High Level Policy Dialogue – Cambodia Towards a Strong and Sustainable Health Sector Development (2016-2020 Health Strategic Plan) 24 June, 2015 Cambodia

Towards a strong and sustainable health sector development Proposed agenda Introduction (20 minutes) Brief welcome by the Minister (MOH) Purpose and introduction (WPRO-Regional Director) Current situation and challenges (40 minutes) Presentation (WHO) Discussion The way forward (60 minutes) Discussion (start with remarks by WPRO-RD)

Outline Current situation and challenges Cambodia’s significant progress in improving population health Health system challenges and donor funding The way forward Increase domestic funding Use the funding more efficiently

Current situation and challenges

Cambodia’s achievements Cambodia is on track to achieving all MDG goals (improvement in Maternal and child health, HIV, TB and Malaria) Life expectancy increased 55 years to 72 years between 1990 and 2013 Measles elimination - Immunization coverage of measles reached 93% (2014) Skilled-birth attendants reaching 89% (CDHS, 2014)

Health MDGs scorecard for LMICs in the Western Pacific Region (2014)

Overview of health financing Sources of funding, 2012 Health expenditure per capita - USD 70 Total health expenditure as % of GDP - 7.2% High out-of-pocket payment Heavy reliance on donor funding Low government spending on health Source: Cambodia NHA Report 2014

Total health expenditure (%) GDP selected countries, 2012 Note: OOP = out-of-pocket health expenditure; GGHE = General Government Health Expenditure Source: Cambodia NHA Report 2014, WHO Global Health Expenditure Database (WHO, 2014) * For Cambodia, GGHE does not include donor funding. Donor funding is included in ‘other%GDP’.

Donor funding contributed to better health outcomes Donor funding has been critical for Cambodia to address population health: The control of communicable diseases (HIV, TB, malaria) Maternal and child health Immunization coverage Helping the poor to access services (Health Equity Funds) Expenditure share by donor category, 2012 Source: Cambodia NHA Report 2014

Donor funding on health to Cambodia The nature of donor funding Volatile and unpredictable Often operated as vertical programs Affected by socio-economic and political factors May not always align with recipient country’s priorities Difficult to make long-term commitment Source: Cambodia NHA Report 2014, WHO Global Health Expenditure Database (WHO, 2014)

Donor funding poses challenges Risk of fragmentation Donor funding, if skewed towards certain diseases or specific programs, may not always reflect the country’s priorities Certain donor funded programs operate separately with their own mechanisms Endangers sustainability Donor funding is about the same amount as government spending from domestic source Global Fund, GAVI and Gates Foundation accounts for one-fourth of total donor funding, the decrease in funding will have big implications on sustainability of these programs

Government spending on health is among the lowest in Asia countries Government expenditure on health as a % of General Government Expenditure, 2012 Government expenditure on health as a % of Total Health Expenditure, 2012 Note: GGHE = General Government Health Expenditure; GGE = General Government Expenditure; THE = Total Health Expenditure * For Cambodia, GGHE does not include donor funding. Donor funding is included in ‘other%GDP’. Source: Cambodia NHA Report 2014, WHO Global Health Expenditure

Out-of-pocket expenditure on health is among the highest in the region OOP expenditure as % of THE, 2012 The components of OOP, 2013 Note: OOP stands for out-of-pocket. Source: Cambodia NHA Report 2014, WHO Global Health Expenditure; Lao NHA. Source: Cambodia Socioeconomic Survey, 2013

Limited resource on prevention and other priority areas (eg.NCDs) Prevention expenditure as a % of total health expenditure Distribution of health expenditure by diseases Source: WHO Global Health Expenditure database, 2014 Source: Cambodia NHA Report 2014

Private sector provides large quantity of services and draws substantial resources Service utilization by providers [%] Distribution of health expenditure by providers Source: Cambodia Socio-economic Survey (CSES) 2012 Source: Cambodia NHA Report 2014

Quality of health services is low in both public and private facilities Source: World Bank Study on health care quality, 2013

Summary of the challenges Heavy reliance on donor funding with vertical approaches High out-of-pocket payments paid for poor quality of services Low government spending on health from domestic sources Large private and informal sector with limited regulatory mechanisms Low quality of services in both public and private sectors

The way forward

Reshape and re-orient health system NOW Economic growth gives the government the means to invest in its people’s health Reshape and re-orient the health system: To improve integration and coordination among programs and different level of health services Take strong ownership and align donor funding with national strategy and priorities Improve transparency and accountability Enhance people’s trust in public services

Increase government spending on health from domestic sources and use it efficiently The amount of government spending on health matters Efficient use of resources with greater transparency and accountability is crucial More domestic funding will strengthen the national ownership More domestic funding allows government to address the country’s health priorities and to work towards long-term sustainability

Rebalance budget allocation towards prevention and primary care More resource for sub-national levels, especially health centres and district hospitals Ensure maintenance of equipment and regular supply of quality medicines and other essential commodities at the primary level Bring compensation and motivation of health workers at the primary level facilities to the adequate level Introduce appropriate interventions to encourage retention of health workers in the rural areas and at the primary level facilities

Improve safety and quality of service in both public and private sectors Strengthen regulatory capacity and reinforce implementation of legislations Develop and update clinical standards based on evidence and improve compliance Strengthen the registration, licencing and accreditation mechanisms Improve quality of medical education and create opportunities for continued professional development Further develop systems for monitoring and oversight of health services

Minimizing out-of-pocket payment and make services more affordable Increase prepayment Balance the supply side and demand side subsidies Health Equity Funds should focus on providing vulnerable populations access to a well-defined package of good quality essential services Leverage private sector through contracting and payment methods (financial incentives) for public benefit

discussion