Improving Health Sector Performance: Institutions, Motivations and Incentives - The Cambodia Dialogue

5. Social Health Insurance in Cambodia: An Analysis of the Health Care Delivery Mechanism

Social Health Insurance in Cambodia 101 5 SOCIAL HEALTH INSURANCE IN CAMBODIA An Analysis of the Health Care Delivery Mechanism Sopheap Ly 1. INTRODUCTION This chapter is based on a r esearch paper that aimed to analyse various mechanisms of health car e delivery, both in theory and in practice, in order to suggest appr opriate mechanisms for a social health insurance (hereafter SHI) scheme. The main question addr essed by the chapter therefore concerns government policy for health car e delivery when the SHI scheme is implemented in 2015. Should the government engage private providers in delivering services to the insur ed by allowing the SHI scheme to contract with private providers, or should it instead invest in building more health facilities and recruiting more staff for public facilities?Although providing services through public facilities would reduce transaction costs, building more public facilities to accommodate rising demand adequately would not be feasible and would consume a lot of time and r esources. 05 Improving Health 8/24/11, 4:23 PM 101 102 Sopheap Ly When we take into account (i) the intention of the government, (ii) the behaviour of health service users and (iii) the capacity of public facilities, the proposition that the private sector should be engaged in the delivery of health services to the insur ed under the SHI scheme is convincing. The 2005 Master Plan for Social Health Insurance in Cambodia articulated an intention to encourage private pr oviders to contract with insurance schemes as soon as an accreditation system is established (MoH 2005). The master plan, however , stated clearly that the package will initially cover only services deliver ed by public pr oviders within the province, meaning that neither national hospitals nor private facilities will be covered under those insurance schemes (MoH 2005) curr ently. The engagement of private sector service pr oviders, therefore, depends on how soon an accreditation system is put in place. As for the behaviour of health service users, r esearch in 2006 found that the utilization rate of public facilities to seek first treatment was very low, accounting for only 22 per cent, while that of the private sector accounted for 69 per cent 1 (48 per cent used private hospitals, clinics, pharmacies, and private consultations and 21 per cent used non-medical shops and outlets) (National Institute of Public Health 2006). 2 Such a low utilization rate reflects low trust in and satisfaction with public facilities. In addition, there were many complaints from public facility users about inadequate medicines, expensive services, long distances, poor staf f attitude, low service quality, and inappropriate opening hours (National Institute of Statistics 2004; Annear 2006, pp. 15–18). Another big challenge facing the government is scaling up the number of public health facilities. The Ministry of Health has voiced great concern over the current shortage of health staf f and lack of capital investment which makes it dif ficult to cover operational costs and invest in health infrastructure over the period 2008–15 (MoH 2008 a). According to the 2008 Health Strategic Plan, the number of commune health centres is expected to increase by about 77 per cent from 957 in 2007 to 1,697 in 2015, and that of district referral hospitals is expected to incr ease by about 20 per cent during the same period (MoH 2008). For health centr es alone, at least 6,640 new staff will need to be employed over the same period. In this r egard, the Health Strategic Plan suggests that the existing criteria should be reviewed and focused on among other factors, (i) the need in major urban areas vs. remote/rural areas; (ii) the potential of private pr oviders; and (iii) the alignment of Health Coverage Plan with the Decentralization and Deconcentration requirements (MoH 2008a). 05 Improving Health 8/24/11, 4:23 PM 102 Social Health Insurance in Cambodia 103 By considering the above constraints and factors, it seems that the government is considering the potential of the private sector. It is unclear, however, whether the subdecr ee on social health insurance will engage the private sector or not. According to some of ficials in the Ministry of Health’s department of planning, it is most likely that the private sector will not be engaged as health car e providers under the SHI scheme. The chapter, therefore, aims to suggest appropriate health care delivery mechanisms for the social health...