Current Issues in Sector-wide Approaches for Health Development: Cambodia Case Study

WHO PUBLICATIONS ON SECTOR-WIDE APPROACHES Cassels, A. A guide to sector-wide upproaches for health development: concepts, issues and working arrungements. WHO, DANIDA, DFID, EC. W H O l W 9 7 . 1 2 . 1997 Asamoa-Baah A and Smithson P, Donors and the Ministry of Health: new purtnerships in Ghana. Discussion Paper No. 8. Forum on Health Sector Reform, WHO. WHOlEIPl99.1. 1999 Foster, M, Brown A and Conway T. Sector-wide Approaches f o r Health Development: A Review of Experience. WHOIGPEIOO.1. 2000 Conway, T. Current Issues in Sector-wide Approaches f o r Health Development: Ccimbodiu Case Study. WHOlGPEl00.2. 2000 Brown A. Current Issues in Sector-wide Approaches for Health Development: Uganda Case Study. WHOlGPEl00.3. 2000 Brown A. Current Issues in Sector-wide Approaches f o r Health Development: Mozambique Case Study. WHOlGPEf00.4. 2000 Conway T. Current Issues in Sector-wide Approaches f o r Health Development: Vietnam Case Studv. WHOlGPElOO.5. 2000 Brown A. Current Issues in Sector-wide Approaches for Health Development: Tanzania Case Study. WHOlGPElOO.6. 2000

June 2000 This study was carried out by the Centre for Aid and Public Expenditure of the Overseas Development Institute, London, UK, for the World Health Organization and the Inter-Agency Group on Sector-wide Approaches and Development Cooperation. This document is not a formal publication of the World Health Organization (WHO) and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors. (c) World Health Organization, 2000

WHO/GPE/00.2 Original English Distribution: General

CURRENT ISSUES IN SECTOR-WIDE APPROACHES FOR HEALTH DEVELOPMENT Cambodia Case Study

Tim Conway Overseas Development Institute

WORLD HEALTH ORGANIZATION Strategies for Cooperation and Partnership Global Programme on Evidence for Health Policy

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ABOUT THE INTER-AGENCY GROUP ON SECTOR-WIDE APPROACHES AND DEVELOPMENT COOPERATION The Inter-Agency Group on Sector-wide Approaches and Development Cooperation (IAG) is a small informal group of experienced senior technical people from international development agencies. WHO provides its secretariat. The group's interest is in advancing policy and practice of development assistance for health development. Toward this end, members of the group meet to review and discuss specific issues and topics in development aid, commission new analytic work, review results and disseminate information both through the communication networks of their own organisations and through WHO's publications series. In 1999, the Inter-Agency Group commissioned five country case studies and a synthesis report to review experience with sector-wide approaches to date. Additional case studies are planned to document the evolution of sector-wide approaches in the context of other development initiatives and instruments, particularly poverty reduction strategies.

For additional information, please contact: Dr K Janovsky, Secretary Inter-Agency Group on Sector-wide Approaches and Development Cooperation World Health Organization CH 1211 Geneva 27 Switzerland tel 41227912568 fax 41227914881 e-mail [email protected]

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CONTENTS ACRONYMS

iv

EXECUTIVE SUMMARY

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1

BACKGROUND AND METHODOLOGY

1

2

CONTEXT

3

2.1 2.2 2.3

Economic and political context Health context Brief history of the SWAp process in Cambodia

3 6 12

3

KEY ISSUES

15

3.1 3.2 3.3 3.4

Reaching agreement on policies, priorities and goals Moving from strategy to workplan Managing joint work Moving towards integrated funding

15 21 24 25

4

PROGRESS AND PROSPECTS

27

4.1 4.2

Opportunities and challenges Prospects

27 28

ACKNOWLEDGEMENTS

30

ANNEXES Annex 1 Annex 2 Annex 3 Annex 4 Annex 5 Annex 6

Costs of outpatient visits, by provider and wealth of patient Donor support to the health sector The Cambodia Mine Action Centre: lessons for a SWAp Terms of reference List of key people met Bibliography

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31 32 33 34 36 37

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ACRONYMS ADB ADD ARI AusAID CARERE CAS CDF CDRI CG CIDA CMAC CoCom CPA CPP DFID ECHO EPI ESAF FUNCINPEC GDP GTZ HSR HSRG IFI IMF JICA MP A MEF MoH MoU MSF NGO Norad ODA p.a. p.c. PCU PER PFP PIP PRK RGC SESC SWAp TBA UNDAF UNDP UNFP A UNICEF

Asian Development Bank Accelerated Development Districts Acute Respiratory Infection Australian Aid Cambodia Reconstruction and Rehabilitation Programme (UNDP) Country Assistance Strategy Comprehensive Development Framework Cambodian Development Resource Institute Consultative Group Canadian International Development Agency Cambodian Mine Action Centre Coordinating Committee (of the Ministry of Health) Complementary Package of Activities Cambodian People's Party Department for International Development (UK) European Community Humanitarian Office Expanded Programme of Immunisation Enhanced Structural Adjustment Facility Front Uni pour un Cambodge Independent, Pacifique et Cooperatif Gross Domestic Product Gesellschaft fur Technische Zusammenarbeit Health Sector Reform Health Sector Reform Group international Financial Institutions International Monetary Fund Japan International Cooperation Agency Minimum Package of Activities Ministry of Economy and Finance Ministry of Health Memorandum of Understanding Medecins Sans Frontieres Non-Governmental Organisation Norwegian Agency for Development Cooperation Overseas Development Assistance per annum per capita Programme Coordination Unit Public Expenditure Review Policy Framework Paper Public Investment Programme People's Republic of Kampuchea Royal Government of Cambodia Socio-Economic Survey of Cambodia Sector-wide Approach Traditional Birth Attendant United Nations Development Assistance Framework United Nations Development Programme United Nations Population Fund United Nations Children's Fund

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Current Issues in Sector-wide Approaches for Health Development

UNTAC USAID VAT VDC WHO WR

United Nations Transitional Authority in Cambodia United States Agency for International Development Value Added Tax Village Development Committee World Health Organization WHO Representative

Currencies US$1 = approximately 3,500 Cambodian riel

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Cambodia Case Study

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Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

EXECUTIVE SUMMARY Cambodia is an extremely poor, post-conflict society. It is in some ways a mirror image of Viet Nam where health and education status is relatively good, given the level of poverty. The Cambodian state, by contrast, has very limited capacity to provide its citizens with productive or social services and is often, through exploitation and dispossession, a significant contributor to poverty. As a result, human development indicators in Cambodia are even lower than one might expect for Cambodia's level of per capita income. Reflecting the level of need, Cambodia has received high levels of overseas development assistance (ODA) since the early 1990s. This aid initially contained much that was of an emergency or relief character, but has subsequently shifted to assistance which is more 'developmental' in character. Problems with development assistance to Cambodia include inadequacies in needs analysis, consultation, coordination, monitoring and evaluation; poor institutional memory; and insufficient attention to issues of sustainability and government or beneficiary ownership (although this latter issue has been better addressed over time through a Consultative Group (CG) process which brings donors and the Royal Government of Cambodia (RGC) into a working relationship). Amongst government ministries, the Ministry of Health (MoH) is considered one of the best. Nonetheless, health indicators are dire, and the state system for the delivery of health care is replete with problems. The health budget is, at around $2 p.c. p.a., far short of what is needed. Only a fraction of this budgeted figure may make it through the disbursement process to reach health centres. Staff are very poorly trained by regional standards and their allocation does not reflect patterns of need. Aid to the health sector has generally been less fragmented and contradictory than aid to other sectors (e.g. education). A coordination system, established during the 1980s, has served Cambodia well, but has recently been seen by many to have become less effective. One interpretation of this would be that the Ministry is now functioning more effectively, reducing the role of the coordinating system. A coalition of donors (including WHO, DFID, Norad and UNDP) is helping the members of a SWAp Working Group within the MoH to gradually push forward towards a sector-wide approach (SWAp) in the health sector. This is now (late 2000) supported by the World Bank. A formal timetable for the move towards a SWAp process was laid out in March 1999. Much of the discussion in this document will therefore focus upon potential developments rather than lessons of experience. While there are gaps that need filling, policy is probably sufficiently well developed to not delay starting a SWAp and could indeed benefit from a more sectoral approach to development assistance. Capacity is poor but the main problems in this regard seem to lie outside the Ministry of Health in its relationships with the Ministry of Economy and Finance (MEF) and provincial administrations. Ownership and political commitment are small but growing. There is a possible contradiction between a sector-wide approach and a provincial-level approach. More needs to be done to encourage broader participation, and to understand how a SWAp would play out at provincial and sub-provincial levels. If a SWAp is to be adopted, it will obviously require an efficient management body and a reliable mechanism for the management of any pooled funds. The established system of health sector coordination will need to be strengthened and adapted if it is to play the role of sectorwide management. Arrangements for oversight of pooled funds will require considerable

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attention if only to allay the fears of donors in the wake of recent problems associated with the use of a trust fund in the Cambodia Mine Action Centre. Whether or not WHO and supporters of SWAps within the MoH manage to convince the government and other donors to undertake a full SWAp, they are undoubtedly right to argue for a shift from a very project-dominated approach to a more sectoral approach, whilst acknowledging a continued role to be played by projects in some aspects of health reform.

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1

Cambodia Case Study

BACKGROUND AND METHODOLOGY

This case study is one of five carried out for the World Health Organization and the InterAgency Group on Sector-wide Approaches and Development Co-operation, conclusions from which have been drawn together in a synthesis entitled 'Sector-wide Approaches for Health Development: A Review of Experience'1. For full references of other country case studies in the series, see inside front cover. The work was carried out by the Centre for Aid and Public Expenditure at the Overseas Development Institute. This report is based on findings from interviews and review of available literature. Field work in Cambodia was carried out for one week in November 1999, and entailed interviews with senior government officials, donors, representatives of other agencies, and non-governmental organisations (NGOs). A list of people met is attached in Annex 5. A week was a very short time to become familiar with complex and sensitive issues, and conclusions should therefore be taken in the spirit of the Terms of Reference: "Given the breadth of the concerns set out below, the aim will be to make well informed judgements, rather than collect large amounts of quantitative data" (see Annex 4). It should also be noted that the report refers primarily to the situation at the time of the field work, and therefore events and opinions may have subsequently developed beyond those described here.

Foster, M, Brown, A., and Conway, T., Sector-wide Approaches for Health Development: A Review of Experience WHO/GPE/2000.1, April 2000. Country case studies include Mozambique, Uganda, Tanzania, Cambodia and Viet Nam.

