Cambodia 1

Cambodia 2

Cambodia Assessment

Ung PhirunChroeng Sokhan

Cambodia 3

Demographics Cambodia

Area (sq km) 181,000

Population

11,800,000

15.6% urban

GNP per capita US $260

Human Development Index

.514

137/174

Literacy rate

Male: 58.6%

Female: 21.1%

Infant mortality rate 100.2 per 1,000

Life expectancy 54 years

World Bank, 1999

Cambodia

Cambodia 4

Health Care Delivery System• Public sector: centralized three-tiered health

care system

• NGOs: 108 working in the health sector

• Private: 382 private clinics and hospitals registered

• 70% of providers are not registered

• Household spending on health in 2000 was 11% of GDP, 80% of all health expenditures

Cambodia 5

Pharmaceutical Sector• Public sector utilizes a centralized procurement

and distribution system

• Donor-funded pilot programs contract out management of public health facilities to private organizations

• Six pharmaceutical manufacturers; only three operating

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Pharmaceutical sector• Total pharmaceutical expenditures for 2000 were

31.46 million USD Households: 57% Donors: 25% MOH: 18%

• There are approximately 3700 retail outlets for pharmaceuticals, of which 75% are unlicensed

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Geographic Accessibility

65% of the population is less than 10 km or 2 hours’ walk of

basic health care facility

Hou

rs

Average number of facility operating hours per day

12.4 12.4

6.6

0

9.97.7

11.3 11.7

0

4

8

12

16

20

24

Private pharmacy Public NGO clinic Private clinic

Weekdays Weekends

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Availability

Public Private clinic

Private pharmacy

NGO

clinic

ODMS

Set of un-expired tracer items in stock

59% 56% 66% 50% 69%

Time out of stock

3% 1% 0% 0% 4%

Prescribed items dispensed

80% 59% NA 54% --

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Affordability

NGO/ Mission

Private Facilities

Pharmacy/Drug Depots

Unlicensed Pharmacies

Pneumonia (pediatric 1-5 years)

Amoxicillin 250mg (IMCI)

.26 2.99 .97 1.4

Co-trimoxazole 80/400 (IMCI)

.91 2.89 .75 .84

Dysentery (pediatric 1-5 years)

Co-trimoxazole 80/400 (IMCI)

.91 2.89 .75 .84

Number of days worked to pay for treatment

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Affordability (2)• Less than 1% of population is covered by any risk sharing scheme

•Payment for health care services is a major cause of impoverishment; 46% of loss of farms was due to health care costs

•Children from poor families have lower treatment rates than those from higher income families (20% vs. 52%)

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Affordability (3)

• Average percentage difference of lowest prices among facilities

– Highly variable, 524% to 1140%

• Median percentage difference between most and least expensive unit price within facilities– 55% to 273%

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Acceptability• Distance, cost, and lack of drugs negatively

influence utilization of public health services

• Overall the public sector was used in 20% of all illnesses and injuries

• Retail drug outlets are the first point of contact for 70% of the population

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Quality of Products and Services

0

2

4

6

8

10

12

14

16

18

20

Public

NGO

Private

• MOH Cambodian drug market study found overall failure rate of 13.5%

• 50% of drugs are not registered

• Failure rates:– Registered: 5.2%– Unregistered 22.3%Tracer drugs that failed quality testing

Per

cent

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Quality of Products and Services (2)

5651

64

0

10

20

30

40

50

60

70

Encounter prescribed antibiotics (PHC and clinics)

Per

cent

MOH NGO Private • In retail drug shops antibiotics were inappropriately recommended 72% of the time (ARI/ no pneumonia)

• 50% actually purchased antibiotics

• Number of drugs per encounter

MOH 2.0 Private 3.8 NGO 2.5

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Quality of Products and Services (3)Exit Interviews

0

10

20

30

40

50

60

70

80

90

100

NamePurposeDurationAdditional InfoName & purpose

Simulated Client

0% 20% 40% 60% 80% 100%

Additionalinfo

Instructions

Possibleproblems

Advice onfever

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Access Gaps• Availability

• Affordability

• Quality of drug products

• Quality of pharmacy services and information

• Geographic access in rural areas

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Potential Strategy• Performance-based network of retail drug

outlets

• Network of health service providers to be served by the pharmacy network

• Group purchasing cooperative for network members

• Community-based care program

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Potential Country Strategy (2)Group

purchasing cooperative

Quality

Standards, training, monitoring,

accreditation

Availability Affordability

Consumers

Network of pharmacies, drug depots

Network of providers

InsurersNGOs

working in health

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Viability• Facilitating factors

Franchises, as a means of meeting public health needs, have a basis in regulations and public policy

The proposed intervention has strong MOH and private sector support

Proposed pilot locations are willing to dedicate human and financial resources

The intervention will build on existing programs that work with drug retailers

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Viability (2)• Barriers

The government supports public-private partnerships, but sometimes exhibits ambivalence about the private sector

Incentives for continued participation are rather limited

Human resource development may require medium- to long-term support to fully develop