This narrative report covers progress in the health sector in 2007 that was essentially discussed and monitored by the Technical Working Group for Health. 2007 was the busiest year in the health sector as the Ministry of Health (MOH) had to both review its achievements and evaluate its implementation of the first Health Strategic Plan 2003-2007, and next, to develop, with technical and financial support from health partners, the second Health Strategic Plan 2008-2015 to align with the CMDGs in 2015. In this connection, a series of strategic reviews were conducted from the end of 2006: i) The Midwifery review in November 2006; ii) the SWiM review in March 2007; iii) The Contracting Review Report and Institutional Development Plan in June 2007; and finally iv) the Health Sector Review in August 2007. Following the results of the Health Sector Review, the second Health Strategic Plan 2008-2015 was developed with the active participation of, and close consultations with all stakeholders and development partners. This strategic document will be ready for launching at the National Health Congress in April 2008. In addition, the Strategic Framework for Health Financing in Cambodia 2008-15 will also be put forward for implementation.
Beside these strategic documents, there was also another important review recently conducted by an independent consultant funded by WHO. The review revealed that in general the TWG-H is performing its functions well, and is considered by CDC as being among best performing TWGs. In particular, the TWG-H provides a valuable platform for information sharing and networking across the MoH, Health Partners (HPs) and other key stakeholders.
The Health MTEF first draft report was finalized by the Department of International Cooperation and discussed at the TWGH-Secretariat in February 2008. Its revision is being made and expected to be presented back to the TWGH-Secretariat in March 2008. Cash disbursement as of December 2007 was presented at the TWGH meeting in January 2008 and revealed the following: Overall, it was 91.1%, with 91.4% at the central level (93.4% for Non-Program Based Budgeting, and 69.8% for Programme Based Budgeting), and 90.4% at the provincial level.
The half yearly update on 2007 AOP implementation was conducted in July 2007, the results of which were presented at the TWGH meeting in August 2007. The Joint Annual Performance Review of achievements during 2007 will be conducted in April 2008. The health sector AOP 2008 has been endorsed by the HSSC in December 2007, and will be published during the JAPR and NHC in April 2008. The overall approved budget was US$157,226,780 of which US$101,000,000 is from the national budget, and US$56,226,780 from donors. On top of this, the MOH expects contributions from the community through User Fees in the amount of US$7,383,630.
The improvement of long-term impact indicators of Infant Mortality Rate (IMR) and maternal health which was reported in early 2007 will be updated in accordance with the results of the next Cambodia Demographic and Health Survey.
The MOH endorsed the Comprehensive Midwifery Review in 2007. In 2007, 188 primary midwives and 40 secondary midwives were recruited and allocated to 166 health centers, of which 60 health centers did not have any midwife in 2006. The total number of health centers without any midwife reduced from 172 in 2006 to 112 in 2007. The MOH continues to place the highest priority on recruitment and retention of midwives and has taken several initiatives in this direction, including advocating with the CAR for increased payment to midwives based on salary scales, professional and risk allowances, and special emphasis on recruiting midwives in the remoter parts of the country where shortages are particularly acute. The MoH and Ministry of Economy and Finance issued the Inter-Ministries Prakas in April, 2007 on incentive for delivery services which was translated into actions immediately and the impacts of which will be evaluated after an appropriate time interval.
Financial resources to improve the accessibility of health services for the poor through alternative health financing schemes such as Health Equity Funds (HEF) are currently being implemented in 36 operational districts (as against 21 in 2006), and 6 national hospitals. The number of poor patients with assistance from equity funds increased from 5,298 in 2002 to 76,203 in 2006, and to 152,213 in 2008. The Inter-Ministerial Prakas on Subsidizing Payments for Health Services for the Poor has been implemented, and its results will soon be evaluated. In addition, MOH is now collaborating with other partners to implement Community Based Health Insurance schemes.
Deliveries at health facilities have risen from 10% to 22%, and most of the increase in the public sector occurred at the health center level. Antenatal care visits have increased from 38% of all pregnant women to 69%, and the percentage of pregnant women with at least one tetanus toxoid injection has risen from 45% to 77%. A woman who received such care during pregnancy is 3 times more likely to deliver in a health facility.