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Current Issues in Sector-wide Approaches for Health Development

2

CONTEXT

2.1

Economic and political context

Cambodia Case Study

2.1.1 Economic growth Economic growth in Cambodia was relatively high from 1994 until mid-1997, when political violence was rapidly followed by the suspension of International Monetary Fund (IMF) and World Bank support, due to persistent failure to account for revenue from logging concessions, and the onset of the east/south-east Asian financial crisis. The impact of these shocks (which hit tourism and construction first) was then exacerbated by bad weather and very poor rice harvests, and by investor jitters and hoarding in the period before, during and after the June 1998 elections. GDP growth fell from 6.5% p.a. in 1996 to 1% p.a. in 1997 and 1998. Inflation rose to 13%. Fiscal performance worsened, with revenue collection in 1997 at 9% of GDP, one of the lowest in the world. Greater political stability and the appearance of government commitment to fiscal reforms led to a recovery in 1999. Growth over the year is expected to reach 4%, with inflation down to 6-7%. However, this growth, as with that in the years 1993-1997, is very concentrated geographically, sectorally and socially. Growth has had only a minor impact, if any, upon the livelihoods of the rural majority. Agriculture is the primary source of livelihood for some 75% of the workforce and contributes 41% of national GDP (but mostly in the form of on-farm consumption). The formal (waged) sector is very small, and dominated by public sector employment. 2.1.2 Poverty profile The lack of financial and human capital has meant that information on poverty has been hard to obtain. The information base is slowly improving, but all statistics should be regarded as best approximations2. Per capita income is estimated at $280 p.a.. Over one third of the population lives below the income poverty line. 90% live in the countryside3. Education and health indicators are extremely poor. Cambodia has the lowest Human Development Index score in south-east Asia. Most of the poor today are subsistence-oriented rice farmers, struggling with difficult production and marketing conditions (infertile soils, a dramatic hydrological regime unregulated by irrigation or drainage structures, and poor transport infrastructure). They and others are poorly served by minimal government social services. While ill health is probably as significant as food insecurity in explaining the high rates of child malnutrition nationally, there are also considerable pockets of endemic hunger. Although Cambodia formerly had enough land for all, market transfers and outright appropriation by powerful government, military or commercial actors is resulting in a serious problem of landlessness. At the same time common property resources (fishing waters, forests and scrub), which have traditionally provided subsistence and income to asset-poor rural households, are being privatised or damaged by over-exploitation . 2.1.3. Historical context for national development Poverty in Cambodia has been exacerbated by devastating political conflict. Cambodia in 1969 had a higher per capita income than neighbouring Thailand. But from the mid-1960s the destabilising effects of the war in neighbouring Viet Nam led to economic stagnation and the 2 3 4

UN, 1998 and Prescott and Pradhan 1997. World Bank 1999a. Kannan 1997.

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Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

eventual overthrow of Prince Sihanouk's government in 1970. A vicious civil war culminating in Khmer Rouge victory in 1975 was followed by the death of an estimated 1.7 million of Cambodia's 10 million population who, sent to undertake gruelling agricultural and construction work, suffered from overwork, inadequate food, inadequate health care and massive political violence. Viet Nam invaded in December 1978. From 1979, a major international relief effort gradually built up, responding to fears that post-Khmer Rouge Cambodia faced mass famine. Throughout the 1980s, a 'low-intensity' civil war was waged against the People's Republic of Kampuchea (PRK) by the Front Uni pour un Cambodge Independent et Cooperatif (FUNCIPEC), the regrouped Khmer Rouge and other anti-Vietnamese groups. In 1982, the emergency was declared over and the PRK was cut off from most of the international aid system. Aid continued to come from the Soviet bloc, a small number of western bilaterals, international NGOs, and a few UN agencies (e.g. UNICEF) whose mandate enabled them to work in countries unrecognised by the General Assembly. This aid stabilised the health and education situation but was not enough to promote a true recovery. In 1989, Viet Nam withdrew its troops and the parties to the civil war entered negotiations that culminated in the 1991 Paris Peace Accords. This established the basis for a massive UN operation (the United Nations Transitional Authority in Cambodia, or UNTAC) which was to supervise the transition to peace and parliamentary democracy. Post-election negotiations led to a compromise CPP-FUNCINPEC coalition in 1993. From January 1996 tensions between the nominal coalition partners heightened. In July 1997 street battles in Phnom Penh resulted in military victory for the Cambodia People's Party (CPP). Cambodia was isolated internationally, and hit by a succession of economic shocks. Following a protracted political impasse, elections were held again in 1998, resulting in a majority for the CPP. Following another standoff, a new government was eventually formed. 2.1.4

Trends in ODA and relationship to national politics

The new government appears to have a genuine commitment to reform, which has allowed it to win back the support of some of the donors who reduced or suspended aid in 1997. However, many of the problems of aid coordination and poor governance, which limited the impact of aid and government activities in the period 1993-1997, remain unresolved. On the government side, very poor educational standards, little exposure to international policy debates and chronic financial crisis result in low capacity, little if any accountability, and considerable corruption. There is a strong incentive for senior staff to seek and defend project funding within their department, given the power and influence this gives them within the underfunded government system. On the donor side, the World Bank Country Assistance Strategy (CAS) identifies the following problems with aid delivery: • • • • •

5

insufficient government ownership of many projects and programs frequency of official visits and consultations the large number of flows outside the government budgetary system piecemeal coordination on sectoral and institution-building issues the proliferation of specialised donor-supported project-management units and of different administrative procedures (procurement, disbursement, for example)5.

World Bank 1999a. 4

Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

Other issues in aid delivery include the difficulties that donors face in participating in joint planning, funding, monitoring and review, due to differing planning and reporting cycles. Donors also vary in the level of trust they manage to develop with partner institutions (and with each other). These problems arguably provide a good case for the introduction of a sector-wide approach to aid delivery. They also suggest many reasons why such an approach will be hard to adopt. Other factors contributing to the small but growing interest in a SWAp include greater emphasis on achieving a more significant level of partnership (between donors and government, and between donors themselves) as Cambodia moves further away from rehabilitation and towards development; and increasing confidence and desire for ownership on the behalf of the Royal Government of Cambodia (RGC). 2.1.5 National development plans The RGC's medium-term agenda for poverty reduction and sustainable economic growth is outlined in the Royal Government's Platform on Second Term, 1998-20036. The government formed in late 1998 has won back international legitimacy and appears to have made a serious commitment to reform7. The February 1999 Consultative Group (CG) meeting committed the RGC to an ambitious programme of change, with quarterly government-donor "stock-taking" meetings. 2.1.6

Budget framework and reforms

The budget is not conducive to economic development or poverty reduction. Defence accounted for 47% of public spending in 1998. Health and education combined accounted for just 13% of public expenditure; most of that was donor-funded. Much external assistance is channelled outside the budget. ODA has accounted for about 50% of public spending throughout the 1990s, having reached a high of 60% in 1997. Revenue collection is very low. As there is virtually no tax collection, revenue is mainly in the form of high duties. Much of the government system runs on informal rather than formal revenue generation. Army units support themselves through illegal road blocks or logging operations. Local officials levy unofficial fees for various activities. Teachers and health workers demand payment from parents and patients in order to compensate for their meagre, late and underpaid salaries. Investors must pay bribes to national and local politicians and officials in order to establish businesses. Pressure from the World Bank and IMF in particular is leading to reform. Value added tax (VAT) was introduced from 1 January 1999. Civil service and military payrolls have been checked in order to remove 'ghost' employees as the first step towards a drastic reduction of the number of (underemployed and underpaid) officials and soldiers. This should in turn lead to an improvement in the quality of public services. Unpredictable informal point-of-service charges are, it is hoped, being replaced by formal user fees, with a consistent policy for the exemption of

6

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The means to these ends are i) safeguarding social stability and security, ii) building human capacity; iii) strengthening infrastructure and fostering an environment for private investment; iv) fully protecting and preserving the natural environment; v) enhancing national revenues in the context of a fully accountable and transparent fiscal policy; vi) encouraging the private sector as an engine of growth, investment and employment reduction: World Bank 1999a. The post-electoral reform programme originally had four main objectives: public administration reform, fiscal reform, military reform (including demobilisation), and improved forestry management. Improvements in the social sectors and governance were added to the agenda at the CG meeting.

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Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

the poor. Finally, the budget for 2000 provides for dramatic increases in the share allocated to social and rural development . 2.7.7

Structure of government

Cambodian administration is structured through a hierarchy of provinces, districts, communes and villages.- This structure has always been hierarchical, although the degree of local democracy has varied somewhat between regimes9. However, it is too simplistic to describe the system as straightforwardly centralised. Provinces do have considerable autonomy, but this is vested in the person of the provincial governor with little effective authority adhering to the formal institutions of provincial government (e.g. the provincial directorate of health)10 . At provincial level and below, relatively few of the basic formal processes and practices of modern government can be assumed to be in place. As mentioned above, the means by which revenue is raised and the channels by which it flows between village, commune, district and province to fund expenditure are largely informal. Donors have supported various programmes in an effort to achieve democratic decentralisation. Notable amongst these is the UNDP's attempt to promote decentralised planning processes through the creation of a hierarchy of elected development committees, with the Village Development Committee (VDC) as its basic building block. In six provinces UNDP's CARERE II project has used what is in effect a social fund model to promote participatory development, local democracy and accountability of state services. VDCs are assisted in producing village development plans, which are submitted to donor-funded provincial bodies for small grants. VDCs work relatively well in local economic terms in the CARERE provinces . The basic idea of a VDC has also been widely adopted by other donors and NGOs in other provinces. In part the difficulties encountered in institutionalising VDCs nation-wide under RGC leadership can also be attributed to inter-ministerial rivalries within the RGC. UNDP is now reconsidering its approach to area-based planning, giving more importance to the commune level. 2.2

Health context

2.2.1 Health status The health status of Cambodians is amongst the worst in the world. Just how bad, however, is subject to debate. In the absence of a functioning system of official statistics, different sources produce quite radically different estimates. Whichever figures are used, infant mortality, life expectancy and maternal mortality are the worst in the region.

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10

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Much the same was of course the case in the budget for 1999. However, the apparent final demise of the Khmer Rouge has reduced the case for allocating 45% of the national budget to defence and security, while the new system of Priority Action Programmes (PAPs) should - in theory - protect social sector expenditure even in the event of revenue shortfall. The anthropologist May Ebihara wrote that under Sihanouk in the 1960s "the relationship between the central government and the village, as mediated through the various government officials, is primarily a one-way road. The government sends down policies, programs, propaganda and laws; while little more than taxes and vital statistics pass upward... while the lowest chiefs have some authority, they are mainly the passive agents of government bureaucracy who help maintain law and order and provide a channel for passing policy down, but who have little real authority to push things through from below" (Ebihara 1968: 527). Ovesen et al 1995: 45 describe the province as "for most Cambodians the focal centre of power"; the Economist in 1996 expressed concern at changes which allowed provinces to raise and spend (without reporting) their own funds, and which threatened to strengthen "province-level fiefdoms" (Economist Intelligence Unit, 1996). See also Biddulph 1996; Conway 1999: 240-288; Conway 2000. UNDP is probably a little optimistic about the possibility of reforming an established hierarchical political culture through externally-facilitated elected committees. That this goal is (laudably) ambitious would seem to be acknowledged in the long-running self-description of CARERE II as an "experiment" in decentralised planning. See also Biddulph 1996; Conway 1999: 240-288; Conway 2000.

