Current Status of Health Care System Cambodia Perspective

Current Status of Health Care System, Cambodia Perspective Phnom Penh Conference on Essential and Emergency Surgery and Anesthesia March 24 -25, 2016 v Kim Savuon, MD Department of Hospital Services Ministry of Health, Cambodia

10/7/2020 2

Geographical, economic Indicators • Cambodia is one of the oldest countries in South East Asia • Total land surface is 181, 035 km 2 • The country is divided into one municipality, 24 provinces and 26 cities • The total population is 15, 053, 112 • The main religion is Buddhism • Around 15 % of the population can be classified as urban, and the remaining 85% as rural 10/7/2020 Sources: Statistics 2010, Ministry of Planning, Royal Government of Cambodia 3

HEALTH SYSTEM ORGANIZATION • -Since 1994 – reorganization of health system places emphasis on the Administrative districts. • -Objective – to improve and extend primary health care through the implementation of a district based health system. • -In 1996 Health system reform becomes a part of the larger national public administrative reform (PAR). 10/7/2020 4

Health Sector Reforms Rectangular Strategy Socio-Economic Development Plan Health Coverage Plan 1996 National Strategic Development Plan Health Strategic Plan 1 1998 Operational guidelines 2002 – 2007 Health Strategic Plan 3 2008 – 2015 Health Strategic Plan 2 2016 – 2020

HEALTH COVERAGE A. HCP Criteria Health Post Health Center (MPA) Referral Hospital (CPA) 10/7/2020 1. Population 2. Accessibility 2000 -3000 Radius=15 km Max=3 hrs walk Optimal=10, 000 Vary=8, 000 -12, 000 Radius=10 km or Max=2 hrs walk Optimal=100, 000 Vary=60, 000 -200, 000 20 -30 km between 2 Referral Hospitals or Max: 3 hrs by car/boat Source: HSSP 2, 2008 -2015, Mo. H 6

B. Summary of health coverage Health Facilities National Level Operational Districts (OD) Referral Hospitals (RH) Health Centers (HC) Health Post (HP) 10/7/2020 2008 7 77 77 956 95 2015 7 89 96 1026 No. of beds 2655 4658 1243 7

Health System Organization Source: HSP 2 MOH

ORGANIZATIONAL CHART OF PROVINCIAL LEVEL Provincial Health Department Operational District Referral Hospital Health Center Provincial Referral Hospital Health Center Health Post 9

Some core indicators for M&E Program Core Indicators 2013 2014 2015 2016 2017 1 Live expectancy at birth (year) 2 Unmet need for family planning (15 -49 years) Abortion rate [OR repeat abortion rate] Teenage pregnancy 15 -19 years M: 67. 1 F: 71. 0 16. 6% M: 67. 3 F: 71. 2 12% M: 67. 5 F: 71. 4 10% M: 67. 7 F: 71. 6 9. 5% M: 67. 9 F: 71. 8 9% 5% [26] 3. 6% 3. 2% 3% 2. 7% 3 4 5 6 Adolescent fertility rate ( Rate per 1000 women) Total fertility rate (expressed per woman) x 12% 11. 5% 11% 10. 5% x 57 56 55 54 2. 8 2. 7 2. 6 2. 5 2. 4 Source: HSSP 3 2016 -2020 10

Some core indicators for M& E Progra m 7 8 9 10 11 Core Indicators 2013 2014 2015 Incidence of cervical cancer x 16. 2 Number and Percentage of women aged 30 -49 years screened for cervical cancer at least once Cataract surgical rate per 100, 000 population Mortality rate from road traffic injury per 100, 000 population Percentage of Injured population with head trauma due to road traffic accident received treatment (compare to total # of RTA injured) x 2016 2017 16. 2 38, 6 00 42, 4 60 46, 710 51, 3 80 1, 20 0 11. 60 1, 30 0 <11. 60 1, 50 0 <11. 60 1, 700 33. 8% <29. 5% 1, 90 0 <11. 60 <29. 5% Source: HSSP 3 2016 -2020 <11. 60 <29. 5 % 11

Number of Students graduated from Universities (National Exit Examination) Year 2013 2014 2015 Medicine X? 239 913 Dentistry 53 136 137 Source: DHR /Mo. H 2015 Pharmacy 233 226 200 BSN 539 190 173 12

Current Service Availability at Health Center levels Service Availability Percentage of Health Centers** Reproductive, maternal, neonatal, child health, family planning and nutrition services Antenatal care Normal delivery Postpartum care Immunization IMCI PMTCT Nutrition ** Only positive responses shown Birthspacing Preliminary Survey Results of Current Implementation of MPA 2008 -2015 98% 89% 97% 99% 96% 65% 79% 99% 13

Current Service Availability at Health Center levels Service Availability Percentage of Health Centers** Communicable diseases Sexually transmitted infections HIV Tuberculosis Malaria Preliminary Survey Results of Current Implementation of MPA ** Only positive responses shown 2008 -2015 89% 65% 98% 87% 14

Current Service Availability at Health Center levels Service Availability Percentage of Health Centers** Non-communicable diseases Hypertension Diabetes Mellitus Others Mental Health Oral Health Eye care Health Education & Promotion 95% 25% 15% 49% 95% Preliminary Survey Results of Current Implementation of MPA ** Only positive responses shown 2008 -2015 15

MPA Guidelines – Management Health Center Financing National Budget Percentage of Health Centers** 92% User Fees 96% HEF 99% CBHI 32% Others## 42% ##includes HSSP 2, Gavi, NGOs, vouchers etc. Preliminary Survey Results of Current Implementation of MPA ** Only positive responses shown 2008 -2015 16

