A workshop held February 27 in Phnom Penh heard that the health sector's contracting
arrangements between NGOs and the Ministry of Health (MoH) are likely to continue
Vincent Turbat, a health economist with the World Bank, told attendees that donors
planned to provide more than $80 million for a range of projects in the health sector
from next year. That could include extending the contracting projects into more districts.
"We can't say that health status will improve just because people use health
facilities more," said Turbat, "but what we can say, especially under the
contracting out system, is that the poor [will] have better access."
'Contracting in' refers to NGOs running health services in partnership with the MoH.
'Contracting out' sees the NGOs managing the health services autonomously.
The conference was arranged by Medicam, an umbrella group of 113 health-related NGOs.
It presented the experiences NGOs encountered while delivering health services over
the past three years. NGOs said that although contracting could not be labeled an
unqualified success, it had resulted in significant improvements.
The ministry used funds from the ADB to contract NGOs to run hospitals and health
centers in five districts since 1999. 'Contracting out' gives NGOs control over budgets
and management. In other districts NGOs have delivered health services within the
MoH under a 'contracting in' scheme.
The workshop heard that despite constraints, 'contracting in' had made some improvements
to the health of local people. 'Contracting out' - which minimizes the role of the
MoH - had shown dramatic improvements.
Save the Children France works on a 'contracted in' basis in Kirivong, Takeo province.
It noted that patient consultations rose from a handful per-inhabitant per-year in
1999 to more than 600 last year. That came despite the district getting only 7 percent
of its budget allocation from the MoH in 2000.
Save the Children Australia, which runs a 'contracting out' scheme in Memot, Kampong
Cham province, saw consultations climb from around 200 to nearly 900 over the same
Despite the scheme's success, it received only a lukewarm response from some MoH
participants concerned at de facto privatization of the health sector and worried
that a service run on borrowed money could prove unsustainable.
Turbat said it made sense for the government to borrow funds, since conditions for
'soft loans' effectively made them 75 percent grant aid. He said that arrangement
was likely to continue.
"The ADB, DfID [the UK's Department for International Development] and the World
Bank are preparing a project with $30 million from each bank and $22 million from
DfID; part of these funds will be allocated through NGOs. We want NGOs to be full
partners in the health sector, not just pilot projects or catering to the poor,"
But the medical coordinator of Médicins Sans Frontières, Dr Wim van
Damme, questioned the impact of contracting on the health sector.
"The MoH is quite happy to use NGOs as a way of to improve the use of donor
money, but what we don't see is that experience used with the government's own money,"
he told the workshop.
Van Damme also criticized the WHO-developed 'boosting strategy' for consigning NGOs
to the role of building technical capacity only. The 'boosting strategy' was developed
to overcome poor service and low usage rates by introducing a series of contractual
arrangements in the public health sector. Van Damme said NGOs were an important part
of civil society.
"NGOs more and more can play a role in areas that the government doesn't; for
example developing equity funds and consumer associations [to advocate health rights],"
Government representatives were non-committal when asked whether Cambodia would eventually
have some kind of national health system. But WHO's Dr Henk Bekedam said the government
could deliver health services with better use of its resources.
"There is enough money around to run the health service - it gets $2 [per person]
from the government, $5 from donors and $29 from individuals," he said.
Bekedam said although health sector reforms had been made, last year's Demographic
Health Survey showed they had not yet benefited Cambodia's health status. The survey
showed there had been little progress on improving infant and child mortality or
improving the low rates of immunization.