SRP Health and Social Policy
Researched and prepared by MP Son Chhay with the help of Dr. Christina Son
SRP Vision for a Social Health Care System:
All Cambodian citizens deserve the right to live a happy secure life with an emphasis on social well-being that includes access to equitable health care within a family, community and society that is self-sufficient in terms of access to water, sanitation and essential services, with potential to learn and participate in the management of their health issues using both acquired and traditional knowledge.
The SRP proposes the following key steps to reforming the current health care system under our Social Health Care Policy:
- To create a proactive health system that aims at promoting healthy living conditions by protecting safety of life and health, in terms of food safety and security, environmental and occupational safety, consumer protection and disease prevention. This will include targeted legislative reforms that address medicine fraud, sanitation, work conditions, controlled use of chemicals in food and so forth.
- To secure a system that will protect people’s health from the negative impacts of economic, social, and developmental activities, and to create an insurance system for the people to have access to quality health care with universal coverage on an equitable basis, particularly for the poor and underprivileged.
- To strengthen individuals, families, communities and society to have the potential for self-care and health promotion, using the learning and participatory approach. In the end preventative health approach is the best approach and it is important that all Cambodian people have the required level of knowledge to make informed health related decisions that affects their well being.
- To build a team of professional health care workers that are competent, properly paid and respect the objectives of their profession especially the Hippocratic Oath to practice medicine ethically and who can eventually become valued members of Cambodian society.
- To develop mechanisms for ensuring transparency in the government administrating the Health care system and including poverty alleviation. It is necessary to decentralise public health authority but a Public Health Administration authority should be properly set up under the Ministry of Health to undertake the responsibilities of developing a health care system to cater to the needs of all communities and to work with relevant non-government organisations in meeting the health objectives of specific communities, both public and private. In terms of monitoring public health care, a Public Health Ombudsman can be established to address complaints and ensure that hospitals and clinics are run to standard. The standards for public care will be established under legislative health measures.
Currently the health care system in Cambodia is facing serious challenges. Rebuilding the health system after the Khmer Rouge and what was, in effect, decades of neglect has been very slow. The Government continues to rely heavily on donor countries to assume responsibility for programs such as the Health Coverage Plan since 1996 and more recently, the Health Sector Strategic Plan 2008-2015. Such Plans, while they appear to be sincere attempts to meet the basic health care needs of Cambodian people through reconstructing and renovating facilities and through the provision of health care equipment and medical supplies are, in reality, severely constrained. As noted in a recent World Bank paper (Hardeman et al. 2004) there are serious obstacles in terms of successful delivery of such Plans in terms of accessibility and quality of care and many facilities remain under-utilised due to continuing corrupt practices within a poorly regulated government sector.
The fact is that the current Cambodian government, expenditure on health remains very low and government health staff to supplement their inadequate salaries resort to practices such as charging informal fees, diverting drugs, equipment and patients into private practices to the point where Cambodians themselves have little faith in their own health care system and are prepared to travel to other countries such as Vietnam and Thailand to seek the appropriate level of medical care.
The SRP believes that we need to urgently address this situation and therefore has prioritised to reform the current health care system as one if its key foundation policies. The proposed health and social policy, of course, would require more studies of both a qualitative and quantitative nature for a complete assessment of various options to explore in developing a sustainable and successful national health and social policy but it is clear that for any such policy to be successful it will need to attract the poor by providing them with more support and reducing their current ineligibility and access issues.
The purpose of this Policy Paper was to provide an overview of the current situation in Cambodia and to highlight key areas that need immediate focus due to the seriousness of the health issues.
B. Methodology used to provide information on Cambodia’s Health System
Surveys were conducted with commune councilors and provincial MP’s throughout Cambodia’s 18 provinces and its capital city Phnom Penh. The team was led by party whip MP Son Chhay with assistance provided by Mr. Keo Phirum and Mr. Seng Mardi. The work was undertaken over a period of several months in 2011. It is always difficult to obtain accurate and current information in Cambodia and access to government documents is severely limited hence the need for the SRP to personally undertake their own field evaluation to understand first hand the issues facing Cambodia’s poor in relation to health access issues.
C. Results and Discussion
The survey study yielded a number of concerns noted below. The most serious related to misconduct within the Public Health Care system:
1- No money no service. Implications for Cambodia’s poor are clear. Many of them cannot access basic health care because they are too poor. Through the survey study period it was found that most complaints were about refusal to treat patients who were unable to pay the fee in advance and many cases the patients were turned away or left to suffer or die. Chronic illnesses consequently were often left untreated.
2- Lack of expertise and medicine. Most hospitals are dirty and still lack qualified doctors, nurses and other medical staff. In many cases it was observed that there were few medical staff present during lunch times or at night at the health centres leading to a sense of physical insecurity in poor areas. All patients were forced to purchase their own medicines which were overpriced at the private clinics or chemists which were owned by the same staff who worked at the public health centre or hospitals providing evidence of inappropriate practices by staff. Most public hospitals and health centres have limited medicine other than paracetamol. Cambodian hospitals were not noted as ‘being clean’ or ‘having modern equipment’ or ‘patients recovering quickly’ as hospitals in neighbouring countries such as Vietnam.
3- Lack of code of ethics for health sector. Clear from the surveys that medical staff are benefitting financially from diverting medicines and equipment to their personal private practices. In addition, many staff treat poor patients with disrespect using abusive and rude language and even refusing to treat patients who are poor or unable to pay even during an emergency situation. In fact, it has become such a common practice to refuse medical treatment it has caused the Cambodian people to lose trust and confidence in the public health sector altogether and turn to unsubstantiated alternative treatments such as spiritual and traditional healing practices.