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Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

Table 1 Indicators of health status Indicator Infant mortality rate (per 1000 live births) Under-5 mortality (per 1000 live births) Life expectancy (years at birth) Maternal mortality ratio

Date and source Petersen 1998: 4; World Bank 1999a: 71 WHO 1999b Petersen 1998:4 WHO 1999b World Bank 1999a: 71 World Bank 1999a: 71 Petersen 1998: 4; WHO 1999a

115 89.4 181 115 54.4 900 473

HIV prevalence is one of the highest in Asia, at 4% of the adult population. Malaria is a major cause of death, with 500,000 cases and 5,000 deaths annually. There are thought to be 10,000 12 TB deaths each year . 2.2.2 Patterns and relationships in health provision Most health expenditure is in the private sector. Private pharmacists are the first point of call for most non-emergency cases. Few, if any, pharmacists are qualified, and the sector is rife with medicines which are out-of-date, banned or prescription-only in most other countries. Private 'doctors', often those who were refugees in border camps during the 1980s and received a medical assistant's qualification, are to be found in villages and markets, i.e. closer and often more conveniently located than state facilities. The rural poor also still make considerable use of traditional healers such as kru khmer and traditional birth attendants (TBAs), particularly in remoter parts of the countryside. For most minor complaints, these traditional medics are reasonably low-cost, and generally do little harm. For more serious or potentially serious situations, however, they are less suitable. The great majority of women give birth at home with only a TBA in attendance. For emergency cases, people tend to go directly to state facilities. The Health Coverage Plan (endorsed 1996, with implementation starting 1997) has attempted to rationalise the distribution of health facilities so that a health centre serves approximately 13 villages and a referral hospital serves 13 centres13. A centre should provide the Minimum Package of Activities (MPA), although only half do so at present . The referral hospitals should then provide the Complementary Package of Activities (CPA). Given chronic underfunding and cumbersome disbursement procedures, public sector health staff are paid very little (on average $20 per month), with payment often several months in arrears. Partly simply to survive, they then charge patients for consultations and supplies. This is an ineffective way to fund local health services, often excludes the poor, and makes it very hard to promote preventative rather than curative health. Several donors have conducted experiments with formalised user fees, generally focusing first upon provincial hospitals. The RGC has now introduced standard user fees and exemption policies, and provided a formula for the utilisation of these funds in the place where they are collected. Donor assistance has had greatest success in vertical programmes, such as TB, malaria and EPI, organised under national institutions. This assistance has resulted in relatively good child 12 13

14

WHO 1999b. Previously, the health structure mirrored the administrative structure, with commune clinics and district and provincial hospitals. Given that some communes have 10,000 inhabitants, while others have just 500, this did not always result in a rational allocation of services. Ministry of Planning/UNDP/Norad 1999.

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immunisation rates15. Aid has also been effective in the health sector reform projects which are rehabilitating the health services. More work still remains to be done in integrating vertical programme services at facility levels under a primary health care approach, although UNICEF and partners have in recent years progressed further in this effort. As with other sectors, the geographical distribution of aid has been very uneven. Some provinces have received more, or better, aid than others for a number of reasons. The coverage plan may have made some contribution to reducing these disparities. 2.2.3 Health financing and expenditure Trends in level of public health spending: budget and disbursement In 1999, public recurrent expenditure for health amounted to almost $20 million, or around $1.7 p.c. p.a. (0.63% of GDP, or 7.3% of the budget). This represents the highest annual health spend in the 1990s; a major jump from expenditure in 1998 (which stood at $12.2 million, or $1 p.c. p.a.); and a significantly higher disbursement of the allocated budget (up to 88% from 73% in 1998). Furthermore, there was an extremely large increase in capital expenditure on health (to $13.2 million) in 1999. These are some of the most encouraging findings with regard to the effects of reform of government health systems16 . Table 2 Trends in public health expenditure Measure of expenditure Population (million) Nominal GDP US $ million US $ p.c. p.a. Health budget (recurrent costs) Recurrent budget (US $ million) as % of nominal GDP Budget per capita (US $ p.c.) Health budget as % of total govt. budget Budget as % rec. budget Aggregate health expenditure Recurrent expenditure (US$ million) Spend per capita (US $ p.c.) As % of GDP Implemented budget as % of recurrent budget Source:

1994

1997 1998 1995 1996 1999 2;00017 11.4 11.0 10.7 10.2 10.5 2,923 287

6%

3,122 298

3,033 283

3,103 282

3,600 319

14.85 22.85 20.25 17.82 24.13 0.51% 0.73% 0.67% 0.57% 0.63% 2.12 1.62 1.89 2.18 1.46 4.00% 6.10% 6.00% 6.00% 7.37%

31.8

7%

9%

5%

8%

7%

7%

12.2 14.6 16.2 10.2 10.9 19.8 1.1 1.3 1.5 1 1.1 1.7 0.43% 0.37% 0.52% 0.48% 0.41% 0.63% 88% 70% 71% 68% 72% 73%

WHO 2000, WHO 1998, World Bank 1999a.

However, at $1.70 p.c. p.a., expenditure is still far short of what is required to achieve reasonable health outcomes. There is urgent need to continue to increase the provision for health in future budgets and hopes are good that this can be achieved. The health budget for 2000 has been increased by 51%, and the new budget introduces a Priority Action Program categorisation which should protect expenditure on priority social sectors (including health) even during revenue shortfalls. 2000 should see greater spending on health18.

16 17 18

In 1996, it was estimated that national coverage was 90% for BCG, 76% for polio, 75% for DPT, and 72% for measles: WHO 1999a: 71; see also World Bank 1999a. WHO 2000. Note that 2000 figures are projections. Stephens, S. 1999. 8

Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

However, the very low performance of public health in Cambodia is not only due to its small share of the national budget. It is also due to chronic disbursement problems which mean that the MoH is unable to spend even the small amount budgeted, especially at provincial and subprovincial levels. It seems this is not the result of low capacity within the health system. Most districts and provinces complete all the paperwork required to ensure the release of the national health budget. Instead, the problems lie in the cumbersome and 'leakage-prone' disbursement system at central and provincial level. There are several points at which the disbursement process fails the health system. Firstly, the cash-strapped Ministry of Economy and Finance (MEF) creates its own monthly 'Expenditure Plans' for each provincial department, which effectively define the real budget. Under these plans, health gets about half of what it receives in the official budget approved by the National Assembly. Secondly, sums allocated to health services are diverted to other ends. The Expenditure Plan sums are channelled by MEF to the provincial health directorates via the governors, rather than via the MoH. The provincial governors are often slow to disburse. Only two-thirds of the half-yearly Expenditure Plan budget for health was actually spent in 199919. Finally, it must be noted that, in the face of the non-disbursement of salaries and other funds (including drugs), the state health system survives through informal user fees . Such heavy reliance upon point-of-service fees is neither efficient nor particularly equitable. The formalisation and standardisation of these charges, combined with a consistent policy of exemptions, will be as important as improvements in the allocation and disbursement of central funds for the foreseeable future. Different models have been developed in different provincial hospitals. Trends in composition of public health expenditure Table 2 describes the composition by function of public health funding as described in the most detailed and recent sources found, namely the World Bank Public expenditure review, published in 1999. This would suggest that the allocation of health resources between levels and activities has oscillated considerably from one year to the next between 1994 and 1996, which is not conducive to the development of stable policy or the refinement of management systems. It also suggests that until 1996 much of the MoH budget was spent on tertiary services. Table 3 Public health spending by function, 1994-6 (all sources: government, ODA & NGO) Function Sector policies and planning Primary health care Disease control Family planning Hospitals Training Drug supply Construction, equipment Total % Total (billion riel)

1994 44.78 16.06 8.01 1.58 25.00 .04 .00 4.54 100.01 87.792

% of total 1995 48.15 11.02 5.96 2.60 23.05 .03 8.95 0.24 100.00 81.865

1996 17.26 26.61 2.68 1.40 8.20 .02 30.82 0.31 87.3T 192.074

Source: Adapted from Table 5 in World Bank 1999b, based on data provided by RGC. Notes: f Totals for 1996 do not add to 100% because NGO contributions (24 billion riels) cannot be sub-divided.

19 20

See MoH/WHO 1999a; van Pelt 1999. It is important to note that this is not standard across all social services. In education, for example, government and households each fund approximately 25% of total expenditure, with donors and NGOs making up the rest (World Bank 1999b). 9

Current Issues in Sector-wide Approaches for Health Development

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The data almost certainly exaggerate the magnitude of the swing between levels and activities, underplaying the degree of continuity or inertia in actual expenditures. This is probably due to inconsistencies in the classification of sub-components of expenditure. They are, however, the only data available from the RGC. WHO reports improvements in budget implementation over the last nine months (to March 2000). This would presumably reduce year-on-year swings in spending. Table 4 provides the latest (1999) data on the composition of the MoH budget and expenditure. Table 4 MoH recurrent expenditure by category, 1999 Expenditure category

Salary Drugs (central tender) Operating costs - central Operating costs - provinces and districtsf Accelerated Development Districts Other Total (US $ million) Source: Table 3 in WHO 2000. Notes: f excluding drugs.

Recurrent budget (in US S million) 3.5 7.9 6.0 3.9 0.8 0.4 22.5

Recurrent expenditure (in US $ million) 3.2 7.5 5.3 2.9 0.8 0.2 19.9

% of budget actually implemented 91% 95% 89% 74% 100% 50% 88%

Trends in private health expenditure Household (private) expenditure on health is, at around $20 p.c. p.a., by far the largest component of health expenditure (82%)21. It should be noted that it is hard to separate public and private health expenditure given that most services obtained from government facilities, until recently in theory provided free of charge, have long been charged for. Research shows that there is little difference between the private and the state sector in costs for outpatient visits (see Annex 1). While the state sector arguably contains better trained staff and provides slightly better clinical treatment, surveys reveal numerous complaints about the quality of service in state facilities (starting with the lack of drugs, beds, equipment and, indeed, trained staff)22. Given these shortcomings and no consistent difference in price, it is unsurprising that the sick often prefer private clinics or self-medication. That household contributions account for the largest part of total health expenditure has serious equity dimensions. Table 5 shows that the cost of a single outpatient visit accounts for a major part of household expenditure for all income groups, with the average cost of a health visit exceeding one month's average total expenditure. The impact of private health expenditure is, however, most pronounced for the poorest. Financing public health through point-of-service fees as currently constituted is, in other words, highly regressive (not to mention inefficient). There are strong links between poor health and impoverishment, with the onset of a health crisis precipitating sale of assets or a move into high-interest debt in order to meet health costs.

