Better Health for All Cambodians: Supporting Communities and Health Centers

Challenge

Health outcomes in Cambodia have improved significantly over the past decades. Between 2005 and 2014 the maternal mortality ratio decreased from 472 to 170 per 100,000 live births and the under-five mortality rate decreased from 83 to 35 per 1,000 live births. Yet, inequities in health outcomes persist among different socioeconomic groups and geographical areas, and between urban and rural populations. The country faces a rising disease burden of noncommunicable diseases (NCDs) such as high blood pressure, diabetes and chronic lung disease. Risk factors for NCDs are high, as the proportion of the population over age 60 will increase nearly by twofold in the coming 20 years, from 6.2 percent in 2010 to 11.9 percent in 2030.

Approach

For over 15 years, the World Bank has supported Cambodia’s health sector, along with financing from the government and other development partners. Pooling of these funds to support reforms in the healthcare system has strengthened government ownership and accountability and improved coordination among development partners, which has been instrumental in the rapid improvement in coverage and quality of healthcare services.

The H-EQIP project has built on the results and innovations introduced through the First and Second Health Sector Strengthening Programs which have aimed to improve access to health services. Innovations have included results-based financing through instruments such as Health Equity Funds (HEFs) and Service Delivery Grants, which are designed to improve the quality of health service delivery and increase the use of healthcare services by the poor.

HEFs have successfully reduced catastrophic spending, increased utilization of health services by the poor, and provided a reliable source of financing to health facilities. To increase utilization and quality of care in underperforming locations, the Ministry of Health established special operating agencies in selected provincial and district referral hospital ands operational district. Hospital staff collectively and individually signed contracts that set annual performance targets, and achievement of these targets triggered payments in the form of Service Delivery Grants. Targets were revised annually to drive further improvements in service delivery. This has helped increase deliveries in public facilities, allowed more technical staff to be employed as required, and reduced stock-outs of essential drugs and supplies. They have also given facilities extra funds to improve service quality which can be spent partly for bonus payments to individual staff where targets have been achieved or surpassed.

Results

Since 2016, the project has achieved the following results:

• The Health Equity Fund provided free access to 2.6 million outpatient visits and 190,000 hospital admissions for the poorest people in Cambodia annually.
• The number of health centers scoring in excess of 60 percent on quality assessments rose from only 49 in 2016 to 442 in 2018.

Bank Group Contribution

The International Development Association has supported the project with a US$30 million credit.

Partners

The H-EQIP project has benefitted from a strong partnership among the Government of Cambodia, which has contributed US$94.2 million, and a Multi-donor Trust Fund (MDTF) Program that receives contributions from the Government of Australia (through the Department of Foreign Affairs and Trade - DFAT), Government of Germany (through Kreditanstalt fur Wiederaufbau - KfW) and the Government of Republic of Korea International Cooperation Agency—KOICA), totaling US$56 million; and from the Government of Japan through the Policy and Human Resources Development Trust Fund financed US$1.0 million.  

Moving Forward

To further support improvements in Cambodia’s healthcare delivery system, the World Bank and other development partners, including the Global Financing Facility for Women, Children and Adolescents; the Australian Government, the German Development Bank, and H-EQIP Multi-Donor Trust Fund, have launched the new Cambodia Nutrition Project, which aims to increase access to and improve the quality of maternal and child health and nutrition services initially in Mondul Kiri, Ratanak Kiri, Kratie, Stung Treng, Preah Vihear, Kampgon Chhnang, and Koh Kong provinces, which lag behind in health outcomes, then will roll out to reach the national coverage during the mid-term of the Project/

Beneficiaries

18-year-old mother, Dam Siv Lean, lives in Pou Teth Village, Bousra Commune, Pechreada District of Mondulkiri province.  She went to Pechreada health center in Mondul Kiri province to deliver her first child. When asked about her treatment at the health center, she smiles and says, “The nurses were nice. Their kind words calmed me down when I was in so much pain.”

Her family belongs to the Punung ethnic group and they are among the poorest in their community. They grow their own rice, but this only feeds the family of five for a few months. Siv Lean and her husband work as day laborers for their neighbors when they have the opportunity, making about US$5 per day.

Siv Lean’s family received an identification card for the poor, which allows them to access resources from the Health Equity Fund (HEF) for free medical treatment. The HEF covered all her delivery expenses at the Pechreada Health Center. Without this fund, she would have had to borrow from local money lenders at a very high interest rate.