Moving toward UHC Cambodia NATIONAL I N I T I AT I V ES, KEY CHALLENGES, AND THE ROLE OF COLLABORATIVE ACTIVITIES Moving toward UHC: Cambodia Cambodia’s snapshot 1 Cambodia’s snapshot Existing national plans and policies to achieve UHC 2 52+48+C Key challenges on the way to UHC 4 UHC Service Coverage Results of Joint External Evaluation Collaborative efforts to accelerate progress toward UHC 6 Index (SDG 3.8.1, 2015) of core capacities for pandemic preparedness (JEE, 2016) 52% References and definitions 8 Score (for capacity) # of indicators (out of 48) 5 Sustainable 0 4 Demonstrated 6 Catastrophic OOP health expenditure incidence at the 10% threshold 3 Developed 14 (SDG 3.8.2, 2009) 2 Limited 22 10.7% of households 1 No capacity 6 Health results Performance of service delivery – selected indicators LMIC Maternal Mortality Under-Five Mortality (PHCPI, 2014-2015) Cambodia average Ratio (WHO) Rate (WHO) Per 100,000 Live Births Per 1,000 Live Births Care-seeking for symptoms of pneumonia 68.8% 61.5% 1020 Dropout rate between 1st and 3rd DTP vaccination 3.3% 7.5% 161 Access barriers due to 117 treatment costs 64.4% 47.4% 29 Access barriers due to distance 35% 35.8% 1990 2015 1990 2015 70 (SDG target) 25 (SDG target) Treatment success rate for new TB cases 93% 80.1% Life Expectancy Wealth Differential at Birth (WHO) in Under-Five Mortality (PHCPI, 2014) Provider absence rate NO DATA 28.9% Caseload per provider NO DATA 9 69 56.4 per day 58 Diagnostic accuracy NO DATA 47.9% More deaths in lowest than highest wealth quintile Adherence to 2000 2015 per 1,000 live births clinical guidelines NO DATA 33.6% See page 8 for References and Definitions. 1 Moving toward UHC: Cambodia Moving toward UHC: Cambodia Existing national plans and policies to achieve universal health coverage (UHC) SERVICE DELIVERY REFORMS HEALTH FINANCING REFORMS Cambodia remains a leading example of how Two major health financing initiatives have a low-income country can quickly advance endeavoured to address high out-of-pocket toward health goals; progress and innovation (OOP) spending: the Health Equity Fund in health financing and in service delivery Program (HEF), which aims to improve access contributed to the achievement of all health- to health services for the poor, and the newly related Millennium Development Goals. The developed Service Delivery Grants, a nationwide government is improving access to care performance-based financing scheme that through a larger health workforce, as well as by rewards delivery of technically sound quality improving the infrastructure of health facilities. health services at all levels of health facilities. There are continuing efforts to improve the Health coverage is expected to expand, with quality of health services, which encompasses social health insurance for the private formal preservice training, in-service training, an sector aiming to cover 1.2 million people ambitious performance-based financing through a mandatory contributory scheme. By program, and efforts to strengthen regulation. 2018, a new civil servants’ scheme (covering However, there is more that needs to be done in 235,000 beneficiaries) and a plan for informal order to accelerate progress and close remaining workers (over 2 million) will be launched, gaps in basic outcomes (including nutrition, increasing coverage to over 40% of the immunization, and neonatal mortality, population. especially with an equity lens to narrow health disparities) and lay the foundation to address GOVERNANCE REFORMS emerging issues such as pandemics and The government of Cambodia has made noncommunicable diseases (NCDs). Cambodia significant progress to elevate its status as has made progress on service delivery, but will a ‘lower-middle-income’ country thanks to need stronger efforts to reduce inequities in care sustained impressive economic growth. The due to geography and income. Strengthening objective of the Third Health Strategic Plan community services and capacity for health (HSP3) 2016–2020 is to build on the success of based budgeting in the health sector, and Progress and innovation
in protection and promotion, including outreach previous strategic plans to “effectively manage increasing levels of financial autonomy and services, as well as the role of community-based and lead the entire health sector to ensure greater funding for peripheral health facilities. health financing and in health workers and volunteers, are major areas that quality health services are geographically Performance-based top-up payments from service delivery contributed for further development. Policy to reorient and financially accessible and socioculturally Health Equity Funds (HEFs) are improving the the health system toward strengthening acceptable to all people in Cambodia.” The efficiency of overall health spending, leveraging to the achievement of all preventive and primary care and addressing National Social Policy Protection Framework underlying public sector investments in health. health-related Millennium social determinants of health is progressing, but (NSPPF) 2016–2025, an inter-ministerial New institutional sustainability measures, requires further investments. initiative, outlines the direction toward UHC. such as the recently created autonomous Development Goals. Ongoing public financial management reforms payment certification agency for HEFs, will include the implementation of a Financial provide strong governance support for critical Management Information System, program- institutional functions. 2 3 Moving toward UHC: Cambodia Moving toward UHC: Cambodia Key challenges on the way to UHC WEAKNESSES AND BOTTLENECKS for outpatient services, also remains low. antimicrobial resistance, Cambodia developed Performance-based top-up IN SERVICE DELIVERY Cambodians often choose to seek care in the an antimicrobial resistance (AMR) policy and Coverage of essential health services. Over private sector and practice self-medication. strategy to combat AMR in the human and payments from Health Equity the last two decades, health in Cambodia There are continuing efforts to improve the animal sectors. Laboratory capacity, surveillance Funds (HEFs) are improving has greatly improved. Maternal and neonatal training of health professionals, as well as a new data, and awareness amongst health care tetanus were eliminated in 2015. As of law of regulation (2016) of the five main health providers and the general public remain the efficiency of overall 2013, 93% of new tuberculosis cases were professions. Strengthening regulation in the challenges to combating AMR. health spending, leveraging successfully treated, and from 1990–2014, the private sector strives to ensure quality of care prevalence of tuberculosis decreased by 60% and enforce alignment with national standards THE STATE OF HEALTH FINANCING underlying public sector (WHO, 2015). In 2016, 82% of people living and practices. New performance-based Overall funding for health. Since 2006, investments in health. with HIV knew their status, and 80% of them financing through service delivery grants (SDGs) government spending on health has remained were receiving sustained antiretroviral therapy also entails administration of quarterly quality low, estimated at 1.0–1.5% of GDP (WHO Global (UNAID, 2017). However, important gaps persist, scorecards at each health facility. Health Expenditure Database—GHED, 2017), particularly for noncommunicable diseases though this has significantly improved during (NCDs), stunting, cancer, and viral hepatitis, Pandemic preparedness. A 2016 Joint 2015–17 and in the 2018 budget. In 2014, total concerted effort is needed to advance social among others. Persistent equity challenges are External Evaluation (JEE) of International expenditure on health (THE) per capita was health protection. evident—income disparities are prominent Health Regulations (IHR) core capacities US$61 (GHED, 2017) and the share of out-of- for antenatal care, postnatal care, and DPT3 found that Cambodia has either limited pocket payments was estimated between 62 and GOVERNANCE CHALLENGES vaccinations. Capacity challenges remain in the or developed capacity in most aspects 74% (NHA, 2014; GHED, 2016). The country Decentralization. Ministry of Health activities primary care system’s ability to provide basic of pandemic preparedness. The most remains dependent on external financing, just are structured in three tiers: provincial health and routine preventive services for NCDs, such critical areas of weakness—where there is under 20% of THE, and significantly higher for departments, special operating agencies as screening for cancer, diabetes, and high currently no capacity—are: development and the immunization, malaria, tuberculosis, and (assigned to operational districts and provincial blood pressure, even as the burden of NCDs is implementation of a national multi-hazard HIV/AIDS programs. hospitals), and service delivery facilities. growing. Rehabilitation, an essential part of the public health emergency and response plan; This allows for greater responsibility at the continuum of care, is limited due to a lack of mapping of priority public health risks and Lack of financial protection schemes. Less subnational level for promoting stronger services and resources. resources; various components of emergency than 20% of people in Cambodia have financial community orientation and monitoring the response operations; and an enabling protection for health, and accessing health delivery of health services. Although there Quality of care. Several factors affect the environment for management of chemical services is prohibitively expensive for much of is strong upward accountability, there has ability to deliver high quality care. There are risks. Areas of strength, where capacity is the population. More than 70% of women in the been insufficient articulation of autonomy at still limitations in basic health infrastructure: demonstrated but not yet sustainable are: IHR lowest income threshold and 40% in the highest subnational levels. The increased availability of the density of health workers is significantly coordination, communication, and advocacy income threshold cannot afford to access health funds at the decentralized level is a positive step lower than recommended thresholds, there is (which builds upon the successful inception services (OECD, 2016). Households with elderly but requires improved awareness and capacity low availability of hospital beds, and outreach of coordination mechanisms under the World members, or members with a disability or a building for health facilities to exercise core services have been particularly weak in the Bank’s Avian Influenza project); immunizations; chronic disease have high rates of catastrophic public financing management functions. The recent past. In addition, geographic and laboratory testing for detection of priority expenditure, emphasizing the need for country also needs to address risks associated economic barriers have precluded people, diseases; indicator- and event-based surveillance financial protection for these groups. Targeting with the decentralization process to ensure particularly women, from accessing health systems; and syndromic surveillance vulnerable groups is a priority for Cambodia, that this does not exacerbate inequities services. Utilization of HEFs, especially systems. In response to the rising threat of as outlined in the NSPPF 2016–2025, and a across provinces. 4 5 Moving toward UHC: Cambodia Moving toward UHC: Cambodia Collaborative efforts to accelerate progress toward UHC EXISTING INITIATIVES SUPPORTED Labour Organization (ILO) and UNICEF are PLANS FOR FUTURE the joint work will closely collaborate with BY EXTERNAL PARTNERS among the other key partners in this space. COLLABORATIVE WORK other investments in health, such as those by External partners are engaged in Cambodia the Global Fund and Gavi, to contribute to to build national capacity and strengthen To strengthen service delivery, there are several Policy and Human Resources Development health system strengthening. Considering that the health system. The Tokyo Joint UHC partner-supported initiatives within the Ministry (PHRD)-funded advisory support other sectors, such as nutrition and water and Initiative, supported by the government of of Health (MOH). H-EQIP is strengthening The joint work under the Tokyo Joint UHC sanitation, compose the foundations of heath Japan and led by the World Bank (WB), in equitable access to health services for vulnerable Initiative falls within two broad areas: for all, challenges in these fields also will be collaboration with the Japan International population groups. JICA is working with MOH strengthening pandemic preparedness and considered under the joint work. Cooperation Agency (JICA), the United Nations to expand service coverage for the informal strengthening the health system to more Children’s Fund (UNICEF), and the World sector. Health workforce development initiatives efficiently deliver services at frontline levels. Other planned activities Health Organization (WHO), is supporting include: a review of national curriculums for Activities related to pandemic preparedness The upcoming activities under the Tokyo the government of Cambodia, and strives to health professional qualifications, enforcement include: analytical work to inform the design Joint UHC Initiative aim to play a catalytic role accelerate progress toward UHC. This support of minimum standards of Health Training of multi-sectoral pandemic preparedness in jumpstarting the foundational activities will enable nationally-led strategic health Institutions (accreditation), and improved plans; developing evidence to support necessary to plug gaps in preparedness and system strengthening to achieve UHC, as well as tracking of in-service health professionals. investments in health security and a financing multi-sectoral coordination, and to support pandemic preparedness. Technical support is provided to produce plan for sustained investments in pandemic and follow up on priority actions identified in clear health center level guidelines to support preparedness and response; strengthening the the recent JEE. This work aligns with, builds Development partners are actively supporting appropriate and high quality primary care. framework for governance and institutional upon, and leverages ongoing World Bank UHC activities through the Ministries of The Disability Rights Initiative Cambodia arrangements; and strengthening multi-sectoral regional and national operations supporting Health; Economy and Finance; and Labour and (DRIC), a joint UN program with the Australian coordination and capacity for implementation. UHC, health systems strengthening (including Vocational Training, as well as the establishment government, is under way to ensure that persons through the GFF), agriculture/livestock, of the National Social Protection Council and with disabilities have an improved quality of life. Strengthening frontline service delivery will disaster risk management, and nutrition, as associated structures. Several multilateral entail: enhancing access to primary health well as the priorities of the government of partners operating in the domain of financing Initiatives are also under way to improve care to understand gaps and bottlenecks to Japan in supporting UHC. The work will be for social health protection are in the Providing monitoring and evaluation of health sector people-centered integrated services at the coordinated closely with key partners such as for Health Network (P4H), a local umbrella performance, including the production of primary care level; mainstreaming maternal WHO, the Asian Development Bank (ADB) and arrangement to maximize alignment through data for National Health Accounts and the and child health and nutrition services for JICA, and also complement ongoing activities active coordination and collaboration. The calculation of financial protection and essential UHC; and enhancing community engagement supported by other development partners Health Equity and Quality Improvement health service coverage indicators. In addition, in service delivery and outbreak surveillance. (USAID, the Centers for Disease Control and Programme (H-EQIP), the Korea International Cambodia is engaged with five other countries The government will receive support to Prevention (CDC), the UK Department for Cooperation Agency (KOICA), the German through the Malaria Elimination in the Greater address cross-border health issues, including International Cooperation (DFID), DFAT, etc.), Development Bank (KfW), the Australian Mekong Subregion Initiative to eliminate strengthening capacity in remote border the UN, technical agencies (e.g., WHO, the Department of Foreign Affairs and Trade malaria in Cambodia by 2025 and by 2030 in the areas at the primary care level and covering Food and Agriculture Organization, UNICEF), (DFAT), and the WB complement government region. Finally, a joint multi-sectoral National hard-to-reach populations, including ethnic and the private sector. funding through local Sector-Wide Management Action Plan for Antimicrobial Resistance will groups, migrants, and the poor. Among Mekong Arrangements. USAID, GIZ, JICA and UN also be developed. countries, cross-border coordination and agencies including WHO, the International collaboration will be strengthened. Furthermore, 6 7 Moving toward UHC: Cambodia References & Definitions (page 1 indicators) UHC Service Coverage Index (2015) – Life Expectancy at Birth (2000-2015), WHO/World Bank index that combines 16 Maternal Mortality Ratio (1990-2015), tracer indicators into a single, composite Under-five Mortality Rate (1990-2015) – metric of the coverage of essential health WHO Global Health Observatory: services. For more information: WHO/World http://apps.who.int/gho/data/node.home Bank (2017). Tracking UHC: Second Global Monitoring Report. Wealth Differential in Under-five Mortality (Single data point, year varies by country) Catastrophic out-of-pocket (OOP) health – Indicator used by the Primary Health Care expenditure incidence at the 10% threshold Performance Initiative (PHCPI) to reflect equity (Single data point, year varies by country) – in health outcomes. For more information: WHO/World Bank data from Tracking UHC: https://phcperformanceinitiative.org/indicator/ Second Global Monitoring Report (2017). equity-under-five-mortality-wealth-differential Catastrophic expenditure defined as annual household health expenditures greater than Performance of service delivery – selected 10% of annual household total expenditures. indicators (Single data points, years vary by country) – Indicators used by the Primary Health Results of the Joint External Evaluation of Care Performance Initiative (PHCPI) to capture core capacities for pandemic preparedness various aspects of service delivery performance. (2016/17, year varies by country) – A voluntary, PHCPI synthesizes new and existing data from collaborative assessment of capacities to validated and internationally comparable prevent, detect, and respond to public health sources. For definitions of individual indicators: threats under the International Health https://phcperformanceinitiative.org/about-us/ Regulations (2005) and the Global Health our-indicators#/ Security Agenda. 48 indicators of pandemic preparedness are scored using five levels (1 is no capacity, 5 is sustainable capacity). https://www.ghsagenda.org/assessments Photo credits: Page 3: Chhor Sokunthea / World Bank Co-authored by: 8