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

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Geographical, economic Indicators The Mental Health Association of Cambodia 11/10/2018 Geographical, economic Indicators Cambodia is one of the oldest countries in South East Asia Total land surface is 181,035 km2 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 Sources: Statistics 2007, Ministry of Planning, Royal Government of Cambodia 11/10/2018 Sources: Statistics 2010, Ministry of Planning, Royal Government of Cambodia

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). 11/10/2018

Operational guidelines Health Sector Reforms Rectangular Strategy Health Coverage Plan Operational guidelines Health Strategic Plan 1 Health Strategic Plan 2 Health Strategic Plan 3 Socio-Economic Development Plan National Strategic Development Plan 2002 – 2007 2008 – 2015 2016 – 2020 1996 1998 In 1995, the Ministry of Health launched the reform of the health system in accordance with public administrative reform of the Royal Government of Cambodia. Health coverage plan, as a part of the health sector reform, specifies the location and number of health center and referral hospital, and also defines responsible areas of these health facilities in providing health services to the people. The health coverage plan was developed based on two criteria: number of people served by each health facility and geographical accessibility to the services, and also based on operational district as implementing level, in which health center provides “Minimum Package of Activities" (MPA) and referral hospital provides "Complementary Package of Activities" (CPA). This new health system has been implemented since 1996 till now.

20-30km between 2 Referral Hospitals or Max:3hrs by car/boat HEALTH COVERAGE A.HCP Criteria Criteria 1.Population 2.Accessibility Health Post 2000-3000 Radius=15km Max=3hrs walk Health Center (MPA) Optimal=10,000 Vary=8,000-12,000 Radius=10km or Max=2hrs walk Referral Hospital (CPA) Optimal=100,000 Vary=60,000-200,000 20-30km between 2 Referral Hospitals or Max:3hrs by car/boat 11/10/2018 Source: HSSP2, 2008-2015, MoH

Operational Districts (OD) Referral Hospitals (RH) Health Centers (HC) B. Summary of health coverage Health Facilities 2008 2015 No. of beds National Level Operational Districts (OD) Referral Hospitals (RH) Health Centers (HC) Health Post (HP) 7 77 956 95 89 96 1026 2655 - 4658 1243 11/10/2018

Health System Organization When we consider the health system organization in Cambodia, as defined in the Health Strategic Plan 2 (HSP2), we find the MPA Guidelines are the main tool for the provision of primary health care services. In fact, these guidelines provide important guidance on activities at the interface between the health system and the communities it serves. Hence, having a comprehensive MPA Guideline is an important first step to strengthening primary health care services. Source: HSP2 MOH

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

Some core indicators for M&E Program Core Indicators 2013 2014 2015 2016 2017 1 Live expectancy at birth (year) M: 67.1 F: 71.0 M: 67.3 F: 71.2 M: 67.5 F: 71.4 M: 67.7 F: 71.6 M: 67.9 F: 71.8 2 Unmet need for family planning (15-49 years) 16.6% 12% 10% 9.5% 9% 3 Abortion rate [OR repeat abortion rate] 5% [26] 3.6% 3.2% 3% 2.7% 4 Teenage pregnancy 15 -19 years x 11.5% 11% 10.5% 5 Adolescent fertility rate ( Rate per 1000 women) 57 56 55 54 6 Total fertility rate (expressed per woman) 2.8 2.7 2.6 2.5 2.4 Source: HSSP3 2016-2020

Some core indicators for M& E Program Core Indicators 2013 2014 2015 2016 2017 7 Incidence of cervical cancer x 16.2 8 Number and Percentage of women aged 30-49 years screened for cervical cancer at least once 38,600 42,460 46,710 51,380 9 Cataract surgical rate per 100,000 population 1,200 1,300 1,500 1,700 1,900 10 Mortality rate from road traffic injury per 100,000 population 11.60 <11.60 11 Percentage of Injured population with head trauma due to road traffic accident received treatment (compare to total # of RTA injured) 33.8% <29.5% Source: HSSP3 2016-2020

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

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

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

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

MPA Guidelines – Management Health Center Financing Percentage of Health Centers** National Budget 92% User Fees 96% HEF 99% CBHI 32% Others## 42% ##includes HSSP2, Gavi, NGOs, vouchers etc. ** Only positive responses shown Preliminary Survey Results of Current Implementation of MPA 2008-2015

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

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

Human Resource for Health Challenges Health Services Weak referral system- limited 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 non-communicable disease difficult Staff have limited training and skills to provide all the services outlined in the package of Health Center 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 Preliminary Survey Results of Current Implementation of MPA 2008-2015

Preliminary Survey Results of Current Implementation of MPA 2008-2015 Challenges Medicines & Supplies Outages of medicines and supplies is common Financing Limited budget available for outreach activities, HCMC meetings and VHSGs 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 Preliminary Survey Results of Current Implementation of MPA 2008-2015

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

Preliminary Survey Results of Current Implementation of MPA 2008-2015 Recommendations Strengthen availability of services such as non-communicable 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 Health Services Preliminary Survey Results of Current Implementation of MPA 2008-2015

Human Resource for Health Recommendations 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 Human Resource for Health Preliminary Survey Results of Current Implementation of MPA 2008-2015

Preliminary Survey Results of Current Implementation of MPA 2008-2015 Recommendations Provide ambulance services for the referral of 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 Infrastructure Preliminary Survey Results of Current Implementation of MPA 2008-2015

Preliminary Survey Results of Current Implementation of MPA 2008-2015 Recommendations 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 Medicines & Supplies Preliminary Survey Results of Current Implementation of MPA 2008-2015

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

Preliminary Survey Results of Current Implementation of MPA 2008-2015 Recommendations Strengthen technical 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 Others Preliminary Survey Results of Current Implementation of MPA 2008-2015

Case study in Tbongkhmom Province 24 Y.o 4th 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 2:25pm. 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

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

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

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

Preliminary Survey Results of Current Implementation of MPA 2008-2015 References: HSSP2, HSSP3 MoH Orders. No. 020 DGH/DHS, dated on 09 March 2015 Presentation of Dr. Or Vandine, DGH in at 37th National Annual Health Congress 2016 Dr. Sok Srun, Director DHS Dr. Indrajit Hazarika, , Technical officer, WHO to Cambodia Preliminary Survey Results of Current Implementation of MPA 2008-2015