21 22

World Bank 1999b. UNDP 1999. 10

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Table 5 Private health expenditure by wealth: average expenditure on an outpatient visit by per capita expenditure quintile, 1997 Income group Expenditure on a single health visit (riel) (p.c. income Consultation Drug Total Transport Quintile) Cost supplies

p.c. monthly household expenditure (riel)

Visit cost as % of monthly expenditure

Richest

60,941

57,543

5,124

123,714

91,524

135%

Fourth

30,039

31,094

6,766

67,899

25,957

262%

Third

27,757

22,338

5,268

55,362

17,466

317%

Second

20,650

14,514

2,875

38,039

12,203

312%

Poorest

12,871

14,899

5,125

32,896

7,565

435%

based on Table 2 in World Bank 1999a

External assistance to the health sector Health has always been a major beneficiary of external assistance to Cambodia. At present ADB and the World Bank are in the middle of major loan programmes, each of approximately $30 million over 4-5 years (i.e. c. $6m p.a.). WHO channels assistance at much the same level (over $5 million p.a. in each of the last two years in combined programme and 'extra-budgetary' contributions). Major bilateral donors include Japan, Australia and Germany. US AID has been a major contributor but, following the 1997 coup, has restructured its aid to avoid government channels. DFID has supported MoH both directly and through WHO and enjoys good links and strategic influence with the Ministry23. Annex 2 summarises the projects and commitments of the main donor projects in the health sector in the current period. Table 6 Sourcing of health expenditure (latest available years) Source of expenditure Household spending Donors/NGOs Royal Government of Cambodia Total Source:

US $ p.c. p.a. $27.00 $5.50 $1.70 $34.20

% of total 79% 16% 5% 100%

Household expenditure calculated from SESC 1997 (monthly household expenditure on health in riels, converted to $ p.c. using exchange rate of 2750 riels: US$1 and average household size of 4.9: all data from SESC). External assistance from 1996, quoted in Char 1999 and World Bank 1999a. RGC expenditure from WHO 2000.

Summary: the balance between public and private health expenditure Health expenditure in Cambodia is too low and too inefficiently deployed to be effective in improving health indicators. There is need to improve the quality and efficiency of both public and private health care provision (recognising the considerable overlap between these theoretical categories). 23

This influence can be explained in part by the relationship developed during long-term engagement of UK aid support to government programmes (Delna Gandhi, personal communication).

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2.3

Cambodia Case Study

Brief history of the SWAp process in Cambodia

The embryonic SWAp process in Cambodia grows quite smoothly out of previous health reforms, notably the Health Sector Reform (HSR) project. This project is entering its third phase, supported by DFID, UNDP, WHO and Norad to the sum of $6.7 million over the period 1998-200024. The introduction of a SWAp in Cambodia seems to have been led by WHO advisors. The Minister expressed approval in February 1998 but it was thought best to delay efforts to initiate the process until after the elections (and, as it turned out, post-election political hiatus) of mid1998. MoH interest in principle was re-confirmed in early 1999. In March 1999 the MoH HSR III project - with the input of donor advisors - produced a short document called Step by step to a SWAp: action plan for 1999 and 2000. This document outlined the limitations of the existing heavily projectised approach, and set out the rationale for a SWAp in Cambodia on the following grounds. Box 1 What are the benefits of a SWAp? • • • • • • •

a coherent sector policy and budget based on a new partnership which maximises the impact and value for money of the combined donor, government and community resources improved Ministry of Health capacity to lead and manage health services and resources more flexible funding arrangements to ensure essential expenditures are covered greater sustainability through government ownership of donor funded activities an effective avenue for donors to make a smooth exit from projects, by reducing technical assistance but continuing financial support an effective means for donors to fund recurrent costs where all sides agree it is necessary and possible a means to back up reforms with financial resources. Source: MoH 1999d

This document also provided a preliminary timetable for the process of moving towards a SWAp (see Table 7). Table 7 Outline timetable for the development of a sector-wide approach Step

Target date

1 Reconfirmation of MoH interest 2 Preparations & options - 6 individual health sector studies 3 Consultation on options for health sector priorities & support 4 SWAp policy paper giving preferred MoH position

Before mid-April 1999 April-August 1999 September-December 1999 December 1999

5 Lead group formed from MoH & key donors 6 2001 Sector Partnership Agreement developed

January 2000 Ql & Q2 2000

7 Common management systems developed

January-December 2000

8 Implementation of the Sector Management Agreement Source: adapted from MoH 1999d.

January 2001

This timetable is slipping. Of the six preparatory studies scheduled for completion in August 1999, only one (the analysis of stakeholder views and ability to participate) has been finished25. This does not, however, seem to be a major problem. Supporters of the SWAp recognise the need to be flexible and to adopt a process approach rather than stick to a rigid timetable. 24

25

The current HSR project started in January/February 1998, intended to run for three years. Prior to this phase, this multidonor project was known as the Strengthening Health Systems (SHS) project. The other topics for individual studies were: 1) health policies and priorities; 2) costing and resources; 3) pipelines available; 4) review of the project approach; and 5) lessons of international experience.

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The stakeholder analysis was valuable in identifying the positions of the main government and donor actors with regard to the desirability and feasibility of a health SWAp. The position of the main donors is summarised in Figure 1 (see page 16).

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Current Issues in Sector-wide Approaches for Health Development

3

KEY ISSUES

3.1

Reaching agreement on policies, priorities and goals

3.1.1

The formulation of a sector strategy

Cambodia Case Study

It is recognised that the Cambodian government does not match up to any donor's ideal. Decades of war and international isolation have undermined the education system and reduced opportunities to learn from other countries. Corruption, both the 'survival corruption' of civil servants paid $15 per month and the grand corruption of senior officials, is rife. Much of the Cambodian government still runs on deep-seated principles of power and protection, and unstable, hierarchical networks of patronage. However, the MoH is one of the more capable ministries within the RGC. It is also one in which fundamental contradictions between different policy approaches supported by different donors have been relatively few and minor. The WHO Representative's report concludes that the Ministry (with support from donors) has developed clear policies to address the critical problems of the sector. To reduce them to two broad sets, these problems are i) poor access (geographical and financial) to public health services and ii) the low quality of these services. Policies therefore focus upon: •

improving the quality but, even more importantly, the distribution of health facilities as outlined in the Health Coverage Plan, 1995, the Guide for the Strengthening of the District Health System in Cambodia, 1995, the Guide to Developing Operational Health Districts in Cambodia, 1996 and the development of a minimum and complementary package of activities (MPA, CPA)

•

increasing the resources available to public health services, both through increased delivery of central funds (commitment to improve the budget share for health and streamlined transparent systems for transmission of budgeted funds to health facilities), and through formalising and making more efficient locally-raised user fees26

•

improving the quality and motivation of public sector health staff through better training, career prospects and better and more regular pay (see above on transmission of funds from the centre and facility-level user fees)

•

regulating the private sector - particularly the pharmacies - which, in the absence of an accessible, good quality public health service, provide frequently ineffectual and sometimes dangerous health services to the majority of the population. This latter policy area has to date received less attention than it deserves.

26

MoH 1996c.

15

Figure 1 SWAp Matrix: Relative Position of Donors on support for a SWAp

Source: Phuah 1999.

Cannot participate

Support concept but unlikely to participate in the current timeframe established by MoH

16

Support and will participate

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While there are areas in which policy could undoubtedly be improved, it is not policy that is seen as the major problem by most of those involved in pushing for a move towards a more sectoral approach27'28. The policies in place are broadly supported by all actors. Disagreements on specifics are noted below. The main doubts about the feasibility or wisdom of a SWAp focus upon capacity. There is particular concern about the inability of the MoH to access the small budget it has. This problem is primarily to do with the transmission of the health budget to provincial health departments through the Ministry of Economy and Finance (MEF) and the provincial governors (see section 2.2.3 above). 3.1.2 Scope of the programme There are numerous institutions which have some involvement in health provision but which fall outside the jurisdiction of the MoH. These include the: •

Department of Health of the Ministry of Women's Affairs

•

military health services

• jail clinics of the Ministry of Interior •

Departments of Health and of Water Sanitation in the Ministry for Rural Development

•

workers' hospitals of the Ministry of Rubber.

While interviewees were unable to estimate the percentage of public health spending that falls outside the MoH in this way, their existence does raise problems for the 'sector-wide' scope of any MoH SWAp. More significant, however, is the fact that existing health sector reforms, and the plan for the SWAp process, could benefit from paying more attention to the private sector as a provider, rather than merely as a competitor with the state sector29. At present the private sector features in policy calculations mainly on the grounds that people prefer it to the public sector except in emergency cases, because of poor staff attendance and morale at government facilities and (perhaps more rarely now) lack of drugs and equipment. The primary challenge regarding the private sector under current policy is, therefore, seen as how to capture more of the household expenditure that presently goes to the private pharmacies and doctors. In other words, much of policy implicitly focuses on how to break the cycle between low utilisation (because of low quality due to low funding) and low funding (because of low quality and therefore low utilisation). There perhaps needs to be more attention to the private sector in its own right, acknowledging that for most cases it will be the first point of contact between the patient and health care for the foreseeable future, and finding ways of improving skills and practices amongst private practitioners. There are moves in this direction, including debates on whether to adopt regulation, approved provider schemes, voluntary codes of practice, and so on but they are not yet developed. Finally, the plans for the development of a sector-wide approach have to date made little reference to the roles of traditional healers (kru Khmer, TBAs etc.) in providing health care. The roles of these providers, together with the contribution of NGOs 27

28

29

It is hard to gauge whether the World Bank considers health sector policy to be adequate. The PER, in discussion of preparation for a health SWAp, comments that "In close collaboration with donors and NGOs, the MoH has already formed a strategy for the development of the health sector... This is embodied in the Health Coverage Plan and in the National Health Policy and Strategies 1996-2000, both of which could serve as the basis of all donor/NGO assistance to the health sector" (World Bank 1999a). This seems to be contradicted by this comment in the CAS draft: "The Government seems to have developed few sector strategies if any in the priority areas it has chosen [which include health]... The current working groups on key reforms are not a substitute for sector strategy development" (World Bank 1999a). Nonetheless, the CAS draft proposes to support a sector-wide approach in the health sector. Of course, the boundaries between the public and private sector providers are very blurred, given that most employees in the state health service work for fees as well as their salary, with private work carried out either outside their hours of government employment or during them.

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(national and international), can however be dealt with later. The most important coverage issue at present is to ensure that the SWAp deals adequately with the relationship between (donorassisted) state health activities and the 'modern' private sector (pharmacies and private doctors). 3.1.3

Government ownership

The SWAp debate is at present driven forward through the work of the Health Sector Reform Project, which involves the MoH, DFID, Norad, UNDP and WHO. The Mid-Term Review of the HSR concluded that there was increasing evidence of a sense of ownership of the approach within the MoH. There is a small core of very capable staff within the Ministry (the SWAp Working Group) who, working closely with WHO, are interested in and enthusiastic about the approach. Most of this team recently took part in a study trip to Ghana to learn from that country's experience of implementing a health sector SWAp. A wider circle of senior staff would seem cautiously interested. There are also senior influential and capable staff who have in the past been openly sceptical about the approach on the quite reasonable grounds that the Cambodian MoH should not be used as a test case for the latest donor fad. This opposition has eased somewhat, partly as a result of conscious WHO efforts to emphasise the continuity between previous reforms and SWAprelated reforms, and to stress that a SWAp is more a process rather than an end state, and thus to play down the idea that a SWAp requires a risky 'big bang' transition. Those Ministry and donor staff involved in the process are being judicious, adjusting the proposed timetable for implementation of a SWAp in order to address concerns about the implications. National ownership of the concept does seem to be increasing slowly. There are also MoH staff who have a stake in a project approach. Most notably, those senior staff in the joint World Bank/ADD Project Management Unit. While some of those interviewed are cautious and have noted some of the obvious obstacles that stand in the path to development of a SWAp, they do not appear to be intrinsically hostile to the idea30. However, this should not be taken as indicative of general support. For some project-funded staff, especially in the provinces, it is more likely that they simply have not yet heard of the proposals. Knowledge of the concept of the SWAp is, like most policy, confined to a relatively small number of senior staff who work closely with international advisors31. Broadening out participation in the SWAp process, both vertically down the hierarchy in the central Ministry and horizontally out into the provinces, must be an important part of the process in the future (a point acknowledged in the mid-term review of the HSR). Unfortunately, the concept of a SWAp is being introduced at a time when long-standing coordination mechanisms in the health sector are widely seen to be in decline. At the apex of this coordination structure is the Co-ordinating Committee (CoCom), supported by sub-sectoral committees (Sub-CoComs) and provincial Co-ordinating Committees (Pro-CoCom). These arrangements, evolved in the 1980s, changed in the early 1990s to reflect the influx of new donor actors, and have generally been regarded as rather good. Recently, however, donors have come to feel that the system has declined. The director of MediCam spelt out some of the problems: •

CoCom meetings are long and could be better structured, and have become more a 'showand-tell' rather than a forum for policy debates. Attendance has dropped, and minute-

30

To look at things in terms of self-interest, it is reasonable to assume that they would be well qualified to take on some of the donor-funded positions that would be required in the transition to a SWAp, and might thus emerge as supporters of a SWAp should enough donors move in that direction. However, the stakeholder analysis which examined perceptions of the desirability and feasibility of a SWAp itself did much to spread knowledge of the approach.

