The Kingdom of Cambodia health system review

Health Systems in Transition

Vol. 5 No. 2 2015

The Kingdom of Cambodia Health System Review

Written by: Peter Leslie Annear, Nossal Institute for Global Health, Australia John Grundy, Consultant, Cambodia and Australia Por Ir, National Institute of Public Health, Cambodia Bart Jacobs, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH Chean Men, University Research Company, Cambodia Matthias Nachtnebel, Nossal Institute for Global Health, Australia Sophal Oum, University of Health Sciences, Cambodia Ann Robins, World Health Organization, Cambodia Chhun Eang Ros, Ministry of Health, Cambodia Edited by: Peter Leslie Annear, Nossal Institute for Global Health, University of Melbourne, Australia Co-Editors: Bart Jacobs, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH Matthias Nachtnebel, Nossal Institute for Global Health, University of Melbourne, Australia Asia Pacific Observatory on Public Health Systems and Policies

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WHO Library Cataloguing in Publication Data The Kingdom of Cambodia health system review (Health Systems in Transition, Vol. 5 No. 2 2015) 1. Delivery of healthcare. 2. Health transition. 3. Healthcare financing. I. Asia Pacific Observatory on Health Systems and Policies. II. World Health Organization Regional Office for the Western Pacific. ISBN 978 92 9061 691 7 (NLM Classification: WA 546 JC2) © World Health Organization 2015 (on behalf of the Asia Pacific Observatory on Health Systems and Policies) All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to the Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, (fax: +632 521 1036, e-mail: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication.

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Contents

Preface................................................................................................................. viii Acknowledgements.............................................................................................. x List of abbreviations........................................................................................... xii Abstract............................................................................................................... xvii Executive Summary........................................................................................... xix Health system context........................................................................................xix Organization and governance............................................................................xxi Health financing..................................................................................................xxii Physical and human resources....................................................................... xxiv Provision of care. ................................................................................................ xxv Major health reforms....................................................................................... xxvii Health system performance............................................................................. xxx Challenges for the future.................................................................................xxxi 1 Introduction.................................................................................................. 1 Chapter summary.................................................................................................. 1 1.1 Geography and sociodemography............................................................. 1 1.2 Economic context......................................................................................... 5 1.3 Political context............................................................................................ 7 1.4 Health status............................................................................................... 10 2 Organization and Governance................................................................. 20 Chapter summary................................................................................................ 20 2.1 Overview of the health system................................................................. 20 2.2 Organization................................................................................................ 21 2.3 Historical background............................................................................... 24 2.4 Decentralization and deconcentration. .................................................. 26 2.5 Planning....................................................................................................... 30 2.6 Intersectoral cooperation......................................................................... 33 2.7 Health information management............................................................ 34 2.8 Regulation................................................................................................... 38 2.9 Patient empowerment............................................................................... 41 iii

3 Financing..................................................................................................... 45 Chapter summary................................................................................................ 45 3.1 Health expenditure. ................................................................................... 46 3.2 Sources of revenue and financial flows.................................................. 48 3.3 Overview of the national health financing system................................ 52 3.4 Out-of-pocket payments........................................................................... 67 3.5 Voluntary health insurance. ..................................................................... 71 3.6 Parallel health systems............................................................................ 73 3.7 Payment mechanisms............................................................................... 73 4 Physical and Human Resources............................................................. 77 Chapter summary................................................................................................ 77 4.1 Physical resources..................................................................................... 77 4.2 Human resources....................................................................................... 85 5 Provision of services................................................................................. 99 Chapter summary................................................................................................ 99 5.1 Public health............................................................................................... 99 5.2 Patient pathways...................................................................................... 107 5.3 Primary ambulatory care........................................................................ 108 5.4 Specialized ambulatory care/inpatient care........................................ 109 5.5 Emergency care........................................................................................ 113 5.6 Pharmaceutical care. .............................................................................. 114 5.7 Rehabilitation and long-term care........................................................ 115 5.8 Oncology and palliative care................................................................... 116 5.9 Mental health care................................................................................... 116 5.10 Dental care................................................................................................ 117 5.11 Complementary and alternative medicine. ......................................... 118 5.12 Health services for specific populations.............................................. 119 6 Principal health reforms. ...................................................................... 120 Chapter summary.............................................................................................. 120 6.1 Analysis of recent reforms. .................................................................... 121 6.2 Future developments............................................................................... 132 7 Assessment of the health system........................................................ 136 Chapter summary.............................................................................................. 136 7.1 Stated objectives of the health system................................................. 137 7.2 Financial protection and equity in financing........................................ 140 7.3 User experience and equity in access to health care......................... 141 7.4 Health outcomes...................................................................................... 143 7.5 Health system efficiency......................................................................... 149 7.6 Transparency and accountability........................................................... 151 iv

