medical sector, often leading to dangerous practices with no peer scrutiny or criminal sanctions

  • Lack of health professionals' self-regulatory bodies and an urgent need to set clear minimum standards of care and competency

Human Resource Development
MEDiCAM is concerned at the low priority placed on human resource development (HRD) and training by senior MoH officials, reflected in seriously under-resourced HRD functions and a lack of recognition of the paramount importance of the training component of the health sector reform. Trainers in many instances do not have sufficient competency for their key role. There is also a lack of quality training in the medical school, practical training is poor with training rooms and laboratories poorly equipped or non-functioning. There is an intractable 'log jam' in the deployment of staff with continued unequal geographical distribution. It is also felt that the nurse training is not adapted to remote areas.

Public and Private sectors roles
As outlined in the MEDiCAM 1999 Position Paper, the public and the private sectors are intimately linked, but operating on a very unequal basis. NGOs observe this unfair relationship, leading to declining confidence in the public health system, to the growing advantage of a private sector which has little regard to those who cannot pay. While the commercially-driven private sector often provides poor quality and expensive health care, within an unregulated laissez-faire environment, the public sector is battling to provide quality services with restricted budgets. One important factor is that the mandatory public health MPA package is seen as unattractive to consumers and too limited for their actual needs.

RECOMMENDATIONS

In order to address these key issues, we urge the Royal Government of Cambodia and donors to:

Transparency

  • Address issues relating to transparency, and at a minimum pursue the essential question of transparency

  • Provide more appropriate technical assistance to the government, especially to the Ministry of Economy and Finance to develop and implement a more transparent system

  • Demonstrate greater political will and leadership on transparency and financial reform, including giving management responsibility over the health budget to staff from the Ministry of Health

  • Expose corruption, overpricing and illegal activities and tackle accordingly

  • Link increased donor funding to increased transparency and good governance.

Under-funding of the health sector

  • Donors continue to lobby the RGC for the "peace dividend" to be channeled from defense/security to the social sector.

  • Provide a new impetus to reform of the health sector, justified by the far-reaching consequences of under-funding and "second-priority" status

  • Widely recognize that the cost of health care is currently the main impoverishing factor in Cambodia

  • Continue Chapter 13 (ADD) but with 100 percent, instead of 97 percent, through the Ministry of Health.

Ethical Standard

  • Clearly establish a professional code of conduct for public health staff, which will be promoted, monitored and enforced

  • Encourage health sector leaders to be positive role models

  • Give high priority to the establishment of a professional regulatory body 

  • Investigate and take subsequent legal action, including criminal sanctions, against those conducting unethical practices

  • Widely promote compassion and ethical values amongst health care professionals

User fees and equity of access

  • Health facilities should not be responsible for the financial burden of providing health care for the poor

  • Ultimate responsibility for adequate funding rests with the RGC

  • Consider intermediary measures involving external (donor) support for an exemption scheme.

  • Conduct further studies on "who will pay and how?", the impact of the "cost recovery" on the poor, performance of existing user fee schemes, existing formal and informal "social funds" in the Cambodian community and the possibility to develop alternative social funds.

Laws and regulations in the health sector

  • Ensure that the supreme council of doctors, once established, functions in an open, trans- parent and public manner

  • Establish self-regulatory professional bodies to regulate other health professions

  • Develop and widely support strong consumer associations in parallel to the establishment of such professional bodies. 

  • Finalize debate at the National Assembly on new laws on medical regulation as soon as possible

  • Prohibit pharmacies from selling or renting their licenses

  • Enforce laws and regulations on drugs, and increase capacity and power granted to MoH

  • Prohibit directors of public hospitals and health departments from engaging in conflicting commercial interests

Human Resource Development

  • Provide Incentives for staff asked to work in remote locations

  • Increase opportunities (notably by modifying entry criteria) for students from remote areas

  • Recognize the acute need to train health managers, notably at the district level (raised in 1999 paper)

  • Cut "ghost" staff from the payroll, raising salaries of remaining staff

  • Augment support provided to Regional Training Schools 

  • Donors continue work with the Ministry of Health to provide technical assistance, equipment and materials for medical training

  • Urgently reform the enrolment and graduation of medical students to be merit and performance based, removing all forms of corruption and nepotism.

Public and Private Sector Roles
n Promote debate between all health stake- holders on the current MPA package including; MPA definition, limitations, the possible need to be more client-centered, or other possible alternatives to render the public health sector more competitive

  • Increase efforts to promote consumer awareness for expectations on quality health care

  • Regulate and enforce the private sector requiring minimum best practice standards

  • Consider the health sector as a whole, including open recognition of the impact of existing conflict of interest in addressing the public/private issue. 

MEDiCAM is an umbrella organization representing some one hundred NGOs active in the Cambodian health sector. This position paper has been prepared and authorized by the elected MEDiCAM Steering Committee, with support from the MEDiCAM Secretariat. The observations represented in this paper arise from direct experience by NGOs with extensive long-term knowledge of the Cambodian health sector.


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