A Bitter Pill
Semi-Autonomy Hoped to be Cure-All for Local Hospitals
By Hor Kimsay Economics Today
Healthcare has been one of the hardest
services to deliver in Cambodia. Now
plans are afoot to overhaul the ailing
healthcare system.
Health services in Cambodia are
starkly divided into public and private
providers. Given Cambodia’s stubborn
poverty and least developed country
status, the public sector unsurprisingly
dominates, especially in rural areas.
While public sector has undeniably
played a crucial role in meeting the health
needs of the population, especially the
underprivileged and disadvantaged, the
demand for hospital care often outstrips
supply. Public healthcare that is supposed
to be free sometimes entails payment,
and the quality of services varies
wildly with location. Few would
be treated at the understaffed
clinics in remote areas given any
other choice.
Development partners are
already heavily involved in
healthcare here, but providing
even basic services is expensive.
Cambodia’s resources are already
stretched—running existing
hospitals absorbs much of the
health budget.
But many treatments are not universally
available. Free life saving surgeries
and treatments for diseases like cancer
for every Cambodian is far beyond the
reach of the current system.
Clearly a complete overhaul is needed.
The Ministry of Health (MOH) is
slowly turning major capital top’s hospitals
into semi-autonomous institutions,
enabling them to make more of their own
decisions.
The National Pediatric Hospital (NPH)
hospital received the permission on Jan
11 to become semi-autonomous.
Dr. Kdan Yuvatha, NPH vice-director,
said that the objectives of semi-autonomy
are improved communication, reduced administrative complexity and
improved Government responsiveness to
local needs. The idea, he told Economics
Today, is to enhance effectiveness and
efficiency of management by allowing
greater discretion, to increase accountability
to the public, and improve local
knowledge of development priorities—to
achieve self-reliance, self-determination,
and increase the role of local responsibility
in ensuring good governance.
Previously, the National Pediatric
Hospital was governed directly by the
Ministry of Health. Now the hospital will
be governed by a hospital consultancy
charged with overseeing all aspects of
management and care.
“Autonomy has provided a greater
degree of local authority than in a traditional,
directly managed public service.
Autonomy can include financial management,
for example, the freedom to spend
within an overall budget, setting pay levels;
personnel management—hiring and
placing staff; setting terms and conditions
of employment, reward and discipline;
and service development, including
offering new services,” explained Dr.
Kdan Yuvatha.
More efficient use of the resources
already assigned to hospitals is one of
the aims.
“If we become an autonomous hospital,
we will have chance to give managers
clear responsibility for performance, so
we can make decisions more quickly with
clear responsibility and accountability at
a local level based on local conditions and local priorities,” Dr. Kdan Yavatha said
But managerial transparency is a must.
Dr. Kdan Yavatha said transparency
is actually a prerequisite for semiautonomous
status. In the case of the
NPH, the seven members of the hospital
consultancy were chosen from different
institutions, including representatives
from the Ministry of Health, the Office
of the Council of Ministers, the Ministry
of Economy and Finance,
the Phnom Penh Municipality,
experts with experience in
health science, and two members
of the NPH’s staff selected
through a vote.
Bled Dry?
Semi-autonomous hospitals
also get to manage their
finances and charges for treatment.
Dr. Kdan Yuvatha downplayed the
differences.
“It was not much different between
before and after the transformation. People
have to pay for healthcare services
in the same way but hospital autonomy
required them to pay a little bit more,”
he said.
Cambodia’s public healthcare currently
suffers shortages of resources,
said Dr. Sin Somuny, executive director
of Medicam Cambodia. “The ability of
public hospital in Cambodia to provide
health service is still limited. The technical
quality, services provide, and staff
politeness is still relatively low.”
For those who can afford it, traveling to Vietnam, Thailand or Singapore is
common.