Current Management at Health Center levels Waste Management Percentage of Health Centers** Health Care Waste 66% Management Infection Prevention 47% Control measures Preliminary Survey Results of Current Implementation of MPA ** Only positive responses shown 2008 -2015 17

Top 10 Presenting Symptoms & Conditions Respiratory symptoms Diarrhoea Digestive symptoms Hypertension Common Flu Fever Skin Infections Joint Pains STI & HIV Injuries Preliminary Survey Results of Current Implementation of MPA Increase decreasing order of frequency 2008 -2015 18

Challenges Health Services • Weak referral systemlimited linkages between the Health Center and Referral Hospital levels • Available laboratory services are very limited • Currently services for management of surgery, hypertension, diabetes, mental health etc. are limited Human Resource for Health • Staff shortages, including the non-availability of a medical doctor makes services for noncommunicable disease difficult • Staff have limited training and skills to provide all the services outlined in the package of Health Center Preliminary Survey Results of Current Implementation of MPA 2008 -2015 Infrastructure • Lack of ambulance affects timely referral of patients • Most health center buildings are old and limited funds are available for their maintenance • Delivery room is often small - no pre- & post-delivery room available • Some health centers lack running water and electricity facilities • Infrastructure for health care waste management is limited 19

Challenges Medicines & Supplies • Outages of medicines and supplies is common Financing • Limited budget available for outreach activities, HCMC meetings and VHSGs Preliminary Survey Results of Current Implementation of MPA 2008 -2015 Others • Low level of awareness amongst the community members regarding their health care needs • Geographical location of health centers affects physical access to services • High burden of reporting & recording for health staff • No accommodation for staff difficulties in providing 24/7 services 20

Recommendations Preliminary Survey Results of Current Implementation of MPA 2008 -2015 21

Recommendations Health Services • Strengthen availability of services such as noncommunicable disease conditions, oral health, eye care and mental health • Encourage the availability and use of national guidelines - Clinical Practice Guidelines/ CPG for Surgery • Introduce additional (basic) laboratory services to aid with the diagnosis and management of patients • Encourage the rational use of medicines • Strengthen the outreach activities Preliminary Survey Results of Current Implementation of MPA 2008 -2015 22

Recommendations Human Resource for Health • Provide adequate number of health workers to the health centers • Consider including medical doctors in the recommended MPA staffing • Provide regular training to health workers to be able to provide safe and quality services Preliminary Survey Results of Current Implementation of MPA 2008 -2015 23

Recommendations • Provide ambulance services for the referral of • • Infrastructure • • • patients Provide motorbikes to health workers for outreach activities Review design layout of health centers to include consultation room, waiting room, room for minor surgeries, pre- & post-delivery rooms, toilets for staff and patients Provide running water facility in health centers Provide facilities for health care waste management Provide computers and internet facilities to health centers Provide facilities for accomodation of health staff Introduce measures to prevent flooding of health centers Preliminary Survey Results of Current Implementation of MPA 2008 -2015 24

Recommendations Medicines & Supplies • Ensure regular, uninterrupted supply of essential medicines in line with the service package outlined in the MPA Guidelines • Ensure availability of medical equipments in line with the service package outlined in the MPA Guidelines • Ensure availability of laboratory reagents and equipment Preliminary Survey Results of Current Implementation of MPA 2008 -2015 25

Recommendations Financing • Ensure timely availability of adequate budget to ensure uninterrupted service delivery • Ensure implementation of activities and budget as outlined in the AOP • Provide adequate funds for outreach services • Provide adequate funds for HCMC meetings • Ensure availability of adequate funds for maintenance of the health center building and equipment Preliminary Survey Results of Current Implementation of MPA 2008 -2015 26

Recommendations • Strengthen technical Others support/supervision from higher levels, especially in health centers with new staff members • Strengthen community involvement in health through the strengthening of the HCMC & VHSGs • Undertake measures to regulate the informal and private provides; promote the utilization of services of the health centers Preliminary Survey Results of Current Implementation of MPA 2008 -2015 27

Case study in Tbongkhmom Province • 24 Y. o 4 th delivery women, from Province. Came to health center at 11 am in Dec 2014 with contraction of uterus. Patient condition was severe, then she was transferred to Referral Hospital at 2: 25 pm. Cervix completely opened but baby still not delivered even with help from 3 physicians. Patient condition continued extremely severe then she was transferred to another referral hospital for emergency operation. Unfortunately; Patient died just within 1 h after arriving another referral hospital Source: Report of Forensic team, Ministry of Health 2015 28

Ministry of Health Orders No. 020 DGH/DHS dated on 09 March 2015 • Assess patient carefully and timely to make sure that referred patient will not be at risk before arriving destination • Set up surgery ward with adequate equipment, human resources to operate timely if needed especially pregnant women who need cesarean • Establish capacity building for staff by inviting skilled, experienced experts from national and international to train staff locally by using method “Problem based learning approach” and share knowledge, experiences to staff at referral hospital and health center to change attitude, knowledge, practice, group working…. Source: Ministry of Health orders No. 020 DGH/DHS dated on 09 March 2015 29

Ministry of Health orders No. 020 DGH/DHS dated on 09 March 2015 30

Thank you Preliminary Survey Results of Current Implementation of MPA 2008 -2015 31

References: v. HSSP 2, HSSP 3 v. Mo. H Orders. No. 020 DGH/DHS, dated on 09 March 2015 v. Presentation of Dr. Or Vandine, DGH in at 37 th National Annual Health Congress 2016 v. Dr. Sok Srun, Director DHS v. Dr. Indrajit Hazarika, , Technical officer, WHO to Cambodia Preliminary Survey Results of Current Implementation of MPA 2008 -2015 32