1

High Level Policy Dialogue – Cambodia

Towards a Strong and Sustainable Health Sector Development

(2016-2020 Health Strategic Plan)

24 June, 2015Cambodia

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Towards a strong and sustainable health sector development

Proposed agenda• Introduction (20 minutes)– Brief welcome by the Minister (MOH)– Purpose and introduction (WPRO-Regional Director)

• Current situation and challenges (40 minutes)– Presentation (WHO) – Discussion

• The way forward (60 minutes)– Presentation (WHO)– Discussion (start with remarks by WPRO-RD)

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Outline

• Current situation and challenges– Cambodia’s significant progress in

improving population health–Health system challenges and donor

funding• The way forward– Increase domestic funding–Use the funding more efficiently

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CURRENT SITUATION AND CHALLENGES

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Cambodia’s achievements

• Cambodia is on track to achieving all MDG goals (improvement in Maternal and child health, HIV, TB and Malaria)

• Life expectancy increased 55 years to 72 years between 1990 and 2013

• Measles elimination - Immunization coverage of measles reached 93% (2014)

• Skilled-birth attendants reaching 89% (CDHS, 2014)

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Health MDGs scorecard for LMICs in the Western Pacific Region (2014)

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Overview of health financing

• Health expenditure per capita - USD 70

• Total health expenditure as % of GDP - 7.2%

• High out-of-pocket payment

• Heavy reliance on donor funding

• Low government spending on health

Source: Cambodia NHA Report 2014

Sources of funding, 2012

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Total health expenditure (%) GDP selected countries, 2012

Note: OOP = out-of-pocket health expenditure; GGHE = General Government Health ExpenditureSource: Cambodia NHA Report 2014, WHO Global Health Expenditure Database (WHO, 2014)* For Cambodia, GGHE does not include donor funding. Donor funding is included in ‘other%GDP’.

Myanmar Lao PDR Indonesia Philippines Thailand China Viet Nam Cambodia0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

GGHE % GDP OOP % GDP Other % GDP

% o

f GD

P

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Donor funding contributed to better health outcomes

• Donor funding has been critical for Cambodia to address population health: – The control of

communicable diseases (HIV, TB, malaria)

– Maternal and child health– Immunization coverage– Helping the poor to access

services (Health Equity Funds)

Expenditure share by donor category, 2012

Source: Cambodia NHA Report 2014

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Donor funding on health to Cambodia

19951997

19992001

20032005

20072009

20112013

0

50

100

150

200

250

0

5

10

15

20

25

30

35

40

External resource in current US$External resources on health as % of THE

Exte

rnal

Res

ourc

es (c

urre

nt U

S$)

Exte

rnal

Res

ourc

es %

TH

E

The nature of donor funding• Volatile and unpredictable• Often operated as vertical

programs• Affected by socio-economic

and political factors– May not always align with

recipient country’s priorities – Difficult to make long-term

commitmentSource: Cambodia NHA Report 2014, WHO Global Health Expenditure Database (WHO, 2014)

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Donor funding poses challenges

• Risk of fragmentation– Donor funding, if skewed towards certain diseases or specific

programs, may not always reflect the country’s priorities – Certain donor funded programs operate separately with

their own mechanisms• Endangers sustainability– Donor funding is about the same amount as government

spending from domestic source– Global Fund, GAVI and Gates Foundation accounts for one-

fourth of total donor funding, the decrease in funding will have big implications on sustainability of these programs

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Government spending on health is among the lowest in Asia countries

Government expenditure on health as a % of General Government Expenditure, 2012

Government expenditure on health as a % of Total Health Expenditure, 2012

Note: GGHE = General Government Health Expenditure; GGE = General Government Expenditure; THE = Total Health Expenditure* For Cambodia, GGHE does not include donor funding. Donor funding is included in ‘other%GDP’.Source: Cambodia NHA Report 2014, WHO Global Health Expenditure

Cambodia

Mya

nmarIndia

Bangla

desh

Philippines

Indonesia

Viet N

am

Lao PDR

Republic

of Ko...

