1. 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

2. 11/10/2018

3. 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

4. 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).
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5. 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.

6. 20-30km between 2 Referral Hospitals or Max:3hrs by car/boat
HEALTH COVERAGE
A.HCP Criteria
Criteria
1.Population
2.Accessibility
Health Post
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
20-30km between 2 Referral Hospitals or Max:3hrs by car/boat
11/10/2018
Source: HSSP2, , MoH

7. 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

8. 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

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

10. 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 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: HSSP

11. 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: HSSP

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

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

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

32. 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