31

18

Current Issues in Sector-wide Approaches for Health Development

•

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keeping is very poor. MoH has acknowledged that there are problems, and is reviewing the terms of reference for CoCom there is an increasing tendency for some NGOs to bypass MediCam to liase directly with elements of the MoH, with a resultant decline in cohesion and coordination within the health NGO sector32.

This analysis is not universally shared but there is agreement that there are problems to be addressed. 3.1.4 Political commitment The strength of political support for a health-sector SWAp is hard to gauge with precision. The Minister recognises the inefficiencies of the project-dominated approach but does not yet seem to have come down definitely in favour of the approach. It was not possible to gauge the extent of high-level political support for a SWAp within the MEF, or at Cabinet level. It is also hard to judge political support or opposition below the ministerial level. This is true to some extent of all donor-supported reforms in Cambodia. There is a real danger that donors are content to accept as indicators of support what are in effect the returning echoes of their own policy advice to senior staff. Below this level and outside Phnom Penh, acceptance or understanding of reforms, even in terms of the introduction of basic standard international practice, may be much more limited. Attention should be paid to the perceptions of provincial governors who remain powerful. As yet, medical professionals have not formed strong professional associations, so these have not made their presence felt as either supporters or opponents of SWAp-based reforms. This, however, may change quite rapidly. There has been increasing militancy in the education sector over the last year with teachers striking for dramatic improvements in pay. There exists the possibility that medical staff will unionise and emerge as a political force, however marginal. 3.1.5 Participation in the SWAp process Ideally, future policy formulation will involve more participation from the provinces and from civil society. Cambodian NGOs (e.g. the Cambodian Midwives Association) have participated to some degree in sector developments through representation in collective NGO bodies (e.g. alongside international health sector NGOs in MediCam: see Box 2). However, it would be better if this involvement was strengthened. This might be hard given that institutional civil society is rather underdeveloped in Cambodia, making it difficult to know whom to consult. Nonetheless, there may be room for user satisfaction studies - perhaps surveys, but perhaps also using group discussions. It also seems that the process of planning and implementing a SWAp would be made slower, more complex but ultimately stronger if attempts were made to involve (or at least consult) provincial health and finance officials, perhaps together with provincial governors, at an earlier stage. This is not to say that the SWAp process must evolve from the provincial level. However, a national policy of transition towards a SWAp will be strengthened if steps have been taken to inform provincial and sub-provincial authorities of what a SWAp means and why it is being proposed. It depends on addressing concerns (and possible misconceptions) that have been identified and understanding strengths and weaknesses at sub-national level. While it is hard to pronounce definitively upon this, it seems that more could be done in this area. WHO has some experience in district and province level processes, but acknowledges that UNICEF has greater expertise here. see Rousseau 1999.

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Box 2 NGOs and health policy debates in Cambodia International NGOs played a particularly significant role in Cambodia during the 1980s, when Cambodia was cut off from most ODA. Responding to the level of need, NGOs adopted 'donorlike' approaches and enjoyed unusually good policy-level contacts. These were somewhat squandered from the early 1990s, as official donors entered the scene and overshadowed NGOs, and many among the NGOs enthusiastically embraced the opportunity to engage in more conventional, locality-based projects. Nonetheless, health NGOs retain a potentially important position in health reform debates. The position of individual NGOs in relation to a SWAp vary considerably. Medecins Sans Frontieres (MSF) regards its mandate as preventing it from participating in pooled funding arrangements (although it would support MoH policy development and follow national guidelines in its work); World Vision, however, has shown willingness in principle to contribute to pooled funds, while other NGOs would be happy to act as contracted agents to deliver elements of the SWAp programme in certain areas. However, the greatest potential channel for NGO participation is through the apex organisation MediCam, founded in 1989 as an umbrella organisation for NGOs in the health sector. In 1996 members voted to employ an Executive Director and small support staff. In the words of the Director, "It's a deal: we encourage NGOs to follow policy, providing we can contribute to it." MediCam is clear about the need for a more meaningful form of coordination and co-operation between MoH, donors and NGOs - not just information exchange, but an effort to deal with a health sector comprised of unconnected activities. It can be an effective intermediary, bringing villagelevel NGO perspectives upon the progress of reforms into policy debate in a coherent manner. It is also surprisingly neutral, being often quite critical of unruly NGO behaviour. This potential for policy influence may be compromised by what the Director sees as declining interest from both the MoH and member NGOs themselves. In part this reflects the general malaise in the health sector coordination system, but it also reflects a worrying trend for elements of the MoH and individual NGOs to negotiate piecemeal on projects, rather than through the coordinating mechanism of MediCam.

3.1.6 Pro-poor content of strategy Health policy is explicit (though not very specific) about the intention to link health reform to poverty reduction33. In the first years following the restoration of major aid flows to Cambodia in the early 1990s, activities took precedence over analysis. There is now more systematic and 'joined-up' policy research into poverty in Cambodia. The preparation for a sector-wide approach to aid seems to make the right connections to this body of research, including surveybased findings on the impact of health expenditure on different income groups (see Table 5, p. 11). 3.1.7

Summary

Health policy is relatively well developed and realistic, assuming i) that goals are understood to be long term, ii) promises of significant increases in the health budget do actually materialise, and iii) ODA to the sector continues at a similar level. More work could be done but donors seem to regard the existing framework as adequate for the moment. More pressing is the need to increase the capacity of the state health system to adopt these and any future policies. Ownership is currently limited but growing slowly. It is hard to predict the pace and ultimate limits on this growth in ownership. Much will depend upon clear political commitment at 33

For example, the Briefing to the Minister regarding Health Sector Reform Phase III Project notes "The purpose of the project is to contribute to the reduction of poverty in Cambodia through the development of quality basic health services, particularly in rural areas". The MoH in the 1999 Consultative Group Position Paper on health states that "Health reform is geared towards improving equity in access to and utilisation of good quality services by the population, especially the poor."

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Ministerial level (not just in MoH) and above. While seeking to establish this commitment, it is worth simultaneously building the case for a SWAp at lower levels of the MoH, both in Phnom Penh and in the provinces. This broadening of the support base also needs to encompass civil society. There is need to think about how to include the private sector, national and international NGOs working in the health sector, traditional healers, and government health institutions currently beyond the jurisdiction of the MoH. Of these, attention to relationships with the private sector is definitely the priority. 3.2

Moving from strategy to workplan

3.2.1

Coordination of workplans

There is as yet no workplan that draws together all development assistance and core government activities in the health sector into a coordinated, prioritised schedule of activities. The Sector Partnership Agreement would fulfil this role34. However, if there is no formal, unified sector-wide workplan, it is possible to argue that there is a relatively coherent de facto ministerial workplan of reform-focused activities scheduled for the next few years. These reforms could be seen as establishing the pre-requisites for the introduction of a SWAp and/or as addressing key issues which might be addressed within a sector-wide approach (depending upon how narrow or broad a definition of a SWAp is used, or when a SWAp is seen to begin). This section will therefore review some of the main features of the current reform workplan and also identify areas which constitute obstacles to the development of a full SWAp workplan. 3.2.2

Improving disbursement of central funds

Much of the small part of the national budget allocated to health cannot be spent, as it is not passed from MEF to the MoH, or from the provinces to the provincial health directorate and districts. The proportion allocated but unspent varies between 4% and 50%, depending on the province. Two sets of reforms have attempted to tackle these disbursement problems. While not yet integrated into a SWAp, they lay the groundwork for the introduction of more sectoral ways of donors working by removing the main rationale for a continuation of the project-based system (distrust of government systems). In the first of these reforms, donors and the MoH have since 1995 piloted a new disbursement and reporting procedure in 23 out of 73 districts in Cambodia. For these Accelerated Development Districts (ADDs), the MoH receives from the MEF a cash advance for 24 types of non-wage operating costs, unified under a single envelope as an imprest account at the MEF. This cash advance is then distributed by the MoH to the ADDs rather than, as elsewhere, distributed by the MEF to the provincial governors. The advance is based upon the budget allocation, for the districts to allocate as they wish. The ADDs must submit invoices for expenditures and a summary of spending by budget line to the MoH before the MEF can reimburse the imprest account by signing a payment order to the Treasury. After several years of problems, the system seems to be delivering benefits. Disbursement of the annual budget in ADDs in the first six months of 1999 was, at 26%, double the provincial average (13%) though 34

This was scheduled for production over the first and second quarters of 2000 but realistically may not begin for another six months at least. Based on the SWAp policy paper, a Sector Partnership Agreement will be produced by the Lead Group specifying in detail 1) policies, strategies and priorities, 2) the funding contribution from each partner, 3) the accounting and monitoring mechanisms involved, including a common set of indicators on sector performance, and 4) any institutional capacity and reform that will be required. MoH 1999d.