Mala

ysia

China

Thail

and

0

10

20

30

40

50

60

70

80

90

19.3 23.9

56.0 34.437.7 39.6 55.0

51.254.4 55 56

76.4

GG

HE

% T

HE

Mya

nmar

Mala

ysia

Lao PDR

Cambodia

Indonesia

Bangla

desh

India

Viet N

am

Philippines

China

Republic

of Korea

Thail

and

0

2

4

6

8

10

12

14

16

1.5

5.8 6.1 6.5 6.97.7

9.4 9.510.3

12.513.6

14.2

GG

HE

% G

GE

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Out-of-pocket expenditure on health is among the highest in the region

Note: OOP stands for out-of-pocket.Source: Cambodia NHA Report 2014, WHO Global Health Expenditure; Lao NHA.

OOP expenditure as % of THE, 2012 The components of OOP, 2013

Source: Cambodia Socioeconomic Survey, 2013

Thail

and

China

Lao PDR

Indonesia

Viet Nam

Philippines

Cambodia

Myanmar

0%

10%

20%

30%

40%

50%

60%

70%

80%

12%

34%

44% 45%49%

58%60%

71%

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Limited resource on prevention and other priority areas (eg.NCDs)

Cambodia (2012)

Thailand (2012)

Malaysia (2013)

Myanmar (2011)

Indonesia (2009)

Philippines (2012)

Lao PDR (2011)

0 2 4 6 8 10 12 14

6.0

6.2

6.2

6.8

6.8

8.0

12.0

Source: WHO Global Health Expenditure database, 2014

Prevention expenditure as a % of total health expenditure

Distribution of health expenditure by diseases

Source: Cambodia NHA Report 2014

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Private sector provides large quantity of services and draws substantial resources

Source: Cambodia Socio-economic Survey (CSES) 2012 Source: Cambodia NHA Report 2014

Distribution of health expenditure by providers

2012 2012 2012 2012National Phnom Penh Other Urban Other Rural

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

18.77.8 11.5

20.5

39.9

88.467.2

32.8

40.2

3.7

20.5

45.4

1.2 0.1 0.8 1.3

Public PrivateSelf care* Traditional care

Service utilization by providers [%]

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Quality of health services is low in both public and private facilities

(29%)

(30%)

(27%)

(14%)

Up to 74% of all patients may be receiving the wrong diagnosis or treatment

Sou

rce:

Wor

ld B

ank

Stud

y on

hea

lth c

are

qual

ity, 2

013

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Summary of the challenges

• Heavy reliance on donor funding with vertical approaches

• High out-of-pocket payments paid for poor quality of services

• Low government spending on health from domestic sources

• Large private and informal sector with limited regulatory mechanisms

• Low quality of services in both public and private sectors

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THE WAY FORWARD

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Reshape and re-orient health system NOW

• Economic growth gives the government the means to invest in its people’s health

• Reshape and re-orient the health system:– To improve integration and coordination among programs

and different level of health services– Take strong ownership and align donor funding with

national strategy and priorities– Improve transparency and accountability– Enhance people’s trust in public services

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Increase government spending on health from domestic sources and use it efficiently

• The amount of government spending on health matters

• Efficient use of resources with greater transparency and accountability is crucial

• More domestic funding will strengthen the national ownership

• More domestic funding allows government to address the country’s health priorities and to work towards long-term sustainability

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Rebalance budget allocation towards prevention and primary care

• More resource for sub-national levels, especially health centres and district hospitals

• Ensure maintenance of equipment and regular supply of quality medicines and other essential commodities at the primary level

• Bring compensation and motivation of health workers at the primary level facilities to the adequate level

• Introduce appropriate interventions to encourage retention of health workers in the rural areas and at the primary level facilities

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Improve safety and quality of service in both public and private sectors

• Strengthen regulatory capacity and reinforce implementation of legislations

• Develop and update clinical standards based on evidence and improve compliance

• Strengthen the registration, licencing and accreditation mechanisms

• Improve quality of medical education and create opportunities for continued professional development

• Further develop systems for monitoring and oversight of health services

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Minimizing out-of-pocket payment and make services more affordable

• Increase prepayment • Balance the supply side and demand side subsidies • Health Equity Funds should focus on providing

vulnerable populations access to a well-defined package of good quality essential services

• Leverage private sector through contracting and payment methods (financial incentives) for public benefit

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DISCUSSION