Ou Ratanak, project manager of People’s
Health Development Association,
said less wealthy Cambodians still shun
public hospitals where possible because
of perceived poor service. “According to
my observations, for private hospitals,
the services quality, environment,
hygiene and sanitation,
and staff manner is much better
than in public hospitals. That’s
why those who can avoid the
public service and prefer the
private sector service. A So
majority of people who have
been going to take the service
from public hospital are the
poor or vulnerable who have no
ability to pay or access to health
service from private sector.”
Ensuring hospital staff
receive suitable recompense
and a voice in management
could help attract human resources.
Sound use of incoming funds could
help purchase medicine and equipment,
allowing semi-autonomous hospitals to
broaden access to health services, and to
offer more and better treatments. That
could in turn encourage more Cambodians
to be treated at home, providing
more resources for Cambodian hospitals.
The current outdated fixed salary system,
and rigid manpower management
rules and regulations mentioned by Ou
Ratanak could certainly improve under
a semi-autonomous system. But there
are concerns that those living below the poverty line may lose out under
semi-autonomy.
“We are worrying how the poor and vulnerable
will access health services,” said
Dr. Sin Somuny. “There is a big number
of people living below the poverty line,
who have no ability to pay for health
fees. This is more serious if we include
the number of population living on and
a little bit above the poverty line. Even if
they are not poor, they are still vulnerable
and have cannot pay for hospital fees.”
Ou Ratanak agreed that the Government
must still take responsibility for the
poor. Each hospital should share part of
its budget with the MoH and NGOs to
ensure service delivery to the poor, he
added. “If we reform the system to hospital
autonomy, we need to ensure that the
management system of transparency and
accountability of the public sector will be
improved. We need to ensure that the
income get from people is really implied
to the improvement the service quality
and the requirement in making the hospital
efficient.”
Dr. Sin Somuny said that Cambodia
is developing the initiatives needed to break the links between poverty and illhealth.
The most effective of these are the
Health Equity Funds, fee-waiver schemes
that aim to provide increased access to
health services and greater community
involvement for the poor. “The Government
should … ensure that the poor and
vulnerable people have full access to public
healthcare … [E]lsewhere in countries
such as Bangladesh, India, Malaysia,
and Singapore, the Government is fully
responsible for the whole expense of
public health. They do not charge the
service fees that ban the poor for access
to healthcare services.”
Dr. Kdan Yuvatha reiterated that semiautonomous
hospitals are different to
private hospitals. Staff and some parts of
the hospital are under the control of the
Government, offering the same free and/
or subsidized treatments, he stressed,
underlining the focus on public health.
“The health equity fund from MoH and
other NGOs is still provided in substitution
the paying of the poor. That is why
the poor and vulnerable will still be able
to access to service care from NPH.”
Ou Ratanak said that equality of treatment
should be the priority. “Our concern
is the disadvantaged people are less of a
priority.”
Dr. Kdan Yuvatha claimed that the
NPH uses the same doctors and staff,
the same quality of medicine, and the
same equipment for both paying and
non-paying patients.
Mam Sochan, a villager from Kandal
province, confirmed that her child had
received care at the NPH free of charge.
She said the hospital provided her free
two meals per day and free food for her
baby as well.
“As my own experiences for several
times stay in NPH, even I did not
pay for services fee, but I cannot
say I was ignored or didn’t
get good care. On the contrary, I
am satisfied with care from the
doctors and staff,” she told Economics
Today.
Thary, 31, from Saang District
in Kandal province said she was
charged by the NPH. She paid
CR20,000 (just under US$5) per
day for two main meals, medicines
and doctors services. She
said that the hospital fees were
still cheaper than a private hospital.
“The staff here are careful and
regularly follow up on my child’s condition.
If I go to private hospital, I have
to pay for the services at higher price.
Moreover, I have to spend more on food
and medicine” Thary said.
Dr. Kdan Yuvatha vowed the NPH
would continue to do all in its power to
treat any sick child, no matter what the
parents’ backgrounds.
Ou Ratanak agreed decentralization
through hospital autonomy is essential to
improve hospital efficiency and address
the division of economic and administrative
power and responsibility. But he
asked that the poor not be forgotten.
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