As for the malaria situation in 2007, the overall decrease in the number of treated cases and deaths in the country resulted from increasing preventative actions, particularly Behavior Change Communication (BCC) and bed net interventions. The number of malaria treated cases in 2007 has declined dramatically (40.7%) from 100,943 in 2006 to 59,848 cases in 2007, the incidence rate has decreased to only 4.2 per 1000 in 2007 from 7.2 per 1000 in 2006, the number of severe malaria cases from referral hospitals has decreased rapidly from 4,392 in 2006 to 2,648 cases in 2007, and the number of malaria deaths has also decreased around 39.1% from 2006 levels (241 deaths in 2007 compared to 396 deaths in 2006). Malaria mortality rate has dropped down slightly from 2.81 to 1.68 per 100,000 in 2006 and 2007 respectively. However, case fatality rate of severe malaria from referral hospitals has gradually risen to 8.3% in 2007 from 7.9% in 2006.
Cambodia is also one of the few countries to have achieved its 3 x 5 target for the HIV/AIDS program in 2005 (i.e., to treat a total of 3 million patients worldwide by the end of 2005), and efforts to implement the continuum of care strategy along with strengthened prevention and control measures continue. The number of patients receiving treatment for HIV/AIDS-related diseases increased from 392 in 2002 to 12,355 in 2005 and 26,664 by the end of September, 2007. Pediatrics AIDS care also has been integrated into the package of continuum of care. The number of children on ARVs was 2,541 at the end of September, 2007.
The fight against tuberculosis has also made visible and impressive progress. Tuberculosis DOTS coverage at health centers increased from 6% in 2000 to 100% by the end of 2004, and this level was maintained in 2005, 2006, and 2007. Consequently, the case detection rate increased from 51% in 2000 to 66 % in 2007. The cure rate for TB was maintained at more than 85%, reaching the target suggested by WHO for global, regional and country levels. Indeed, Cambodia was one of the few countries to attain its 2005 TB control targets.
In order to clearly define the operational issue and to strengthen the capacity of the Department of International Cooperation including the support of the TWGH function, the policy framework and operational guidelines for this newly institutionalized body were finalized, and a consultative workshop was conducted in August 2007 with participation of representatives from Provincial Health Departments, MoH Departments/Institutions/National Programs, and stakeholders. Database development is another milestone achieved by the MOH as a result of the 1st phase of DIC database development and the results were presented at the TWGH meeting in December 2007. Second Phase to complete the work of DIC Database Development with the technical assistance will be formulated by AusAID and WHO.
A National Workshop on implementing the Priority Mission Groups (PMGs) and Merit-Based Pay Initiative (MBPI) was organized in October and an inter-ministerial workshop on MBPI was organized in November 2007 by CAR with the joint participation of MEF, MOH and Development Partners. Following the inter-ministerial workshop, the RGC has formed a Task Force on MBPI for the MOH whose recommendations to the Deputy Prime Minister are awaited.
In relation to the draft new organic law, the MoH wishes to align its implementation arrangement of provincial health priorities with the law when it is enacted. At the same time, the MOH will ensure continuation of harmonization and alignment effort within the mandate of the central ministry to implement its long-term Health Strategic Plan for achieving the Millennium Development Goals. It is understood that the draft law intends to encourage community participation in health service delivery at community levels through appropriate resource allocation policies. We would welcome opportunity to participate in the finalization of the draft law.
It is also noteworthy that Cambodia was selected as the first wave country for the implementation of the International Health Partnership (IHP) launched by the United Kingdom and other major donors. Currently it is closely collaborating with the WHO and other development partners to develop key initiatives as part of the IHP. The MoH delegation will join the IHP Inter-Regional Country Health Sector Teams' Meeting from 28 February to 01 March 2008 in Lusaka, Zambia. The MoH is in the process of harmonizing the working of the GFATM CCM and the work of the TWGH.
Overall, it is clear that 2007 has been a year of landmark achievements in the health sector in Cambodia. From infant and child to maternal and newborn health and control of communicable diseases, progress was noteworthy and built on past achievements. This was coupled with a series of strategic reviews and institutional capacity building that will serve to strengthen the public health system, improve service delivery, and ultimately contribute to the RGC's goals of significant improvements in the health status of the Cambodian people.
Phnom Penh, 25 February 2008