21

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still half what the official budget provides (i.e. 50%). Household surveys indicate that utilisation rates in ADDs are significantly higher than elsewhere35. In April 1997, a second nation-wide reform was introduced. Less complex than the ADD system, this aims to improve disbursement through improved transparency. Previously, provincial and district health administrations did not know what sums they were in theory supposed to receive. Under the reforms, the MEF informs the MoH of the credit sums allocated to each provincial health department each month. The provincial health departments, meanwhile, report to the MoH what they have received from the governors, and what they estimate to remain unspent. The MoH compares these figures, and in a working group informs donors and NGOs of the situation in each province. This allows them to raise poor disbursement performance with the provinces concerned and to tailor funding to complement, rather than substitute for, state funding. The effectiveness cannot yet be clearly identified. It has probably contributed to greater disbursement (over 90%) in some provinces but very low disbursement (about 20%) in other provinces shows that transparency alone is not sufficient. 3.2.3

Matching plans to budget

There is no sector-wide budget, nor is there a cohesive programme which combines core government activities (national and provincial), vertical programmes, and donor-supported, area-based integrative programmes. Once again, the Sector Partnership Agreement should fulfil this role of matching programme to expenditure plans. Within the Ministry of Health, the SWAp Working Group is pushing the process along with support from the donors involved in the HSR (i.e. DFID, Norad, UNDP and WHO). Government ownership of the approach is gradually increasing but is still somewhat ambiguous. The timetable proposed in Step by step to a SWAP (May 1999) does not now look realistic, but revising this timetable does not seem to be regarded as a major problem. Having encountered scepticism, WHO has invested time addressing officials' fears, and gone back over the rationale for a SWAp by inviting MoH staff to identify what they find inconvenient about the project approach, and then illustrating how a SWAp could help to address these problems. They have also emphasised the process aspects, and been explicit in saying (to both MoH and other donors) that the goal is a more rational and efficient balance between project and sectoral aid rather than the imminent termination of project aid. Thus, while the small core of Health Sector Reform Group (HSRG) staff (i.e. the MoH groups staff together with advisors from WHO, DFID, Norad and UNDP) set the timetable, they appear willing to modify it as required to meet the broader constraints upon the MoH as a whole. 3.2.4 Negotiating government - donor agreements Obviously, no agreements have yet been signed on the adoption of a sector-wide approach. However, the agreements underpinning the institutional partnerships involved in the HSR provide a good foundation for the later evolution of SWAp agreements. These agreements between the RGC and DFID, Norad, UNDP and WHO incorporate a timetabled plan of action (which includes working towards a SWAp). They could provide a basis for inter-agency efforts towards joint planning and review which could be pursued in the short term (i.e. before a complete sector-wide approach was agreed and adopted). There are also agreements between some bilaterals; memoranda of understanding (MoU) between WHO and other organisations (including GTZ, UNDP and UNICEF); agreements between the RGC and donors with regard to following up World Bank-convened Consultative 35

On the ADD, see MoH/WHO 1999a; see also World Bank 1999b and van Pelt 1999.

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Group meetings; and, arguably, benefits from the United Nations Development Assistance Framework (UNDAF) process, such as agreements between members of the UN Development Group to share planning cycles. 5.2.5

National or provincial level SWAp?

There is potential for future conflict because, along with sector-wide approaches formulated at the national level, there is a parallel process of donor support to area-based planning at a provincial or sub-provincial level. The potential for contradiction is exacerbated because different donors are associated with the different approaches. WHO supports a sector-wide approach in health (as, arguably, ADB supports a sector-wide approach in education), while UNDP and to a lesser extent UNICEF support targeting reform at the sub-national level in a more integrative, multisectoral approach. While the approaches can in theory complement each other, there is a real risk that in practice they will pull in different directions. UNICEF has worked at improving district health services (and to a lesser extent provincial services) for a long time. It was one of the major channels for international aid during the 1980s when most multilateral and bilateral channels were blocked. As such, it has more experience than almost any other agency in the Cambodian health - and indeed education - sectors. It is also a significant contributor to the sector, providing almost $ 18 million to Cambodian health sector development (1996-2000). Those staff interviewed stated that UNICEF would prefer that a sector-wide approach to health was developed at a provincial level, starting in those provinces in which previous rounds of donor-supported reforms have built up the requisite capacity. These would include the four provinces (Kandal, Battambang, Svay Rieng and Siem Reap) in which UNICEF has invested most and in which it maintains resident provincial health advisors (PHAs) and permanent health teams and, presumably, other provinces in which other donors already support PHAs and capacity building. However, it seems somewhat contradictory to talk of focusing a sector-wide approach, conventionally understood to encompass all forms and levels of health services. Cambodia is small in both area and population, and has very limited state resources. In this context the concentration of these scarce resources in the tertiary sector, while clearly not ideal, makes somewhat more sense than it does when it occurs in larger countries. The financial and human resources available in the state health sector are so limited that many public health functions that are conventionally considered to be best delivered by local, district or provincial facilities cannot be provided at these levels, but must serve a larger population drawn from a wider catchment. To the extent that these services are provided, the economy of scale in Cambodian public service management dictates that they are provided by national institutes. Rural Khmers will thus often travel for considerable time and distance to reach a Phnom Penh hospital or clinic, bypassing local, district or provincial facilities. If Phnom Penh hospitals and facilities are in many cases the first point of call for people from the provinces with serious illnesses, access to and the funding of national facilities must, therefore, be accounted for in planning services, including planning that takes place at the provincial level. Approaching sector-wide planning at the provincial level leaves many important public health functions outside the box, and the approach thus well short of 'sector-wide'. To summarise, while UNICEF may be justified in pointing to the obstacles that stand in the way of a national SWAp by arguing for more attention to the provincial and district levels (which the MoH/WHO led SWAp proposal neglects), it is not clear that a truly sector-wide approach can be adopted in only a small number of pilot provinces. An attempt to create integrated and rationalised health planning and management in a particular province would be much more akin

23

Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

to a large, geographically-defined, multi-donor project. If it is not built into national policy, and does not incorporate national tertiary institutions, it is not a SWAp. And if a provincial-level 'SWAp-like' project were adopted, success in the chosen provinces might well contribute to failure at a later date to achieve a SWAp at the national level. (There are some parallels here with the politics of VDC formation.) While the proponents of a province-level SWAp approach confirm their commitment to this principle, it seems likely that in practice those focusing upon provincial and district processes will not pay full attention to the national debates. The focus of donor efforts should be upon national, not provincial, agreements. 3.2.6

Information systems for sectorwide monitoring

Health outcome information in Cambodia has improved rapidly in recent years. Much of this information is supplied by the National Institute of Public Health (NIPH), supported by GTZ and ADB. The MoH has developed a set of national indicators required in order to monitor health sector performance36. These include indicators for financial resourcing, access and utilisation, quality of services, and health outcomes. The next stage will be to progress from identifying the kind of indicators needed to developing systems to supply these indicators. 3.3

Managing joint working

3.3.1 Management structure The SWAp process has not reached the point of proposing a management structure for the implementation of a sector-wide approach. This section will briefly summarise some factors that seem relevant to these future choices. Recent experience with trust funds in Cambodia The Cambodian Mine Action Centre (CMAC) is probably the closest thing Cambodia has to a mini-SWAp, in that it is a nation-wide programme. It has a remit which integrates strategic planning, prioritisation, and preventative (mine education) and 'curative' (mine clearance) activities. Its largest single funding component is a consolidated trust fund in which donors pool contributions. In view of problems in 1999 concerning the prioritisation of operations and the use of funds within the Centre, it is worth considering both the strengths and weaknesses of the CMAC model. The following points about the deficiencies of CMAC organisational structure 37 and management can be drawn upon as lessons relevant to any SWAp37 : • • • •

rapid growth outstripped the capacity to monitor the lack of a fully unified budget hindered capacity to monitor donors were reluctant to acknowledge problems once problems were publicly acknowledged, the response was slow.

Other experiences with joint funding arrangements There is some experience with two or more donors pooling funds in a shared project. The HSR III project, for example, consists of four donors operating through one account with the MoH38 The joint ADB-World Bank Performance Management Unit (PMU) in the Ministry is also cited by the organisations involved as a positive step. WHO would prefer that the World Bank and 36 37

38

MoH 1999a, WHO 1999b. Annex 3 provides some more details. The proportion of the total HSR project funds which go directly through the MoH account is however only small: the bulk goes through WHO (Delna Gandhi, personal communication). 24

Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

ADB work through MoH structures, rather than create a parallel body. A joint PMU is better than two PMUs, but is still not ideal. Although limited, these achievements provide positive experience of different donors working to standardised systems. This provides some foundation to efforts to establish pooled funding arrangements under a SWAp. UNDAFandCDF There was a common perception amongst donor staff that the UNDAF in Cambodia was of limited value at present, given that it did not involve the government from the outset. The result was an introspective process and outcome in whieh the UN agencies turned their attention inwards, concentrating upon how to work better amongst themselves. This was seen as inherent in the guidelines rather than a flaw in implementation. The guidelines stipulate that UN agencies are to produce a draft Common Country Strategy independently and only then share this with the government. Nonetheless, some reported that the process was positive in that it engendered stronger partnerships between the UN agencies, which could contribute to future moves towards a sector-wide process. At the same time as the UNDAF was being finalised, the heads of UN agencies were all actively involved in the donors working groups set up after the CG meeting in Tokyo in 1998. 3.3.2 Managing the annual cycle Since a Government decision to go ahead with a SWAp had not yet been made, no plans exist for managing the annual SWAp cycle of review and forward planning. However, the concept of unified missions did meet with general support, though there were doubts in the World Bank office about the abilities of the World Bank headquarters to accept such arrangements. 3.4

Moving towards integrated funding

The capacity to move funds through government systems is the largest impediment to the adoption of a true SWAp. It was mentioned above that public health expenditure is a very small fraction of total government spending or GDP. This is compounded by the fact that, of the small sums allocated to health spending at the provincial level, much is never disbursed39. The MEF disburses sums to the provincial governors. The governors then have effective discretion about the disbursement of this money, as the provincial directorates of health are not provided with information about the sums that they should receive. In an effort to improve disbursements, donors and the MoH piloted a new disbursement and reporting procedure in 23 ADDs. These are described above in 3.2.2. Curtis reviewed the financial management capacity of the MoH, using a modified version of the modern audit process used by commercial accountancy firms. This review found: The accounting systems and procedures are reasonably developed at central level and accounting skills are present, though concentrated in only a handful of individuals. The most striking dimension of capacity is in terms of structure and authority as most financial management authority and functions are retained in the Ministry of Economy and Finance. Overall the procurements system is 39

There is a third major problem with the distribution of public expenditure on health, namely that only one-third is allocated for disbursement at the provincial level. While much of the centrally-distributed funds is spent on activities in the provinces (drugs and vertical health programmes), this pattern also reflects a concentration of health funds on national institutions, training centres, and national hospitals.

25

Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

comprehensive but inefficient and the accounting capacity is constrained by a lack of delegated authority and functions40. With some modifications to account for progress since this was written (probably relatively minor), this could stand as a good analysis of the current state of MoH capacity and suggests aspects of MoH and MEF processes which should be addressed before or during implementation ofaSWAp.

40

Curtis 1998. 26

Current Issues in Sector-wide Approaches for Health Development

4

PROGRESS AND PROSPECTS

4.1

Opportunities and challenges

Cambodia Case Study

Given that Cambodia is in the very early stages of SWAp development, we have approached the question of the progress of and prospects for the programme, by reviewing opportunities and challenges faced by RGC and the donor community. 4.1.1

Opportunities

Some of the opportunities are that: •

the MoH is one of the most capable of government ministries. WHO assessments consider that most aspects of current MoH systems are up to the task of developing a SWAp

•

capacity improvements have also been achieved at sub-national (provincial and district) levels, although progress is very uneven

•

health policy is relatively well developed and realistic, and there is the intention to link health reform with poverty reduction. The policy has broad support from donors

•

there is a workplan of health sector reforms which could establish the pre-requisites for a SWAp and/or address key issues within a SWAp

•

some NGOs have demonstrated the interest and capacity to take an active part in developing health policy, although this may be at risk of decline

•

there appears to be greater knowledge of the principle of a SWAp spreading amongst donors and within the government. The stakeholder analysis has made a valuable contribution to this process of dissemination

•

there would appear to be a small but growing support base for a SWAp within the MoH. Support from the Minister is not certain, but is at least possible. At least some key figures within MEF also appear basically receptive to the idea of a health SWAp

•

improvements in disbursing central funds have laid the groundwork for the introduction of more sectoral ways of working by increasing trust in government systems.

