Joint Annual Health Sector Review 2003

JOINT ANNUAL HEALTH SECTOR REVIEW 2003

Ministry of Health Cambodia

April 2003

1.Introduction

1.1The present report summarises key achievements in the health sector during 2002 and highlights areas for attention in 2003. To date, the Ministry of Health has established a framework for sector-wide management with a focus on poverty reduction for the next five years. The sector-wide management initiative has strong support from external partners through a structure of coordinated assistance.

1.2Certain problems are highlighted: low access to priority maternal and child health services, difficulties around recruitment of midwives, delays with procurement of drugs for 2003, cash shortage combined with slow release of funds, low salaries for health staff and insufficient incentives for those working in poor and remote areas.

1.3The report indicates milestones to be achieved in 2003 in addressing these issues, and also the continued priorities for 2004 and therefore the annual sector review provides a framework for operational planning at central and provincial levels for 2003-2004.

1.4Reports on benchmarks for the key areas of the health sector strategic plan established to track progress are attached. These benchmarks are relevant also for the National Poverty Reduction Strategy as well as the monitoring and reporting process of the Government / Donor Consultative Group in Social Development.

1. Overall Achievements in 2002

1. In August 2002, the Health Strategic Plan (HSP), the first of its kind for Cambodia, was launched and endorsed by the Prime Minister. The plan provides a common framework for all partners in the sector, including government and external for the period 2003-2007. The document outlines strategies for health service delivery, behavioural change, quality improvement, human resource development, health care financing and institutional development for the key purpose of developing effective and efficient services that improves health for all Cambodians especially the poor and marginalized population.
2. The strategic plan is completed by three additional documents: a medium term expenditure framework that outlines costs and financial inputs from government and external agencies, a monitoring and evaluation framework that lists indicators, data sources and key events for analyzing sector performance, and guidelines for developing annual operational plans for all MOH institutions.
3. In 2002, the Ministry of Health developed a major sector-wide initiative, the Health Sector Support Project (HSSP) for 2003-2007 to be supported by the World Bank, the Asian Development Bank and DfID, UK including counterpart funds from the Royal Government.
4. The components of HSSP aim at improving affordability and accessibility of health services among low-income groups including further development of health infrastructure and civil works, enhancing efficiency and reform of the health sector, and addressing public health priorities through support to national programmes.
5. Another significant event in 2002 includes mobilizing funds from the Global Fund for AIDS, TB and Malaria (GFATM). The Ministry and its partners were able to secure US$ 16 million to support actions aimed at lowering transmission and prevalence of HIV/AIDS in Cambodia. The funds will be utilized to support private public partnerships, care and for improved prevention.
6. Accomplishments in health sector development include the review of health coverage plan and efforts to revise the plan for constructing and developing health facilities through a series of workshops among provincial and central MOH staff in 2002. A strategy for delivering hospital services at district, provincial and national levels will be completed in the first quarter of 2003 and will be used as the basis for civil works development financed by World Bank and ADB through the HSSP.
7. Through the umbrella framework of Integrated Fiduciary Assessment and Public Expenditure Review programme, the Ministry of Health conducted a review of health expenditure in 2002. The findings highlighted the need to enable better access among the poor to public sector services. The issues raised were further discussed through several video conferencing sessions at the joint IFAPER meetings between government and donors in October 2002.
8. A significant milestone in 2002 was the development of the national poverty reduction strategy for 2003-2005. The Ministry defined a package of key health component strategies and actions from the sector strategic plan aimed at:

a)Improving health service coverage and utilization among poor and socially excluded Cambodians emphasizing prevention and low-cost high impact curative services,

b)Enhancing accessibility and affordability of key essential services through alternative health financing schemes and social safety nets that protect the poor from catastrophic expenditures, and

c)Providing information, improving participation and empowering the poor to make informed choices in producing health.

2.9Following the review of the Health coverage Plan, the Ministry of Health added 2 Operational Districts: Sangker OD in Battambang Province and O Chrou OD in Banteay Mean Chey Province. To date, in the country, there are now 75 Operational Districts, 68 Referral Hospitals (not included National Hospitals), 942 health Centers and 23 Health Posts.

