Cambodia is about to become a lower middle-income country. Significant
gains have also been made in the rebuilding of the health system through an
extended process of health reform beginning in the 1990s. Health status has
substantially improved since 1993. Mortality rates significantly dropped and
life expectancy at birth was 62.5 years in 2010, a 1.6-fold increase from 1980.
Cambodia is on track to achieve the Millennium Development Goal targets.
Since the beginning of the reform, the Ministry of Health (MOH) has
increasingly assumed the leading role in health-system planning and
development, in partnership with the development agencies. The MOH
is solely responsible for the organization and delivery of government
health services, through 24 MOH Provincial Health Departments, 81
health Operational Districts each with a Referral Hospital delivering a
Complementary Package of Activities, and a number of Health Centres
providing a Minimum Package of Activities.
Reforms in health service management and administration are being
implemented. A first step is the conversion of almost one third of all health
Operation Districts to the status of Special Operating Agencies, which enjoy
a greater degree of autonomy in human resource and financial management
and receive additional funds through a direct Service Delivery Grant. The
conversion is to provide greater management autonomy, increased staff
incentives and more efficient service delivery.
The Cambodian health market has a wide variety of health-care providers.
The emphasis placed on economic growth has not been fully reflected in
government support to the development of the social sectors, including
health care. One consequence has been the rapid growth of a disparate and
loosely regulated but extensive sector of private health-care providers. While
the public sector is dominant in the promotion and prevention activities
for essential reproductive, maternal, neonatal and child care health, and
major communicable diseases control, the private practicitioners remain
particularly frequented for curative care. According to the 2010 Cambodian
Demographic and Health Survey., only 29% of unwell or injured patients
sought care first in the public sector, while 57% sought care for their last
episode at private providers.
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While government funding for health care has increased significantly, it
remains at only 1.4% of GDP. Official development assistance is stable
at 15–20% of total health expenditure. The out-of-pocket payments
provided 61% of the total health expenditure. National data indicate that
the overwhelming proportion of out-of-pocket expenditure is paid to
private providers. A number of demand-side financing schemes provide
social health protection, including Health Equity Funds, voucher schemes,
voluntary community-based health insurance and (to a small extent)
private health insurance.
An ongoing process of national health reform began in the 1990s. Reform
has been guided by a long-term process of national health planning. The
most recent is the Health Strategic Plan for 2008–2015. Development
partners have helped collectively to shape health policy-making, in
support of MOH objectives outlined in the Health Strategic Plans. Recent
health reforms have focused on strengthening the MOH’s capacity to
manage health-service delivery. Providing access for the poor is at the
heart of health reforms.
The longer-term health system aim is to move towards universal
coverage. There are a number of challenges remaining.
Achieving the goal of universal coverage requires improved collection
and use of health care data and a long-term view. The improvements in
government commitment to health need to be maintained. The heavy
reliance on out-of-pocket spending must decline. The adoption and
effective implementation of the draft Health Financing Policy is the first
important step.
Donor support is essential, but greater alignment of donor programmes
to the national priorities is needed. This is also important when the period
of piloting and experimentation, particularly in the supply of services and
health financing area, is over.
Health-system policy needs now to return to strengthening the supply
side. Improving the quality of care is now the most pressing need in
health-system strengthening. In the public sector this requires attention
to funding, management processes and the remuneration of public-sector
workers. For the private sector, it poses the immediate necessity for
extended regulation, accreditation and enforcement.