4.1.2

Challenges

Some of the challenges are that: •

the primary capacity problem with implementing a SWAp lies in health financing arrangements in the provinces and in their relationship to the MEF

•

there is as yet no clear assessment of the degree of support for, or opposition to, a SWAp approach that might emerge from provincial and sub-provincial health authorities. This is potentially a major blind spot in assessing the viability of a sectoral approach

•

several important donors also remain unconvinced of the wisdom of a SWAp approach

41

As in Viet Nam, French and Japanese aid are more significant as a share of the total than in many other developing countries (the first donor because of colonial links and a desire to maintain francophone influence, the latter because of proximity). Neither is keen to embrace a sector-wide approach, preferring to continue to assist with national hospitals and institutes and, to a lesser extent, national vertical programmes. 27

Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

•

there has been a decline in the long-standing coordination mechanisms. These problems need to be resolved before significant progress can be made towards a SWAp

•

while the Health Sector Reform Working Group has a mechanism for the 'national execution' of donor funds, which works well and with which donors are reportedly happy, the problems with CMAC must be borne in mind when attempting to address donor concerns about pooled funds under RGC management

•

institutional civil society is under developed, making consultation for programme design and implementation potentially difficult

•

donor contributions to the sector are off-budget and there is no link at sector level between programme and expenditure plans

•

capturing the contribution of the private sector within a plan for national provision will be essential, given the very high proportion of health expenditure it commands

•

some donors favour a sub-national approach to sector reform in preference to a national approach. Although in theory these approaches could complement each other, there is a risk that they may pull in different directions.

4.2

Prospects

It is interesting to compare the current position of Cambodia with the history of health SWAps in other countries. Table 8 was compiled by MoH staff who participated in a Ghana study tour. Table 8 Comparison of components of sector-wide approach in Ghana and Cambodia

28

Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

It attempts to identify which of the steps that led to a SWAp in Ghana have been achieved in Cambodia, and where gaps remain. There is a timetable in place for the introduction and development of a SWAp. Whether Cambodia is seen to be already 'in' a SWAp depends upon the point at which a SWAp process is taken to be operative. Some WHO staff would argue that a SWAp process already exists. Some events specified in the timetable have not occurred on schedule and it seems likely that others will also be delayed. There is a momentum, and those promoting the SWAp are adopting a long-term view, and pushing change only at the rate at which it can be compatible with ownership and sustainability. They also emphasise that the process should be formulated and presented in terms of a shift along a continuum from highly projectised to more sectoral, rather than as a single step-wise transition. This seems a sensible approach which could potentially do much to improve the effectiveness of health services in Cambodia.

29

Current Issues in Sector-wide Approaches for Health Development

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ACKNOWLEDGEMENTS The author would like to thank all those in the Government of Cambodia, development partner agencies and NGOs, who so willingly gave up their time to support and inform this research and provide much valuable insight and material. Thanks are also due to those who kindly commented on drafts of the report, and especially the WHO Representative and his staff who organised the programme. The views expressed in this case study are those of the author and should not be taken to be representative of any other party. Responsibility for any remaining errors of fact or interpretation are also those of the author.

30

Current Issues in Sector-wide Approaches for Health Development

Annex 1

Cambodia Case Study

Costs of outpatient visits, by provider and wealth of patient

Average expenditure on an outpatient treatment, by type of provider, 1997 Provider Cost of a single visit Total cost Consultation Transport Materials State 37,960 Local (khum) clinic 2,508 73,858 33,390 District health centre 2,052 2,634 48,349 22,663 Provincial hospital 6,013 91,279 28,553 56,603 Central hospital 5,891 149,626 84,639 59,096 Modern private Pharmacy 8,153 37,720 14,851 14,715 6,138 84,743 Private doctor / nurse 38,933 39,673 5,382 63,999 Private clinic 34,900 23,717 5,021 52,482 128,753 Private hospital 71,250 Traditional private Kru Khmer 50,492 3,662 99,053 44,899 48,144 2,820 Other traditional 18,930 26,395 Other 10,682 71,323 Other providers 34,965 25,577 71,546 5,322 33,122 33,102 Average, all providers Source: World Bank 1999b, Cambodia Socio-Economic Survey 1997.

Average expenditure on an outpatient visit, by wealth group p.c. monthly Average total cost of Wealth group expenditure (quintile) an outpatient visit 91,524 123,714 First (richest) 25,957 67,899 Second 17,466 55,362 Third 12,203 Fourth 38,039 7,565 32,896 Fifth (poorest) Source: Note:

World Bank 1999b. Wealth defined by per capita monthly expenditure.

31

Current Issues in Sector-wide Approaches for Health Development

Annex 2

Cambodia Case Study

Donor support to the health sector

Name of Donor

Period of Support

Major Project Activities

Funding (USS)

1997-2001

• • • •

25,000,000

Bilaterals/UN Agencies ADB(l) (Strengthening Basic Health Services) ADB (2) (Strengthening Basic Skills) World Bank

1997-2000 1997-2001

JICA(l)

1994-1996

JICA(2) JICA(3) UNICEF

1996-2000

USAID

1995-2000

AusAID

1997-2002

WHO (Regular budget)

1996-1999

WHO/DFID/UNDP (SHS III)

1998-2000

GTZ

1995-2004

UNPPA

1997-2000

European Union

1998-2001

DPID

1996-1999

Construction & Rehabilitation of health facilities Essential Drug Supply Supplies and Equipment Institutional Strengthening/Contracting Pilot Studies • Human Resources Development * Construction of District Hospitals and Health Centres • Institutional Strengthening • Tuberculosis control • Malaria Control • HIV/AIDS * Construction of new MCH Hospital • Supplies & equipment • MCH activities • MCH/EPI/ARI/CDD * Tuberculosis * Strengthening District Health Services • Essential Drugs • Human Resources Development • Health Information Systems • Nutrition ' B i r t h Spacing • Child Health • Human Resources Development * Construction of district hospitals & health centres • Construction & rehabilitation of National Institutes • Health Education/Health Promotion • Human Resources Development * National Health Systems & Policy Development • Human Resources Development • ARI/CDD Control • Tuberculosis Control • Malaria Control • Strengthening Health Systems • National Policy Development • Human Resources Development • Health Financing . Construction of NIHP • Construction of Health Centres • Human Resources Development • Laboratory Support • Family Planning * Reproductive Health • Birth Spacing • Sexual Health * Malaria Control HIV/STD Control • Prevention & Control of Malaria • Prevention & Control of Dengue Fever

Source: reproduced from Phuah 1999. Note:

1) Data from SHSIII Project Document (1998). 2) Figures are provisional as submitted to MOH in initial project documents. 3) No information was available on the French Cooperation.

32

5,300,000 30,000,000

21,000,000 696,200

17,750,000

14,000,000

13,200,000

4,985,600

10,000,000

7,414,650

3,500,000 1,500,000 1,176,000

Current Issues in Sector-wide Approaches for Health Development

Annex 3

Cambodia Case Study

The Cambodia Mine Action Centre: lessons for a SWAp

CMAC is administered by a Governing Council composed of RGC officials. RGC contributions (about 10% of total funds which amount to $9m-12m p.a.) are combined with donor funds placed into a UNDP administered Trust Fund. Expatriate advisors should provide accountability to donors. In the case of CMAC, the warnings of advisors were ignored for far too long. Following increasing alarm about appropriation of money and the distribution of benefits, an external audit was, belatedly, carried out. Although most donor financing is in the form of general funds to be spent as CMAC feels necessary within a strategic plan, there has been provision for donors who were not comfortable with this to take on a defined component of the CMAC national action plan. Germany, for example, funds demining in Siem Reap province. To the extent that CMAC clearly did fall short of what it should have been, factors contributing to this failure include: •

rapid growth outstripping capacity to monitor. CMAC was created following UNTAC, was seen as a worthy cause with which donors were glad to be associated, and so expanded too fast for proper safeguards to be implemented

•

lack of a fully unified budget. The three components of CMAC funding - government, consolidated donor trust fund, and donor-specific component funding - were obviously chosen to enable donors to retain greater control but at the cost of a unified overview of the whole operation

•

reluctance to acknowledge problems. CMAC was seen as a 'super-agency'. Donors, including the top UN adviser, appear to have thought that to investigate rumours would jeopardise continued funding

•

slow response once problems were publicly acknowledged. Concerns were openly voiced for the first time by the Norwegian government in July 1998, but other donors did not act for another year. Three senior expatriate advisors resigned in protest before problems were acknowledged.

Sources: Cochrane 1999; Fontaine 1999; Sheridan 1999; South China Morning Post 1999 (no author); http://www.camnet.com.kh/cmac/.

33

Current Issues in Sector-wide Approaches for Health Development

Annex 4

Cambodia Case Study

Terms of reference

Background The Partnerships for Health Sector Development Project seeks to commission a consultant to carry out and report on a series of country case studies - and subsequently to prepare a synthesis paper - on current issues in sector programmes and development assistance in the health sector. The work will be carried out on behalf of Inter-Agency Group on Sector-Wide Approaches and Development, for which WHO provides the Secretariat. The purpose of the assignment is to provide insights and recommendations relevant to the policies and practices of agencies which are members of the group as well as to the governments with whom they interact. The scope of work which follows is based in part on discussions and issues arising at a preliminary meeting of the Inter-Agency Group (1 June 1999). It will be further refined following the completion of a preliminary desk study by the Centre for Aid and Public Expenditure (to be completed by 31 July 1999), and comments received from members of the Inter-Agency Group (1AG). Countries Case studies will be carried out in Mozambique, Tanzania, Uganda, Cambodia and Viet Nam. These countries have been selected because of their engagement in the development of sector approaches as well as the nature of their cooperation with international financial institutions (CDF, ESAF). Their physical proximity within Eastern and Southern Africa and South East Asia will allow efficiencies in travel. Work in additional countries may be financed by other partners in the IAG. In preparing the synthesis paper the consultant will also draw on relevant experience from other countries. The studies in each country will take the form of policy analyses and will be based on interviews with key actors and reviews of documents. Given the breadth of the concerns set out below, the aim will be to make well informed judgements, rather than collect large amounts of quantitative data. Scope of work Reports should assume an understanding of the rationale for and basic concepts of sector-wide approaches. They will focus on issues emerging as sector programmes are implemented in practice. In each of the country studies, and in preparing the synthesis paper, the consultant will pay particular attention to the following questions: policy quality and policy process: what evidence is there to suggest that the process of developing sector programmes has influenced the content of sectoral policies? Most agencies supporting SWAps see them as a way of promoting pro-poor health policies: how has this intention been expressed in practice? Is there any evidence to suggest that sector programmes have been successful in promoting a greater concern for health outcomes? To what extent do donor concerns about ownership and national concerns about consensus limit the scope for real policy negotiation? managing relationships between governments and development partners: what have we learnt about the negotiation/transaction costs of SWAps? How effective are the various types of accord/compact / MOUs? What conclusions can be drawn about the need for and effectiveness of, conflict resolution systems? Is there any evidence that processes such as UNDAF have increased the effectiveness of UN agencies as participants in sector programmes? planning: a great deal of emphasis has been placed on the preparation of sectoral plans of different kinds: what conclusions can be drawn about sectoral planning processes? Are sector programmes over-determined? Is there a risk that the focus on planning reduces flexibility and the need to adjust policies in the light of changing levels of performance? Do donors demand too much detail in preparing programmes work and operational plans? How much variation in planning processes is beginning to emerge between countries? scope of sector programmes: does it remain true that many SWAps constitute a discrete programme within the sector? To the extent that this hypothesis is correct, what elements of sectoral spending tend to be omitted? With what implications? What needs to happen to move on toward time-slice funding of national sectoral budgets? What evidence is there to suggest that sector programmes have been successful in influencing intrasectoral resource allocation in line with stated policies?

