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

9. Understanding Rural Health Service in Cambodia: Results of a Discrete Choice Experiment

202 Seng Bundeth, Net Neath, Pagaiya Nonglak and Sok Sethea 9 UNDERSTANDING RURAL HEALTH SERVICE IN CAMBODIA Results of a Discrete Choice Experiment Seng Bundeth, Net Neath, Pagaiya Nonglak and Sok Sethea BACKGROUND Brief Overview of Cambodia’s Health Service System In Cambodia, health centr es and health posts, mainly located in r ural areas and providing the minimum package of activities (MP A), are the first point of patient contact. These facilities ar e staffed by nurses and midwives and do not normally include doctors, except in the case of former district hospitals. The health post is the lowest level of facility and is usually served by one or two staf f. The next facility level ar e the referral hospitals, which ar e classified according to their capacity to pr ovide the Complementary Package of Activities (CPA). Although their staffing includes full-time doctors, CPA 1 09 Improving Health 8/24/11, 4:25 PM 202 Understanding the Rural Health Service in Cambodia 203 hospitals do not have general anaesthesia sur gery. CPA 2 hospitals have general anaesthesia surgery, and CPA 3 hospitals, the highest level, usually located in provincial centres, offer additional specialized services. In 2003, fifteen referral hospitals were classed as CPA 3 (MoH 2006a). The five MoH national hospitals top the hierar chy of government health care facilities. All are located in Phnom Penh and of fer a range of specialized tertiary services. Three private non-profit hospitals, which are members of the Kantha Bopha Gr oup, are also included in official statistics as “national hospitals”. Of those, two are in Phnom Penh and another one is in Siem Riep. The Ministry of Health plans to incr ease the number of operational districts and health facilities to enhance the accessibility of car e (MoH 2008). The private health sector has grown substantially since 1993, and there are now more for-profit than public facilities in Cambodia. Recently, two private hospitals have been established in Phnom Penh. In addition, there are many dif ferent types of agencies within the private health sector , ranging from medical clinics (without beds) to polyclinics equipped with high-technology equipment. There are 2,457 medical clinics without beds and 274 with beds. Accounting for only 9.5 per cent of the country’s population, Phnom Penh harbours a dispr oportionate share of private facilities (Table 9.1). TABLE 9.1 Licensed and Unlicensed Private Sector Clinics in 2003 Population Maternity Medical Medical Dental Dental facilities clinics clinics clinics clinics without with without with beds beds beds beds Phnom Penh 1.3 million 2 573 205 213 35 9.5% 7.4% 23.3% 74.8% 48.5% 100% Rest of country 12.0 million 26 1,884 69 226 0 90.5% 92.6% 76.7% 25.2% 51.5% 0% Total 13.3 million 28 2,457 274 439 35 Source: Office of Ethics and Regulation, Hospital Services Department, MoH, 2004 (quoted in MoH 2006a). 09 Improving Health 8/24/11, 4:25 PM 203 204 Seng Bundeth, Net Neath, Pagaiya Nonglak and Sok Sethea Four paediatric, private, non-profit hospitals are managed and funded outside the government sector. Additionally, the Centre for Hope Hospital operates virtually entirely outside the Ministry of Health. Some NGOs, such as the Repr oductive Health Association of Cambodia and Reproductive and Child HealthAlliance, also run health clinics, particularly in reproductive health care. However, the boundary between this sector and the government is blurr ed because some non-government agencies and international development agencies work in partnership with the Ministry of Health and contribute substantial management and financial support to the operation of government hospitals and health centr es. SITUATION AND TREND OF HEALTH WORKFORCE Even though the private, for -profit sector boasts the most facilities, the majority of Cambodian health workers are employed in the public sector. Table 9.2 pr esents the existing public health workfor ce for the most important clinical cadres. These figures do not include workers who work exclusively in the private sector , though many in the public sector of fer their services in private facilities as well. Whereas the public health workfor ce headcount expanded by 9 per cent between 2004 and 2008, the population gr ew by only 6.5 per cent. Combined with the gr owth in private for -profit facilities, these figur es suggest that the ratio of health workers to population has been...