2.10In order to link the development of the Health Coverage Plan with the Royal Government’s Decentralization policy, the Ministry of Health has developed and finalized the Policy and Guideline on Community Participation in Health Centers. To date, 812 Health Centers or 86% of total planned Health Centers are providing MPA services and are equipped with medical materials and essential drugs and run by staff who have been trained on MPA.

2.11The number of hospitals that have major surgery capability has increased from 31 in 2001 to 35 in 2002. The Referral Hospitals that has started major surgery in 2002 are: Kirivong, Pearang, Mondol Kiri and Memut.

2.12The MOH has continued developing the health financing system. This includes the review of National Charter on health financing at referral hospital, the establishment of Equity Fund and the expansion of contracting of health services to NGOs in the Districts with poor people and in remote Districts (from 5 to 11 District in 2004). By end of 2002 more effort has been made to strengthen financial management skill at the national level in order to improve accountancy and report procedures.

2.13Out of the national health budget allocation of 171,881,4000,000 Riels (or 44,526,937 USD), 93% was mandated for spending, and 77% was actually expended on recurrent costs of health service delivery.

2.14In summary, the MOH and partners together have achieved remarkable results, especially against most of the benchmarks set between the Royal Government and the international community.

2.15A detailed update on indicators, benchmarks and priorities are provided in the following section.

HEALTH SERVICE DELIVERY

Strategy 1

Further improve coverage and access to health services, especially for the poor and other vulnerable groups through planning the location of health facilities and strengthening outreach services.

I.Indicators

/ Baseline 2002 / Target 2003 / Priorities 2004
The number of health centres that receive MPA drugs* / 812
The number of functioning CPA1/2/3 Referral Hospitals / Baseline to be established / Criteria developed for functioning CPA1/2/3 Referral Hospitals**
Average number of outreach visits per remote village*** per year / Baseline to be established /  6 outreach visits per village per year
Up-dated health coverage plan / No baseline / Health coverage plan up-dated, including clear guidelines for FDHs, HPs, CPA1/2/3 RHs and linked to the health infrastructure development plan

*An alternative indicator could be the number of functioning health centres, and to define functioning as meeting some or all of the following criteria: (a) adequate supply of MPA drugs, (b) at least 5 staff of which one is a secondary midwife, (c) open at least 4 hours per day and with 24 hours on call service, (d) providing all basic MPA services every day, (e) at least 1 outreach session to every village every 2 months, (f) referring patients, (g) community participation.

** After having developed criteria for functioning Referral Hospitals, it will be possible to establish the baseline, i.e. the number of functioning CPA1/2/3 Referral Hospitals

***Definition of remote village will be developed in 2003

Strategy 2

Strengthen the delivery of quality basic health services through health centers and outreach based upon MPA

Indicators

/ Baseline 2002 / Target 2003 / Priorities 2004
Review of MPA / No baseline / MPA reviewed and updated
Guideline for health posts / No baseline / Guideline for health posts developed
No. of health centers that implement IMCI / 45 health centers / 100 health centers / 200 health centers
Average number of outreach visits per village per year / 13 outreach visits per village per year / 13 outreach visits per village per year /  13 outreach visits per village per year
No. of health centers with functioning VHSGs and HCMCs* / Establish baseline
Joint MoH / MoEYS policy / agreement on school health / No baseline / Joint policy/agreement on school health developed / Start implementation of school health programme, including expanding twice a year deworming to all primary schools
Consultations (new cases) per inhabitant per year
- All consultations
- Children under 5 years / 0.38
0.54 / 0.4 / 0.42
Percentage of children under 1 year that received DTP3 / 64% / 75% / 80%
Percentage of pregnant women who received at least 2 ANC consultations / 29 % / 30 % / 32 %
Percentage of deliveries attended by trained public health staff / 20.3 % / 22 % / 24 %
Percentage of pregnant women who received at least 2 TT vaccinations / 45 % / 50%
Percentage of married women aged 15-49 years using a modern contraceptive method (current users by 31/12)(public sector services) / 18.3% / 19 % / 20%
Percentage of children aged 6 – 59 months who received vitamin A:
- March
- November** / 57%
34% / 65%
65% / 70%
70%
Percentage of women who received 1 capsule vitamin A within 8 weeks of delivery / 13% / 50% / 65%

*Functioning VHSG:  5 meetings per year: Functioning HCMC:  10 meetings per year. The baseline for 2002will be established later this year

** The 2002 baseline and 2003 targets shows higher coverage for the March distribution due to the fact that vitamin A was distributed as part of the measles campaign. No measles campaign is planned for 2004 and hence, the target for the March and November distribution are the same.