34

Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

links with the PFP and medium-term budget frameworks: to what extent are sector programmes fully reflected in overall budget plans? Is new thinking on the comprehensive development framework likely to influence this process? Where is there scope for more effective macro-sectoral dialogue? preconditions and conditionalities: do we need to revisit the whole idea of preconditions for SWAps if it is a term that is increasing being applied indiscriminately? To what extent do donors still impose conditionalities within the context of sector programmes? What form do these conditionalities take? Is there any evidence for their effectiveness? capacity building: to what extent does adequate capacity in national management systems have to be in place prior to the implementation of pooled funding arrangements? Is there a risk of a hiatus in the provision of essential services when moving toward a SWAp? sector performance: have we got any further in developing manageable ways of monitoring performance? Does monitoring improve over time? Does it take into account distributional issues which are often overlooked by routine systems? decentralisation: it was predicted that designing sector programmes in decentralised systems would be difficult - what has been the experience to date? To what extent have fears about SWAps acting as a centralising force been realised in practice? What national approaches to earmarking of sector priorities have been agreed and applied by central and local governments? civil society and NGOs: most governments and development agencies emphasise the importance of broad participation in the development of sector programmes: how has this intention been reflected in practice? with what effects? OUTPUTS AND TIME FRAME The consultant will submit draft reports and make a presentation to the Inter-Agency Working Group in November. Final reports are to be completed by 3 1 December 1999. Additional ToRs on debt relief (added later) 1 . Is there a government policy on poverty reduction in place or in the process of production? 2. Are there plans for the production of a poverty reduction strategy paper (PRSP)? If the answer to 1 is yes, what is the relationship between the government policy and PRSP? 3. If the answer to 2 is yes, what is the process for producing it - who will? Government? IMF, Bank, all three? Others? Time frame? 4. Is the MoH involved in writing/advising on the health component of the PRSP? If not, why not? If so, how? 5. What do we know about negotiations (if any) and about conditionalities (if any) attached to HIPC Initiative II? How is the poverty focus reflected in the health policy and in the health sector expenditure framework?

35

Current Issues in Sector-wide Approaches for Health Development

Annex 5

Cambodia Case Study

List of key people met

Organisation Government Ministry of Health

Name

Position

Dr. Hong Sun Huot Dr. Char Meng Chour Dr. Youk Sambath

Minister of Health Director, Planning Dept. Deputy Director, Budget & Finance Dept., and member of SWAp Working Group SWAp Working Group

Ms. Khout Thavary Dr. Or Vandine

Deputy Director and PCU Manager Cambodia Disease Control and Health Development Project (WB) & Basic Health Services Project (ADB) Essential Drugs Bureau, Dept. of Food & Drugs Deputy Director General for Health ADB Project Manager, Basic Health Services (Joint PMU) Deputy Chief of Technical Office, National Tuberculosis Programme Advisor

Dr. Chroeng Sokhan Dr. Mean Chhi Vun Dr. Krang Sun Lorn Dr. Keo Sokonth Ministry of Educaticon, Youth and Sports

Mr. Mike Ratcliffe Mr. Seng Kan

Ministry of Economy & Finance Bilaterals AusAID

Manager, Programme Management and Monitoring Unit Director, External Finance

Mr. Chou Kim Leng

Programme Officer, Development Cooperation Ambassador Resident Representative Assistant Resident Representative Chief Adviser, JICA TB Project

Ms Christine Hansen

Canadian Embassy JICA

Mr Normand Mailhot Dr Norio Matsuda Mr. Saito Katsuyoshi Dr Ikushi Onozaki

USAID

Dr Jeffrey Ashley

British Embassy IFIs ADB

Mr Lawrence Pickup

World Bank

Mr. Bonaventure Mbida Assama

UN Agencies UNICEF UNDP

WHO

NGOs MediCam World Vision Internat ional CDRI

Chief, Office of Health Humanitarian Assistance Deputy Head of Mission

Mr. Urooj Malik Ms. Sheryl Keller

Resident Representative Health Advisor, Joint World BankADB PMU Chief, Resident's Office

Dr. Maurice Hours Dr. Andrew Morris Mr. Scott Leiper Ms. Dominique Ait Ouyahia-McAdams Mr. Mike Curtis Dr. W.J. Piggott Dr. Henk Bekedam Ms. Alice Levisay

Health Technical Consultant Head of Health Section Programme Manager Resident Representative

Dr. Stephane P. Rousseclu Dr. Kyi Minn Dr. Martin Godfrey Mr. Sok Hach

Executive Director Health Coordinator Research Coordinator Researcher

Budgetary Advisor WHO Representative Team Leader, HSR III Institutional Development Advisor

36

and

Current Issues in Sector-wide Approaches for Health Development

Annex 6

Cambodia Case Study

Bibliography

(no author) 1999 "Japan vows to bail out landmine agency" South China Morning Post 19 October (CamClips file). Annear, P. 1998 "Health and development in Cambodia." pp. 193-221 in Asian Studies Review Vol. 22 No. 2. Bidduplh, R. 1996 Participatory development in authoritarian societies: the case of Village Development Committees in Banteay Menachay Province, Cambodia. Unpublished Master of Development Administration thesis, National Centre of Development Studies, Australian National University. CARE 1996 Jivit Thmey baseline survey. CARE International in Cambodia, Monitoring and Evaluation Unit: Phnom Penh. Cassels, A. 1995 "Health sector reform: key issues in less developed countries." pp. 329-347 in Journal of International Development Vol. 7 No. 3. Cassels, A. 1995 Aid instruments and health systems development: an analysis of current practice. WHO Forum on Health Sector Reform Discussion Paper No. 3. WHO: Geneva. Cassels, A. 1997 A guide to sector-wide approaches for health development: concepts, issues and working arrangements. WHO: Geneva. Char, M. C. 1999 Cambodia's health status, policy reforms, and investment implications. Paper presented at the Manila Social Forum, 8-12 November. http://aric.adb.org/conference/msf/papers/cam-p8_2.htm Cochrane, J. 1999 "Clearing a minefield of graft" South China Morning Post May 23rd 1999 (CamClips file). COCOM 1998 COCOM: Briefing notes. Phnom Penh. Conway, T. 1999 Poverty, participation and programmes: international aid and rural development in Cambodia. Unpublished PhD thesis: Department of Geography, University of Cambridge. Conway, T. 2000 Elections and assassinations: local democracy and rural development in Cambodia. Paper presented at the annual meeting of the Association for Asian Studies, San Diego, 9-12 March 2000. Mimeo. Curtis, M. 1998 The Sector-Wide Approach: developing common financial management in the Cambodian health sector. MA Dissertation, Leeds University. Curtis, M. 1999 From a project to a Sector-Wide Approach. WHO. Ebihara, M. 1968 Svay, A Khmer village in Cambodia. PhD dissertation: Columbia University 1968 / University Microfilms, Ann Arbor 1971.

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Economist Intelligence Unit, The (EIU) 1996 Cambodia and Laos: Country report, 1 quarter 1996, London. Fontaine, C. 1999 "Cambodia land mine chief resigns" Associated Press 4 August 1999 (CamClips file). Foster, M. 1999 Lessons of experience from health sector SWAps. CAPE, ODI: London. Hill, P. S. 1998 "Planning and change: a Cambodian case study." Conference paper, Annual Scientific Meeting, Royal Australian College of Physicians: Melbourne. IRC 1994 Household health survey report: Kompong Leng and Chul Kiri Districts, Kompong Chhnang Province, Cambodia. Phnom Penh: International Rescue Committee. Kannan, K. 1997 Economic Reform, Structural Adjustment and Development in Cambodia. working paper no. 3. Cambodia Development Resource Institute. Kulig, J. C. 1988 "Conception and birth control use: Cambodian refugee women's beliefs and practices." Pp. 235-246 in Journal of Community Health Nursing Vol. 5 No. 4. [USA] Lanjouw, S., McCrae, J. and. Zwi, A. B. 1999 "Rehabilitating health services in Cambodia: the challenge of coordination in chronic political emergencies." pp. 229-242 in Health policy and planning. Vol. 14 No. 3. Mbida-Assama, B. 1999 Discussion note on partnerships - draft. Phnom Penh. McGrew, L. 1990 "Health care in Cambodia." pp. 77-81 in Cultural Survival Quarterly Vol. 14 No. 3. MoH n.d. Guide for the strengthening of the District Health System in Cambodia. Phnom Penh: mimeo. MoH 1996a Guide to developing Operational Health District in Cambodia. Phnom Penh. MoH 1996b 1995 Health Coverage Plan. Phnom Penh: Planning and Statistics Unit. MoH 1996c (in collaboration with WHO) The National Charter on Health Financing in the Kingdom of Cambodia: comments and interpretations. Phnom Penh. MoH 1999a Consultative Group Position Paper. Information: Phnom Penh.

Department of Planning and Health

MoH 1999b Health situation analysis 1998 and future direction for health development 19992003. Department of Health Planning and Information: Phnom Penh. MoH 1999c Monitoring and evaluating health sector performance: national level indicators. The Health Reform Monitoring and Evaluation Working Group: Phnom Penh. MoH 1999d Step by step to SWAp: action plan for 1999 and 2000 (summary). Ministry of Health Health Sector Reform III Project: 9 pp: Phnom Penh (Khmer and English).

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Current Issues in Sector-wide Approaches for Health Development

Cambodia Case Study

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Cambodia Case Study

WHO 1999aAnalysis of the Health Sector in Cambodia. Office of the WHO Representative in Cambodia. 3 pp: Phnom Penh. WHO 1999b Draft report of a joint mission to explore a 'Country Cooperation Strategy for One WHO. August 1999. 5pp: mimeo. WHO 1999c Health Sector Reform Phase III Project 1998-2000: briefing to the Minister of Health. 9 pp: Phnom Penh. WHO 2000 Briefing note: government expenditure on health in 1999. Mimeo.

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