1. Cambodia1

2. 2 Cambodia Assessment Ung Phirun Chroeng Sokhan

3. Cambodia3 DemographicsCambodia Area (sq km)181,000 Population 11,800,000 15.6% urban GNP per capitaUS $260 Human Development Index.514 137/174 Literacy rate Male: 58.6% Female: 21.1% Infant mortality rate100.2 per 1,000 Life expectancy54 years World Bank, 1999 Cambodia

4. 4 Health Care Delivery System Public sector: centralized three-tiered health care system NGOs: 108 working in the health sector Private: 382 private clinics and hospitals registered 70% of providers are not registered Household spending on health in 2000 was 11% of GDP, 80% of all health expenditures

5. Cambodia5 Pharmaceutical Sector Public sector utilizes a centralized procurement and distribution system Donor-funded pilot programs contract out management of public health facilities to private organizations Six pharmaceutical manufacturers; only three operating

6. Cambodia6 Pharmaceutical sector Total pharmaceutical expenditures for 2000 were 31.46 million USD  Households: 57%  Donors: 25%  MOH: 18% There are approximately 3700 retail outlets for pharmaceuticals, of which 75% are unlicensed

7. Cambodia7 Geographic Accessibility 65% of the population is less than 10 km or 2 hours’ walk of basic health care facility Hours Average number of facility operating hours per day

8. Cambodia8 Availability PublicPrivate clinic Private pharmacy NGO clinic ODMS Set of un- expired tracer items in stock 59%56%66%50%69% Time out of stock 3%1%0% 4% Prescribed items dispensed 80%59%NA54%--

9. Cambodia9 Affordability NGO/ Mission Private Facilities Pharmacy/ Drug Depots Unlicensed Pharmacies Pneumonia (pediatric 1-5 years) Amoxicillin 250mg (IMCI).262.99.971.4 Co-trimoxazole 80/400 (IMCI).912.89.75.84 Dysentery (pediatric 1-5 years) Co-trimoxazole 80/400 (IMCI).912.89.75.84 Number of days worked to pay for treatment

10. Cambodia10 Affordability (2) Less than 1% of population is covered by any risk sharing scheme Payment for health care services is a major cause of impoverishment; 46% of loss of farms was due to health care costs Children from poor families have lower treatment rates than those from higher income families (20% vs. 52%)

11. Cambodia11 Affordability (3) Average percentage difference of lowest prices among facilities –Highly variable, 524% to 1140% Median percentage difference between most and least expensive unit price within facilities –55% to 273%

12. Cambodia12 Acceptability Distance, cost, and lack of drugs negatively influence utilization of public health services Overall the public sector was used in 20% of all illnesses and injuries Retail drug outlets are the first point of contact for 70% of the population

13. Cambodia13 Quality of Products and Services MOH Cambodian drug market study found overall failure rate of 13.5% 50% of drugs are not registered Failure rates: –Registered: 5.2% –Unregistered 22.3% Tracer drugs that failed quality testing Percent

14. Cambodia14 Quality of Products and Services (2) In retail drug shops antibiotics were inappropriately recommended 72% of the time (ARI/ no pneumonia) 50% actually purchased antibiotics Number of drugs per encounter  MOH 2.0  Private 3.8  NGO 2.5

15. Cambodia15 Quality of Products and Services (3)

16. Cambodia16 Access Gaps Availability Affordability Quality of drug products Quality of pharmacy services and information Geographic access in rural areas

17. Cambodia17 Potential Strategy Performance-based network of retail drug outlets Network of health service providers to be served by the pharmacy network Group purchasing cooperative for network members Community-based care program

18. Cambodia18 Potential Country Strategy (2) Group purchasing cooperative Quality Standards, training, monitoring, accreditation Availability Affordability Consumer s Network of pharmacies, drug depots Network of providers Insurers NGOs working in health

19. Cambodia19 Viability Facilitating factors  Franchises, as a means of meeting public health needs, have a basis in regulations and public policy  The proposed intervention has strong MOH and private sector support  Proposed pilot locations are willing to dedicate human and financial resources  The intervention will build on existing programs that work with drug retailers

20. Cambodia20 Viability (2) Barriers  The government supports public-private partnerships, but sometimes exhibits ambivalence about the private sector  Incentives for continued participation are rather limited  Human resource development may require medium- to long-term support to fully develop