8 Conclusions. ............................................................................................. 153 Key findings. ....................................................................................................... 153 8.1 Health and health care achievements.................................................. 153 8.2 Lessons learnt from health system changes...................................... 156 8.3 Remaining Challenges............................................................................ 158 9 9.1 9.2 9.3 9.4

Appendices. .............................................................................................. 161 References. ............................................................................................... 161 Useful websites on Cambodia................................................................ 174 HiT study methodology and production process................................. 175 About the authors. ................................................................................... 176

List of Figures Figure 1.1 Map of Cambodia.......................................................................2 Figure 1.2 Population pyramids for 1950, 2000, and forecast for 2050, Cambodia....................................................................5 Figure 1.3 Percentage of population below the national poverty line, Cambodia, 2004–2011...........................................7 Figure 1.4 Percentage of children under 5 with ARI and malnutrition, Cambodia, 2010................................................. 13 Figure 2.1 Organization of the Ministry of Health and affiliated institutions............................................................................... 22 Figure 2.2 Contracting arrangements for Special Operating Agencies... 27 Figure 3.1 Total health expenditure as percentage of GDP, selected countries in South and South-East Asia, selected years, 1995–2010....................................................... 47 Figure 3.2 Total health expenditure per capita, selected countries in South-East Asia, selected years, 1995–2010 (PPP constant 2005 international US$)................................... 48 Figure 3.3 Share of total health expenditure by funding source, 2013.... 49 Figure 3.4 Out-of-pocket expenditure as percentage of THE, selected countries in South and South-East Asia, selected years, 1995–2010....................................................... 49 Figure 3.5 Government expenditure as percentage of GDP, selected countries in South and South-East Asia, selected years, 1995–2010 (excluding Official Development Assistance)........................................................ 51 Figure 3.6 Government health expenditure by Budget Chapter, 2013 (% of total budget)........................................................... 51 v

Figure 3.7 Revenue sources and flows within the public health system............................................................... 53 Figure 3.8 Institutional arrangements of National Health Equity Fund.............................................................................. 61 Figure 3.9 Distribution of providers in annual per-capita OOP spending on health care, 2012................................................ 68 Figure 3.10 Distribution of annual household OOP spending on health care by income quintile, 2012....................................... 69 Figure 4.1 Hospital beds per 1000 population, selected countries.......... 82 Figure 4.2 Average length of hospital stay for acute care, selected countries................................................................... 82 Figure 4.3 Number of midwives, Cambodia, 1996–2011 (public sector).......................................................................... 88 Figure 4.4 Ratio of nurses and midwives to physicians in selected countries (Cambodia data 2008).............................................. 90 Figure 4.5 Number of physicians per 1000 population, selected countries, 1991–2009............................................................... 91 Figure 4.6 Number of nurses and midwives per 1000 population, selected countries, 1991–2009................................................ 91 Figure 4.7 Number of dentistry personnel per 1000 population, selected countries, 1991–2009................................................ 92 Figure 4.8 Number of pharmacists per 1000 population, selected countries, 1991–2011................................................ 92 Figure 5.1 Utilization of in- and outpatient services, by sector, 2010.... 111 Figure 5.2 Results from the first Client Satisfaction Survey, 2012........ 112

List of Tables Table 1.1 Trends in population/demographic indicators, Cambodia, 1980–2012....................................................................................4 Table 1.2 Macroeconomic indicators, Cambodia for selected years..........6 Table 1.3 Life expectancy and mortality rates, Cambodia, 1980–2012.... 10 Table 1.4 Mortality from communicable and noncommunicable diseases, Cambodia, 2002 and 2008......................................... 11 Table 1.5 Main causes of reported death per 100 000 population, Cambodia, 1996–2010................................................................ 12 Table 1.6 Distribution of causes of death (%) among children aged