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Public health decentralisation can contribute to poverty reduction

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Having better access to quality healthcare services means that poor communities don’t have to spend much money on healthcare. Instead, they can invest in agricultural assets such as modern machinery, high yield fertilisers and seeds, thus contributing to the improvement of agricultural production inputs. Hong Menea

Public health decentralisation can contribute to poverty reduction

Academic literature suggest that Cambodia’s poverty reduction strategy should focus on two pillars: improving agricultural production inputs and the creation of incoming-earning opportunities for rural communities. Those studies state three important components: access to land ownership, education and healthcare. The finding notes that when those poor communities have better access to these three components, they can improve their agricultural production and are able to make income, thus contributing to poverty reduction.

The Cambodian government has adopted and implemented decentralisation policy over the past 10 years. But the recent announcement by Minister of Interior Sar Kheng to transfer 20,000 medical personnel and to allocate $166 million to each capital and provincial administration presents an emerging policy outcome. The move not only demonstrates the government’s commitment to good governance, but it also aligns with research finding on poverty alleviation strategy in the Kingdom.

It’s estimated that the out-of-pocket spending on healthcare per capita in 2014 was $68 and every Cambodian contributed $43 to this spending. Those in rural areas spend 11 per cent of household expenditure on health, while the poorest households tend to spend more – approximately 20 per cent of the total household expenditure.

Limited resources

The World Bank figure indicates that 90 per cent of the poor reside in remote Cambodia. In this sense, poverty is a predominantly rural issue, whereas those in urban areas enjoy a better standard of living and access to public services, mainly healthcare.

Despite the significant improvement of healthcare in Cambodia, the access to quality healthcare for those in rural areas have made little or no improvement. A study of child deliveries found that 96 per cent of deliveries in urban areas occur in hospitals, compared to just 46 per cent of deliveries in Kratie province. The study notes that 53 per cent of deliveries occur at home and attended by unskilled birth attendants. This huge data gap is driven by difficult access to affordable healthcare services between those in rural and urban areas.

Cambodia’s healthcare remains dependent on donors and managed in a very centralised system. Manpower and resources are centralised in urban areas and at the Ministry of Health. A report in 2014 noted that only 30 per cent of the budget was allocated to the sub-national administrations. A study in 2010 noted that 54 per cent of doctors were stationed and employed in Phnom Penh which accounted for just 9.3 per cent of the total population.

These create the huge density between health personnel and the population. A public health review conducted by researchers at the University of New South Wales in 2010 found that doctor density between 2000 to 2009 stood at two per 10,000 people. While nursing and midwifery live births density stood at nine per 10,000 people.

Poverty reduction

The better access to quality healthcare can contribute to the modernisation of agriculture. The Kingdom relies heavily on agriculture which employs three-fifths of its labour force. The figure of the Food and Agriculture Organisation estimates that agriculture accounts for 35 per cent of Cambodia’s GDP. Having better access to quality healthcare services means that those poor communities don’t have to spend much money on healthcare. Instead, they can invest in agricultural assets such as modern machinery, high yield fertilisers and seeds, thus contributing to the improvement of agricultural production inputs.

Analysis suggests that this policy intervention will reduce the disparity in the development stages of Cambodia. Economists argue that unskilled labor has undermined a country’s economy from getting off the ground. Cambodia is a classic example of that assumption. The study of the International Labour Organisations in 2015 indicated that about 250,000 to 300,000 of young Cambodians enter the workforce per year. The majority of them are unskilled labour and didn’t even finish high school.

If they have better access to cheap and quality healthcare services, they can save some money and invest in their children’s education. Throughout this cycle, the next 10 years’ workforces will be more educated and skillful than those who entered the workforce 10 years ago. They are the manpower and the hope of the development stages of Cambodia’s economy.

Arguably, these will also strengthen good governance at sub-national governments. If those poor communities and their children are educated and have a better living standard, they will be more active in political participation. And they are more likely to assert their political rights to safeguard their interest, thus leading to institutional reforms and public accountability.

Perhaps it’s too early to make any assumptions about its success and failure. But this is a good policy intervention to ensure that those in rural areas are not left behind.

Sopharith Sin is a recipient of Australian Awards and a postgraduate student in Public Policy and Management at the University of Melbourne, Australia. The views expressed are solely his own.


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