Joyce Couwenberg

 

After three decades of warfareand social destruction, a structural health care system in Cambodia is non-existing. Cambodians do not use public health care facilities, but visit their traditional healers or use very expensive private medical services. Health net International (HNI) works together with the local population to help build a better and structural public health care system in Cambodia. "Our projects have improved the quality and stimulated the use of public health care."

 

During the Vietnam war, at the end of the 1960s, Cambodia was driven into a civil war. Subsequently, the Khmer Rouge led by Pol Pot seized power and started experimenting in social engineering, completely destroying the social structure in Cambodia. Cambodians from the city were driven into the countryside and families were separated and spread all over Cambodia. This period is known as the 'Cambodian holocaust'. In 1979, the Khmer regime was overthrown by Vietnamese troops, which occupied Cambodia. In the years that followed low intensity warfare existed between Vietnamese troops and Khmer Rouge guerrillas. Despite several attempts by the United Nations, a fragile political stability was not reached until the death of Pol Pot in 1998.

 

After decades of terror, Cambodians were expected to rebuild their country. The economy was recovering due to a strict fiscal discipline. However, with an average life expectancy of 54.4 years, the health status of the Cambodian population was one of the poorest in South East Asia. Prenatal care was very poor and diseases such as malaria and HIV still pose a serious threat to the Cambodian population. Willem van de Put, director of Healthnet International (HNI), visited Cambodia several times during the past decades: "Cambodians have lived in terror for years. Even the new generations, who have not experienced the war, still bear the pain of that period. "Approximately half of the Cambodian population shows signs of post-traumatic stress disorder (PTSD), emotional disorder or anxiety syndrome. In order to help people in war-affected countries, HNI believes it is important to listen to the local population and work with local resources. Van de Put: "Too many organisations take their western philosophies to a country and force them onto the local population. That does not work, not if you want to build a lasting health structure. You have to see what is there and what the local population wants."

 

The Pereang district

During the war, the health sector was fragmented. Cambodians could choose between different health services. There were the private practitioners, the traditional healers and there was an underfunded public health system. Because of this development, Cambodians started looking for instant cures. The market for syringes and intravenous drugs increased rapidly. Private practi-tioners did not necessarily give people what they needed, but what they wanted. This led to an annual expenditure of $33 per capita, 80 percent of which was paid out-of-pocket. Getting sick was the quickest way to poverty.

To improve public health care, the Cambodian government started a pilot study in 1998 in several districts to see which health care system could be implicated in Cambodia. The government divided the districts into three groups: the contracting-out districts, the contracting-in districts and the reference districts. In contracting out districts, complete district management was signed over to private contractors. In contracting in districts, district management was signed over to private contractors under strict public service regulations. Standard public service was provided in the reference districts, continuing existing government policies. HNI was given a contracting-in district: the Pereang district.

"When we studied the situation in the Pereang district, we found several problems with the existing health system", says Van de Put. "First, the medical staff was extremely underpaid. To support their families, most members of the staff provided private medical care at their homes for high prices. Second, the public health care was considered unreliable by the local population, because too little was known about what went on in public facilities. Our goals were to improve the quality of the public health system and to provide a decent salary for the medical staff."

 

Performance

HNI introduced a performance-based staff incentive structure in which the medical staff was to be rewarded for their work instead of being paid regarding. A third of their salary therefore depended on their performance. Additionally, HNI tried to discourage staff members to provide private medical service by adding a clause to their contract. The local population was asked to pay an equity fund as it was found that free medical care did not reach the poor but the well-connected. The extra income was used to pay the extra salary of the staff members.

By providing a better salary, most staff members gave up their private practices and paid more attention to their work at the public medical Article Training of midwives. Birth is re-enacted for learning purposses 8 Global Medicine facilities. The quality of the medical care improved and patients were given more attention. As the prices for the public medical care were announced to the local population, more Cambodians started using the public health system instead of the more expensive private services. HNI had reached their goals by improving the quality of the public health system and in making it accessible for the local population. "In three years, our projects have improved the quality and stimulated the use of public health care, while the amount of money spent per capita on health services decreased."

After the pilot study, it was concluded that the contracting-out system was the most efficient system for Cambodia. HNI continues their work in the Pereang district on a contracting-out basis. "We have expanded our project to several extra districts and even two new provinces. In the Pereang district, you can see a work ethos developing: everybody is working hard and keeping an eye on their colleagues. We should be able to leave in three or four years, gradually handing over our posts to Cambodians," says Van de Put. "Of course we will stay in contact after we leave."

Van de Put does have some questions about the contracting-out system. "Handing everything over to private contractors has its disadvantages. We can see many examples in our own country. When you are running a business, you want to make a profit and show how well you're doing. Vaccination of the local population does not contribute to this view and may therefore be neglected. It would be my opinion to thoroughly screen the different aspects of a health system and then decide which parts can be signed over to private contractors and which parts should be held on to by the ministry of health. We are discussing this with the Cambodian government." 

Safe motherhood

Another project of HNI focuses on mother and child. Infant mortality rates in Cambodia are the highest in the region. Maternal mortality rate is estimated at 437 deaths per 100,000 births. The high mortality rate is mainly due to abortion complications, ecclampsia and hemorraghe. HNI works together with the Provincial Health Department in implementing the Cambodian National Health Coverage. HNI tries to improve the quality of health education and promotion by training of trainers in management skills and providing health education. Van de Put: "Midwifes for example are trained in small groups. They are taught about childbirth by re-enacting the birth of a child with dolls." The first results of this project show that training of trainers and supervisors is necessary but not sufficient to improve the quality of the health system. Problems seen in the Pereang district also play an important role here. The quality of the care is decreased by low salaries for the staff and a low motivation that derives from it. "Although many projects start of as an individual project, we try to connect them after a while," says van de Put. "Things we learned in one project can be a solid base for a new project. The things I learned about the health system and the mental state of the local population when I was in Cambodia with 'Médécins sans Frontieres' has been vital for the projects of HNI. It gave us an understanding of the believes and customs of the cambodians, which made it easier to win their trust."

In total, HNI runs five projects in Cambodia and many more in other war-affected countries all over the world. Van de Put: "Our strength lies in co-operation with specialised groups. We don't need to do all the research ourselves or manage all the subprojects. There are many other organisations which are better equipped to do certain work. For example, we work together with a research group in London which focuses on malaria. They do research for us and we give them access to the bfield. This way, we can target many aspects of a health system at once." HNI is very pleased with the development in Cambodia. "When we started there, Cambodia's health system was worse than most third world countries. Now their health system is almost up to the standards of neighbouring countries such as Vietnam. Cambodians are working hard to rebuild their country."

 

For more information on the projects of Healthnet International, visit their website at www.healthnetinternational.org.

 

References:

1. www.lonelyplanet.com
2. http://www.mekong.net/cambodia