Public health reform in Cambodia: hospitals gain autonomy

Svay Rieng (Cambodia). 16/08/2007: Public hospitals in Phnom Penh will become Referral hospitals. For hospitals in the provinces, like the Svay Rieng ‘referral hospital’ above, the reform will have to wait ©John Vink/ Magnum

Ka-set
http://cambodia.ka-set.info/

By Ros Dina

A small revolution is on its way in the Cambodian public health system. Indeed, by the end of this year, no less than four public hospitals in Phnom Penh will become autonomous. The law, which has already been adopted and enforced for several years at Calmette hospital will progressively be extended by the Ministry of Health to the National Paediatric Hospital, the Khmer-Soviet Friendship Hospital, Kossamak Hospital and the National Maternal and Child Health Centre. Consequences for those institutions are that they will be able to manage their budget themselves in a much more flexible and reactive way, but they will also be in charge of more responsibilities. Here is a little explanation, by the main protagonists in this major change.

Autonomy already enforced
Things are all set, says Sok Panha, deputy director of the Department of Planning and Health Information (DPHI) and in charge of the Ministry of Health’s Equity Fund project: four new Cambodian public hospital institutions are ready to acquire full autonomy in the next few months. It is already the case of Calmette Hospital, which became autonomous a few years ago, and of the Pasteur National Public Health Institute in Tuol Kork, which switched over last year, but the four main health centres in the Cambodian capital will progressively have to manage their resources and expenses themselves, with a view to improve quality and efficiency.

“We are currently turning the medicine-control laboratory into an autonomous body – their task is to ensure the quality of pharmaceutical products”, says the deputy director, who also initiated the process and took the necessary steps with those four public hospitals. According to her, the reform is synonymous with development and efficiency and should allow the strengthening of the quality of health services. As the state provided and managed hospitals’ budgets until now, the institutions lacked flexibility and resources to adapt quickly to the needs of patients, even when they generated important income.

Autonomy does not mean privatisation
“Being autonomous does not mean being privatised”, says Sok Panha, who insists on the notion of public service. “We will give them the responsibility of managing the way they function themselves. Today, the Ministry [of Health] is still in charge of the daily management, indirectly. By continuing to work like this, hospitals are not given any responsibilities and their services are poor quality because they fully depend on the Ministry when it comes to solving issues. If we leave them to take action themselves, I believe they will know perfectly how to save energy, water or take care of public building conservation in the best possible way, for instance.”

A quicker implementation of decisions
For Chhour Y Meng, head of the National Paediatric Hospital, being autonomous means that hospitals have at last the right to solve problems themselves and straight away, and therefore to save time, a particularly precious notion when patient’s lives are at stake. At the moment, when his hospital needs equipment or certain investments, Chhour Y Meng must apply at the appropriate service at the Ministry. Applications go from one office to the next and several months usually pass before requests are eventually given the green light.

“In the current system, drugs are supposed to be provided to hospitals once every six months. Before being able to effectively use the medicine ordered, we must wait eight to nine months… This does not respond to emergency situations in any way”, the director says. For equipment orders, we also have to be very patient… to the detriment of patients. He gives an example: “The hospital needed a machine for the testing of [blood] platelets as there was an important dengue fever epidemic going on. The application was finally validated, long after the epidemic. So, what is this machine useful for, several months later? Of course, we can still keep it somewhere until next year!”, he deplores.

Coordinated objectives
For the director of the paediatric hospital, this new status will be a real breath of fresh air and will at last allow the health sector to develop in Cambodia. Better reactivity facing sanitary problems, quicker and improved services, modern equipment, drugs that are appropriate, better-trained human resources: those are the many improvements that Chhour Y Meng wishes to fund thanks to a budget managed in an autonomous way, as close as possible to the daily reality of his institution.