Strategy 3

Strengthen the delivery of quality care, especially obstetric and paediatric care, in all hospitals through measures such as CPA

Indicators

/ Baseline 2002 / Target 2003 / Priorities 2004
CPA guidelines / CPA guidelines finalised / Review of CPA guidelines
Number of RHs that perform major surgical interventions, including C-sections / 35 Referral Hospitals / 39 / 39
Number of hospitals implementing the baby friendly hospital initiative / 0 / 3 Hospitals* / 7 Hospitals
Number of hospital admissions per 1000 population**:
- All admissions
- Children under 5 years / 20.6
28 / 22 / 24
Hospital mortality rate / 2.6 / 2.4 / 2.2

*These hospitals will start implementing the initiative during 2003, but may not yet meet all the criteria by end of 2003

**This includes admissions reported by all national hospitals, as well as the Kantha Bopha hospitals in Phnom Penh

Strategy 4

Strengthen the management of cost-effective interventions to control communicable diseases

Indicators

/ Baseline 2002 / Target 2003 / Priorities 2004
Report that fully analysis the reasons for slow progress in reducing child mortality. / No baseline / Report Completed
No. of health centers implementing DOTS / 381 health centers / 671 health centers / 775 health centers
Detection rate of smear positive pulmonary TB / 57% / 62% / 68%
No. of Operational Districts with voluntary counselling and testing (VCT) / 22 Operational Districts / 32 Operational Districts / 52 Operational Districts
No. of provinces implementing 100% condom use / 24 / 24 / 24
Percentage of children aged 12– 59 months who received mebendazole:
- March
- November / No baseline available (not included in HIS reports) / Revised HIS to include report on children aged 12-59 months who received mebendazole during each round
Review of disease surveillance system / No baseline / Disease surveillance system reviewed
Guidelines for outbreak response at provincial and Operational District levels / No baseline / Provincial and OD level guidelines developed
% of endemic villages that have re -treatment and replacement of bed nets annually / 74 % / 90 % / 95 %
Malaria case fatality rate (severe cases only) / 8.2 % / 7.45 % / 6.7 %
Malaria Incidence Rate/1000 / 8.6 / 7.8 / 7
Dengue case fatality rate / 1.23% / 1.1% / 1%

Strategy 5

Strengthen the management and coverage of support services such as laboratory, blood safety, referral, pharmaceuticals, equipment and other medical supplies and maintenance of facilities and transport

Indicators

/

Baseline 2002

/ Target 2003 / Priorities 2004
Percentage of patients who received antibiotics
- IPD*
- OPD** / 100%
50.2% / 90%
45% / 85%
40%
Percentage of children under 5 years with diarrhoea and treated in health centres who received ORS*** / 81.4 % / 90% / 100%
Percentage of essential drugs (15 items listed) at health centre that faced stock-out*** / 7.6 % / Target for 2003 to be established by MoH
Review of the existing referral system / No baseline / Referral system reviewed
No. of RHs that have blood bank or depot / 31 / 33
No. of HCs with refrigerator / 96 / 296 / 596
No of high temperature incinerators / 24 / 38 / 54

*Based on information collected during supervision of a limited number of Referral Hospitals (21 Referral Hospitals in 2002). The Ministry of Health standard is 70% of all in-patients

**Based on information collected during quarterly supervision of all health centres. The Ministry of Health standard is 32% of all out-patients

***Based on information collected during quarterly supervision of all health centres.

Introduction

The Ministry of Health collects information on a number of coverage and utilization indicators through its Health Information System (HIS) and these indicators are routinely used by health managers for purposes of planning and monitoring. The most frequently used coverage and utilization indicators have been included here, as the availability of data allows us to monitor these indicators annually.They represent a subset drawn from more comprehensive lists of indicators currently in use by the various national programs and are meant to provide incremental measures of progress towards the achievement of Health Service Delivery outcomes.

