Cambodia moves beyond its past to lift health outcomes

Cambodia is emerging. After decades of international and domestic conflicts, the country is showing significant economic and social progress.

Since 1995, Cambodia has been one of the fastest growing economies in the world, averaging seven per cent annual economic growth. Average income level now approaches US$1,000 per capita. Income disparity has levelled out after 2007, and poverty has officially fallen from 50 per cent of the population in 2004 to 20 per cent in 2011 by local measurements, and now estimated to be below the 2015 Millennium Development Goals (MDG) target of 19.5 per cent. The share of the poorest 20 per cent of the population in total consumption was 9 per cent in 2011, which is on course to achieve the 11 per cent target.

This economic growth has been accompanied by significant improvements in the health status of the Cambodian people, due in part to recent consistent increases in the health budget and the efforts of development partners working in close collaboration with the ministry of health.

Improved health indicators

One reason for this success has been the use, where possible, of evidence-based policy during the health planning process, supported by a range of implementation researches of national institutions and development partners.

A recently published study of the Cambodian health situation by the WHO-supported Asia Pacific Observatory on Health Systems and Policies provides a comprehensive review of the achievements showing Cambodia has achieved or surpassed many of its own MDG.

Life expectancy at birth has increased from 61.9 to 71.4 years during 2000-2012. Infant mortality rate (MDG4) declined from 95 to 28 deaths, well below the 50 per 1,000 target figure, while the under-five mortality rate decreased from 124 to 35 deaths per 1,000 live births during 2000-2014, below the 65 per 1,000 target.

The maternal mortality ratio (MDG5) decreased from 437 to 170 deaths per 100,000 live births during 2000-2014, well below the 250 per 100,000 target. Attended births rose dramatically from 58 per cent in 2008 to 89 per cent in 2014, above the 75 per cent target.

On MDG6, communicable diseases, including HIV/AIDS, malaria and tuberculosis, have all been largely brought under control. Now, non-communicable diseases account for an equal number of deaths as infectious diseases.

HIV/AIDS prevalence among the general population declined from 2.4 per cent in 1998 to 0.7 per cent in 2014, though still above the 2015 target of 0.4 per cent. Malaria mortality rate declined from 1.5 per 100,000 population in 1993 to 0.8 in 2013, achieving the 2015 target.

Persisting challenges

While the improvements in Cambodia’s health system have been notable, major changes in service delivery are still required. Most of the population turn not to the public system for health care but to a range of private providers, many of whom are unqualified.

The recent tragedy in which more than 200 people in one village — Roka in Battambang province — were infected with HIV from the routine use of dirty syringes dramatises the acute need for urgent action. The unqualified medical practitioner who was responsible for this now faces a prospect of life imprisonment.

Ironically, Cambodia has been lauded for its progress in reducing HIV infections to 0.7 per cent of adults (15-49 years old) according to UNAIDS, the joint UN programme on HIV/AIDS. United States ambassador William Todd said recently that the government deserved to be commended for bringing the Roka outbreak to the attention of the outside world.

In fact, the Roka tragedy sounded the alarm not just for HIV/AIDS control and treatment but also for the improvement of the quality of care provided at both public and private facilities, and for much stricter regulation and control.

Also, urban-rural and socio-economic disparities persist and health outcomes are not yet as good as in other countries of the region. Unsafe drinking water, lack of sanitation, high neonatal mortality and malnutrition are some of the most relevant impeding factors.

Even so, the growth and development of health equity funds have international significance. The funds provide free access to government health services for all those living below the poverty line and who qualify under an objective means test. Coverage reaches more than two million people who previously were mostly unable to access healthcare due to costs. Funding comes jointly from the government and donors. The funds are Cambodia’s largest social protection scheme.

As a new health strategic plan 2008-15 takes place, Cambodian health planners face challenges posed by current shortcomings in the health system. The low quality of health services (public and private) and persistent health inequities are major concerns.

Moreover, the successful expansion of health infrastructure, relatively low levels of utilisation, and the rapid increase in the number of private providers all focus attention on the limitations of public health service delivery. The private sector remains largely unregulated.

The new health strategic plan aims to address these issues with an emphasis on extending the coverage of health equity funds, moving more quickly towards performance-based financing in service delivery, improving pre-service training and the implementation of licensing and accreditation of health care providers, and stronger monitoring and follow-up.

The next five years is a critical time for the health of all Cambodians.

Peter Annear is head of the Health Governance and Financing Unit at the Nossal Institute for Global Health at the University of Melbourne. He is a health economics with experience in international development since the 1970s, particularly in Asia, as a researcher, consultant and advisor for the WHO, World Bank, and other international agencies.

This article has been produced by SciDev.Net's South-East Asia & Pacific desk.