Cambodia Assessment Ung Phirun Chroeng Sokhan

1. Cambodia

2. Cambodia Assessment Ung Phirun Chroeng Sokhan Cambodia

3. Cambodia World Bank, 1999 Cambodia

4. Health Care Delivery System • Public sector: centralized three-tiered health care system • NGOs: 108 working in the health sector • Private: 382 private clinics and hospitals registered • 70% of providers are not registered • Household spending on health in 2000 was 11% of GDP, 80% of all health expenditures Cambodia

5. Pharmaceutical Sector • Public sector utilizes a centralized procurement and distribution system • Donor-funded pilot programs contract out management of public health facilities to private organizations • Six pharmaceutical manufacturers; only three operating Cambodia

6. Pharmaceutical sector • Total pharmaceutical expenditures for 2000 were 31.46 million USD • Households: 57% • Donors: 25% • MOH: 18% • There are approximately 3700 retail outlets for pharmaceuticals, of which 75% are unlicensed Cambodia

7. Geographic Accessibility Average number of facility operating hours per day Hours 65% of the population is less than 10 km or 2 hours’ walk of basic health care facility Cambodia

8. Availability Cambodia

9. Affordability Number of days worked to pay for treatment Cambodia

10. Affordability (2) • Less than 1% of population is covered by any risk sharing scheme • Payment for health care services is a major cause of impoverishment; 46% of loss of farms was due to health care costs • Children from poor families have lower treatment rates than those from higher income families (20% vs. 52%) Cambodia

11. Affordability (3) • Average percentage difference of lowest prices among facilities • Highly variable, 524% to 1140% • Median percentage difference between most and least expensive unit price within facilities • 55% to 273% Cambodia

12. Acceptability • Distance, cost, and lack of drugs negatively influence utilization of public health services • Overall the public sector was used in 20% of all illnesses and injuries • Retail drug outlets are the first point of contact for 70% of the population Cambodia

13. Quality of Products and Services • MOH Cambodian drug market study found overall failure rate of 13.5% • 50% of drugs are not registered • Failure rates: • Registered: 5.2% • Unregistered 22.3% Percent Tracer drugs that failed quality testing Cambodia

14. Quality of Products and Services (2) • Number of drugs per encounter • MOH 2.0 • In retail drug shops antibiotics were inappropriately recommended 72% of the time (ARI/ no pneumonia) • 50% actually purchased antibiotics • NGO 2.5 • Private 3.8 Cambodia

15. Quality of Products and Services (3) Cambodia

16. Access Gaps • Availability • Affordability • Quality of drug products • Quality of pharmacy services and information • Geographic accessin rural areas Cambodia

17. Potential Strategy • Performance-based network of retail drug outlets • Network of health service providers to be served by the pharmacy network • Group purchasing cooperative for network members • Community-based care program Cambodia

18. Potential Country Strategy (2) Group purchasing cooperative Network of pharmacies, drug depots Network of providers Quality Standards, training, monitoring, accreditation AvailabilityAffordability Insurers NGOs working in health Consumers Cambodia

19. Viability • Facilitating factors • Franchises, as a means of meeting public health needs, have a basis in regulations and public policy • The proposed intervention has strong MOH and private sector support • Proposed pilot locations are willing to dedicate human and financial resources • The intervention will build on existing programs that work with drug retailers Cambodia

20. Viability (2) • Barriers • The government supports public-private partnerships, but sometimes exhibits ambivalence about the private sector • Incentives for continued participation are rather limited • Human resource development may require medium- to long-term support to fully develop Cambodia