4- Extortion of money and illegal practices. It is clear that most poor villages have lost faith in government administrative structures and procedures that are still based on corruption and inequality. For example, with the Health Insurance Card system which was developed to benefit the poor, it is the commune chief who is given the power to subjectively identify the beneficiaries but, in effect, many poor families are rejected and the benefit is given to the commune chief’s family members instead. Even the poor who successfully obtain the Health Insurance Card are still rejected because they can not pay additional bribes. It is not enough to blame the situation on social and income insecurity alone, clearly the current system as it is being administered allows individuals to directly benefit from such corrupt practices but it is clear that the health sector needs to be better legally regulated to prevent illegal practices.
5- Fake and expired medicines. This has been a long concern. These are medicines that contain no active ingredient or the wrong one. Education programs to teach the public about these fake medicines are not enough. These fake medicines have been responsible for a number of deaths and have undermined health programs such as malaria eradication programs and caused further lack of confidence in Cambodia’s health care system. There clearly needs to be a quality controlled process for the distribution of medicines that must be registered and legal consequences for any manufacturer caught producing medicines that are fake or not of proper quality. The recent issue in Pakistan with Heart medicines containing malarial active ingredients that led to the death of potentially hundreds of recipients further illustrates the widespread nature of this concern in the region.
6- Ineffectiveness of health insurance card for the poor. This was verified in our survey although exact figures were difficult for us to obtain, Cambodia’s current CPP Government in a recent study noted that despite high health care cost relative to income only 14% of mothers held a Health Insurance Access Card exempting them from certain health care fees. Among most of concern was that 53% of mothers still have to pay for childhood vaccinations (UNICEF 2009) which undermines the success of any such program leading potentially to the failure of eradication of the disease globally.
7- Poor nutrition and lack of food. Poor health is clearly correlated with poor nutrition. Income insecurity leads to restrictions on food purchases and in the communes surveyed there were clear indications of under-nutrition. For example, garment factory workers have reported fainting while working that was found to be due to a combination of poor nutrition and poor working conditions.
8- Lack of shelter and decreased living areas. Social insecurity has often been expressed in terms of insecurity of land tenure (UNICEF 20009). The CPP Government however continues its practice to forcibly evict people from their homes through their ‘land acquisition concession’ policy leading to hundreds of thousands of people being left homeless and exposed to diseases such as malaria and typhoid.
9- Low payment for medical staff. Income insecurity also continues again in spite of recommendations that the Cambodian government ensure better wage conditions for public servants. Medical staff will resort to illegal practices to supplement their low wages, however many are working in areas where the average income in between $1 - $2 per day and where families are in a chronic state of financial insecurity subject to vagaries in the market place especially farmers, market sellers, taxi drivers, construction workers and garment factory workers. However, in spite of the poverty, many Cambodians will, if a family member is ill, desperately seek to attain the necessary funds including borrowing money and selling their belongings and medical staff exploit this fact.
10- Feelings of powerlessness and helplessness. Impacts on the overall psyche of the Cambodian poor. Cambodia’s poor feel they have little worth in their own country. It is not just access to health care but lack of land tenureship, access to sanitation and water. Many diseases in Cambodia are hygiene and water related which the people can not deal with but which they reasonably would expect their government to resolve but many communities in the surveys undertaken were observed to live in areas where rubbish was uncleared and there was a lack of proper toilets, and where standing water and mosquitoes were evident.
11- Mismanagement of Health budget and aid. International donors provide about two-thirds of the public spending on health and over the years have financed the construction of hundreds of hospitals and clinics. But money and buildings alone are not enough to overcome a culture afflicted by corrupt practices and mismanagement of funds. The WHO estimated that between 5 to 10% of the health budget in Cambodia disappears even before it is even paid by the Ministry of Finance to the Ministry of Health. But they found in countries where they have active policies targeting health reform and investigating corrupt practices results are dramatically reversed. (WHO Bulletin 2006)
The SRP policy proposes introducing a number of administrative and legislative reforms for a socially beneficial health care system. It is important to strengthen the decentralisation process to tackle the poverty problems where the Ministry of Public Health, as a government agency responsible for public health, needs to realign and readjust its administration to tackle current public health problems. It is not enough or even sustainable for any country to depend solely on NGO’s to take on the leadership and responsibility that the current government clearly still lacks. NGOs have an important role but they should be working closely with government administrative structures and policies not in place of them. It is important to distinguish that NGO’s form part of the private system which requires also regulatory controls and appropriate monitoring.
What is clear from our work was that any policy development within the Health portfolio can not be developed in a vacuum. Cambodia will need to consider a multifaceted approach to successfully reform the Health Care system along socio-economic guidelines that will include:
1. A strong macro-economic environment: is necessary for forming a social public health strategy. Since the economic situation reflects the well-being of people in the society, it also shapes the total health condition of people and their healthcare expenditures.
2. Legal reform: To realise an effective public-health system respective laws and regulations have to be in place. Government policies need to be accompanied by new laws and regulations specifically developed for Cambodia but modeling on the success of other nations such as Nigeria that successfully combated medicine fraud in their country.
3. Recognition of the important role of socio-cultural factors: Especially for a country such as Cambodia social condition and trends need to be carefully considered and understood when determining an appropriate social public health policy, especially those guiding the behaviour and attitude of the people. Therefore, in addition to having a global perspective, any planning at the provincial level or lower, needs to consider where appropriate local socio-cultural norms. This includes indigenous cultural practices, demographic distribution, social considerations and any other relevant considerations to create an equitable and just social health care system for the Cambodian People.