However, risks might appear due to an excess of autonomy. Indeed, hospitals operate in jumbled order as they set their own priorities themselves, without any global perspective or goals for public health. “We will work along the government policy”, the director says. Besides, he prefers talking about “semi-autonomy”. “Unlike the current situation where management and decision-making are scattered in several places, we will have, thanks to the reform, a governing board in charge of the direct management of the hospital project. When we have to comply with obligations enacted by the government, we will organise a meeting between a committee and the governing board. The latter will be able to make a decision and have it implemented as soon as possible”, he explains.

Public services: serving the interest of the public?
Director of the Khmer-Soviet friendship hospital Say Seng Ly shares the enthusiasm of his colleague Chhour Y Meng and brushes aside rumours about the reduction of health budgets and disengagement on the part of the state. “We refuse to hear rumours saying that what belongs to the state is shrinking. I insist on pointing out that, on the contrary, this reform allows the state to broaden its scope of action. The fact that we are given more autonomy, especially financially-speaking, will help us modernise human resources and equipment in public hospitals”, the director suggests.

What about care provided to the most destitute ones?
As they will remain public institutions, those autonomous hospitals will charge themselves healthcare brought to patients. But according to Say Seng Ly, this will change nothing for the poorest ones, who cannot afford to pay for hospital bills. The only difference, he claims, is that from then on, they benefit - on top of theoretical gratuity of care - from quality services. “Making a public institution autonomous is not meant to kill the poor, but on the contrary to help them. When the hospital generates money, the poor will also benefit from quality services, wards will be clean… Because we will take money from the wealthy ones to give it to the poor”, Say Seng Ly says, convinced.

The Equity Fund as a backup
Facts are that directors of these public hospital will not need to act like this at all. Public hospitals will be able to charge for healthcare given to the poor, as they do not come for free, but the rich will not have to pay for the bill… Instead, the Equity Fund, created in 2000 by the government in collaboration with foreign partners and managed by the Ministry of Health, will serve as a backup. According to Sok Panha, who is in charge of this fund, the state injects between 500,000 and 600,000 dollars every year into it, and in addition to that, donor countries and institutions grant an extra million dollars. “The money from the fund is already used in six hospitals in Phnom Penh – Calmette, Kossamak, the Paediatric Hospital, the Khmer-Soviet Friendship Hospital, Angduong and the National Maternal and Child Health Centre – and also helps some ten provincial hospitals and some district institutions and health centres throughout the country”, she stresses.

Three out of four poor people will be exempt from paying fees
According to data provided by Sok Panha, the Equity Fund has already taken care of the fees of almost three million poor people, i.e. 68% of Cambodians living below the poverty line (4 millions, or 35% of the total population). Destitute patients will not need to pay for anything, at least in theory. “The person in charge of the concerned hospital institution must issue a report presenting the number of poor people who benefited from health services in their hospital without having to pay. Then, the Equity Fund pays back the amount due”, Sok Panha explains.

Public hospitals: hospitals for the poor?
Will the resources of these autonomous public hospitals actually come from rich patients who can afford access to healthcare? The director of the Khmer-Soviet Friendship Hospital acknowledges that at the moment, the greater majority of patients is poor or belongs to the emerging middle class. As for the wealthiest, they rarely go to public hospitals but prefer private clinics in the capital or hospitals abroad in neighbouring countries. Say Seng Ly believes that if public institutions manage to improve, be more modern and buy high-technology equipment thanks to the independent management of resources, wealthy people will think twice and might turn again to the public sector, less costly and more accessible than healthcare abroad. “I think that after two years of autonomy, we will manage to attract all categories of patients, and especially the wealthier, who will turn to our services with complete confidence”, the director says.

Before fully enjoying their autonomy, directors of public hospitals in Phnom Penh will still have to personally plead for their own cause before high-ranking civil servants and the government. Professor Teng Seung, director of the Kossamak Hospital, is hopeful about his application, even though he has already presented it several times to the Ministry of Economy and Finances and the Ministry of Health. He was recently called by the Council of Ministers to answer the final questions raised by the reform, the ultimate stage before the Council approves it and prime Minister Hun Sen signs it. The director, like his peers, is waiting to be given the go-ahead by the government to be able to make his own way.