It is noted, however, that there are some concerns regarding the accuracy and reliability of the data collected through HIS as well as regarding the clarity and consistency of the definitions of some of these indicators. The Ministry of Health plans to address these concerns as part of its monitoring and evaluation framework, which includes revision of the HIS, verification of reported data, and promoting the use of available data at all levels.

Current Situation

1. The Health Sector Strategic Plan 2003 – 2007 identifies maternal and child health as main priorities and continues to stress the importance of communicable disease control. The current levels of maternal, infant and child mortality, however, suggest that there is an enormous scope for improvement in strengthening the health care delivery system and in extending the coverage and use of basic health interventions to populations not yet reached.
2. The number of health centres and referral hospitals that provide appropriate services in line with MPA and CPA has increased considerably. For example, not less than 86% of planned health centres have been established and receive MPA drugs. It should be noted, however, that a number of these health centres may not provide all services included in MPA.
3. Although slowly increasing, utilization of public health services remains low:

Utilization of health centres, with 0.38 consultations per inhabitant per year in 2002 (HIS), falls well below the WHO international standard of 0.6 for rural areas and 1.0 for urban areas.

The number of patient admitted to public hospitals remains modest with 20.6 admissions per 1,000 population (HIS 2002).

1. A positive observation is that the utilization of public health services by children under the age of 5 is significantly higher than the overall utilization:

Utilization of health centres by children under 5 is 0.54 consultations per child per year (HIS 2002).

The number of children admitted to public hospitals is 28 per 1,000 children (HIS 2002).

1. The immunization coverage remains low with only 40% of the children aged 12-23 months fully immunized (CDHS 2000). In comparison with 2001, the reported coverage for 2002 was lower for most of the antigens. The main reasons identified by health staff are the late and irregular arrival of funds and irregular implementation of outreach services in many Operational Districts, particularly in remote areas. This is also reflected in a low coverage of vitamin A supplementation, reported at 34% among 6-59 months children for the second distribution round in November.
2. On the other hand a successful measles campaign was conducted over the three last years, which resulted in a reduction in the number of reported measles cases from 13,827 in 1999 to only 1,361 in 2002.
3. The Ministry of Health has adopted a new cold chain and now provides health centres with refrigerators. It is believed that this will facilitate immunization at the health centres and will provide more flexibility in the planning and implementation of outreach.
4. The contraceptive prevalence rate is low with less than 20% of women in the reproductive age using modern contraceptives, while ⅓ of currently married women have an unmet need for contraception (CDHS 2000).
5. With 20% of deliveries attended by trained health staff (HIS 2002), the majority of Cambodian women deliver at home with untrained traditional birth attendants and receive inadequate antenatal care prior to delivery.
6. Not less than 35 Referral Hospitals (out of 51 planned CPA2 and CPA3 Referral Hospitals) perform major surgical interventions, including caesarean sections. On the other hand, the c-section rate remains very low, which indicates difficulties with access to these services.
7. The Ministry of Health has successfully extended DOTS to the health centres and the number of health centres providing TB treatment has increased rapidly. This is reflected in an increasing detection rate of smear positive pulmonary TB.
8. The 100% condom use programme is implemented in all provinces and it is recognised that the successful implementation of this and other preventative interventions, such as social marketing of condoms and IEC, have contributed to the observed reduction in the prevalence rate of HIV/AIDS among the adult population
9. Morbidity and mortality from malaria has decreased due to effective interventions, resulting in improved diagnoses and treatment and in effective prevention, such as the distribution of impregnated bed nets.
10. Notwithstanding the current and acute problems with the procurement of drugs, it should be noted that, during recent years, significant progress had been made in the supply and management of drugs. In the area of rational use of drugs, on the other hand, only limited progress has been achieved and much work remains to be done to improve prescription practices and to curb the over-prescription in general and of antibiotics and injections/perfusionsin particular.

Areas of Concern

The following issues are raised: