97572 Cambodia: Health Sector Support Project September 24, 2010 CAMBODIA HEALTH SECTOR SUPPORT PROJECT Improving Health Services for the Poor Overview The Health Sector Support Project, which started in 2003, aimed to improve both the accessibility and the quality of health services in Cambodia by rehabilitating, maintaining and constructing civil works, providing equipment, and funding improved drug quality and availability. Support has also been extended to the tuberculosis (TB), malaria, dengue fever and sexually transmitted infections (STIs)/HIV/AIDS programs. In addition, the project funds the oversight of policy, legislation and regulatory frameworks. In 2008, an estimated 2.3 million poor people were covered by the Health Equity Fund (HEF) schemes. The project’s support for national disease control programs contributed to reducing dengue fever outbreaks and the fatality rate and TB and malaria infection and mortality. Challenge MULTIMEDIA Some of the challenges facing Cambodia included significant health inequities among the socio-economic groups creating an impact largely on maternal and child health outcomes, considerable financial barriers to essential health services particularly for the poor, high out-of- pocket expenses and heavy reliance on donor funding. Cambodia’s health system has improved over the past decade. There has been a reduction in child mortality, HIV/AIDS, TB, malaria and vaccine-preventable diseases. The overall fertility rate has decreased substantially and life expectancy has improved. However, Cambodia still faces important challenges. There has been no improvement in maternal mortality (472 deaths per 100,000 births in 2005), access to sanitation and clean water remains inadequate, malnutrition is extensive (37 percent of children under five years of age are stunted), and chronic non-communicable diseases and injuries from road traffic accidents have increased. Significant inequalities in access to health services still exist between rich and poor and between urban and rural areas and all have high out-of-pocket expenditures. It is particularly difficult for the remote and rural populations to access health services. More Results Approach The International Development Association (IDA)-financed 2.3 Health Sector Support Project supported the government’s Health Strategic Plan 2003-2007. The project aimed to improve the health of poor people, particularly women and million children and predominantly in rural areas, through: the development of affordable and accessible basic number of poor Cambodians curative and preventive health services; covered by Health Equity Fund schemes the strengthening of institutional capacity to plan, manage, finance and implement health sector strategic policies and to manage resources effectively; MORE INFORMATION increasing the utilization of health services; and Cambodia and the World Bank Health in Cambodia controlling and mitigating the effects of infectious disease epidemics and malnutrition. Health Sector Support Project Feature: Health Equity Fund The project, which is scheduled to close in December 2010, Brings Medical Care to the Poor is being implemented jointly with the Asian Development Feature: Good Health Comes to Bank (ADB), the U.K. Department for International Chackrey with Smile Development (DFID) and the United Nations Population Fund (UNFPA). Results   In 2008, an estimated 2.3 million poor people were covered by the 50 Health Equity Fund (HEF) schemes. When 227,457 of them got sick during the year, they used the HEF schemes to pay for their health care. IDA supported 13 of the 50 schemes, and the others were financed by other development partners and the national budget. Ten remote districts contracted with non-governmental organizations (NGOs) for piloting the innovative performance-based contracting of health services, with co-financing from the ADB. An independent evaluation concluded that performance contracting through NGOs led to significant improvements in key health service indicators. Three referral hospitals, a training building for the National Malaria Center, an information center for the national AIDS authority and 18 health centers were constructed and six health centers were renovated by July 2010. About 240,000 people will have access to the health centers. The project’s support for national disease control programs contributed to reducing the impact of disease. The incidence of malaria in high-risk areas declined from 8.6 cases per 1,000 people in 2002 to 3.9 cases in 2008; the cure rate for tuberculosis increased from 89 percent in 2003 to 92 percent in 2009; and the fatality rate from dengue fever declined from 2.4 to 0.7 percent between 2000 and 2008. Six major studies were undertaken that provided new baselines for health policy development: the General Population Census of Cambodia (2008), the Anthropometric Survey (2008), the Equity and Development Report (2007), the Health Expenditure Tracking Survey (2007), the Poverty Assessment (2006) and a report on the 2005 Demographic and Health Survey. I am happy because I can bring my husband here for treatment. If I didn’t get support from the Health Equity Fund, I wouldn’t be able to bring him here. I hope he gets better soon. — Rith Roeung, 51-year-old mother of eight, whose husband was confined at the Battambang Provincial Referral Hospital Bank Contribution The project was financed through a US$16 million credit from IDA; two IDA grants totaling US$11.25 million, a US$1.84 million grant from the U.K. Department for International Development (DFID), and US$3 million in government counterpart funding. Partners As the lead agency, IDA works in partnership with six development partners. DFID, the Australian Agency for International Development (AusAID), the United Nations Children’s Fund (UNICEF) and UNFPA pool funds with the Bank, while the Agence Française de Développement (AFD) and the Belgian Technical Cooperation (BTC) provide parallel funds. UNICEF and UNFPA also maintain their own discrete funds. IDA manages US$80 million of the Multi-donor Trust Fund (MDTF) with contributions from DFID, AusAID and IDA’s US$30 million credit. The donors work through a partnership framework of joint annual reviews and common reporting mechanisms, and aim to align with the government planning processes. This is the first sector-wide flagship program with 22 donors active in 122 projects in the health sector. I will bring my wife here again for the baby’s delivery. I rely 100 percent on this center and I don’t want to take any risks by using a traditional birth attendant. — Som Vanny, 40-year-old farmer, who brought his pregnant wife for ante natal care at the Battambang Provincial Referral Hospital Moving Forward The Second Health Sector Support Program (HSSP2), which started in January 2009 to support the implementation of the government’s health strategic plan (2008-2015), aims to ensure improved and equitable access to essential quality health care and preventive services with special emphasis on women, children and the poor. The program continues to consolidate and build on the successes of the first project and: supports the expansion and improvement of existing health facilities; finances grants at the sub-national level to leverage improved performance and service delivery; strengthens health finance management with an emphasis on the social health protection of the poor and the disadvantaged; strengthens human resources planning and management in the public health system; and improves governance and stewardship of the sector. Internal contracting has been implemented in fifteen Special Operating Agencies (SOAs) through sub-national grants, improving service delivery and increasing the utilization of public health facilities. Under the program, access to health care services in remote and under- served areas has a special focus on improving maternal and child health, which are both off- track for the achievement of the Millennium Development Goals. Under the MDTF, the program also funds technical advisory services to deepen the policy dialogue and reforms in the areas of human resources, decentralization, health financing and governance. I was so pleased when I learned the Health Equity Fund would pay. We are safe. — Phoung Pha, 22-year-old mother of twins, who gave birth at the Battambang Provincial Referral Hospital