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.

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.