Project Director Describes Health Sector Success
H.E. Prof. Eng Huot: “HSSP helps the RGC to implement its Health Sector Strategic Plan, and strengthen the sector’s capacity to manage resources efficiently.”
The Health Sector Support Project (HSSP), which is supported financially by the World Bank, has been implemented by the Ministry of Health for seven years. The HSSP was scaled up to HSSP II in the context of better harmonization among development partners and alignment to government policies, strategies and system. The World Bank Cambodia monthly Newsletter interviewed H.E. prof. Eng Huot, HSSP Project Director, on the project’s achievements and the challenges it faces.
Please could you let us know what the goal of HSSP is?
HSSP1 was the flagship Project of the Ministry of Health from 2003 through 2009, with some civil works activities continuing into 2010. It was the principal vehicle through which the MOH implemented its sector wide management approach as a prelude to a full scale sector wide approach. Four of the MOH’s key health development partners – Asian Development Bank (ADB),World Bank, UK Department for International Development (DFID), and United Nations for Population Fund (UNFPA) — joined together with the MOH under the HSSP1 umbrella to launch a range of strategies and interventions in line with the first Health Sector Strategic Plan, 2003-07. HSSP1 has three components: (i) improved delivery of health services, (ii) support to priority public health programs, and (iii) strengthening of institutional capacity.
The objectives of the HSSP were to increase the accessibility and quality of health services and tossist the Royal Government of Cambodia (RGC) to implement its Health Sector Strategic Plan, and strengthen the sector’s capacity to manage resources efficiently.
What are the main challenges facing the Health Sector in Cambodia?
In common with many low income countries, the main challenges facing the health sector in Cambodia include the availability, accessibility and affordability of health services with low quality of care resulting in low utilization and coverage of these services, and weak institutional capacity to plan, implement, supervise, monitor and evaluate health services. Additional factors include low motivation of health workers and managers due to low compensation, and lack of clinical skills of the required levels to ensure appropriate, timely and cost effective treatment of diseases and illnesses. Finally, health promotion and the adoption of healthy lifestyles by all sections of the population continue to be key challenges in the sector.
How has HSSP helped to deal with these challenges?
HSSP helps in six main ways:
First, in terms of availability of public health services, HSSP1 funded the renovation and expansion of health infrastructure in line with the Health Coverage Plan. This includes referral hospitals and health centers. In addition, HSSP1 provided medical and essential drug kits per Minimum package of Activities and Complementary Package of Activities specifications thus improving the quality of care, transport such as critically needed ambulances, and furniture, including hospital beds.
Second, based on lessons learned from the pilot experiments in the previous ADB funded Basic Health Services Project, HSSP1 contributed to the expansion of NGO contracting of health services in remote and poor districts of the country, such as Mondulkiri and Ratanakiri provinces. A total of 11 Operational Districts (ODs) were contracted to NGOs. A final evaluation of NGO performance in 2009 showed significant increases in utilization and coverage that were the primary objectives of the initiative.
Third, HSSP1 improved the affordability of health services through the establishment of Health Equity Funds at health facilities in selected ODs, typically those with higher than average poverty head count ratios. Over a million people living under the poverty line were the target beneficiaries. Health Equity Funds (HEFs) are third party purchasers of health services for poor people who might not otherwise be able to afford them. Patient costs that were covered through direct payments to poor people under the scheme included consultations and essential drugs, travel costs and food costs for accompanying family members. Local NGOs were employed to deliver these benefits to poorer clients. Evaluation research shows that support from HEFs directly contributed to poverty reduction and decline in the household debt burden for significant sections of the poor. Based on the HSSP1 experience the MOH has now decided to expand HEFs to all parts of the country.
Fourth, HSSP1 also contributed to improving quality of care through expanding support for in service and pre service training of health workers, particularly skilled primary and secondary midwives which allowed the MOH to deploy them to health facilities. By mid 2009, all health centers in the country had at least one midwife, a significant improvement over the baseline situation when more than did not have any. HSSP1 funding also helped strengthen supervision and monitoring across the health sector at all levels: central to provincial, provincial to district and provincial hospital, and district to health center. Expansion of the public health facility network, provision of essential drugs and consumables, and supply of medical equipment, transport and furniture, have also contributed to sustained quality of care improvements.
Fifth, communicable diseases constitute a major portion of the burden of disease in the country. Recognizing this, HSSP1 provided varying degrees of funding and support to the prevention and control of malaria, dengue, tuberculosis, and HIV/AIDS. HSSP1 support enabled the procurement and supply of insecticide treated bed nets, one of the most cost-effective malaria prevention interventions, to thousands of households in endemic areas, and ensured that they were retreated per extant guidelines. Health promotion was supported through production and wide dissemination of IEC/BCC (Information-Education-Communication/ Behavior Change Communication) materials, and the implementation of community participation activities. HSSP1 support also contributed significantly to improvements through expansion in coverage of directly observed short course treatment (DOTS) for TB, and training of health providers, and procurement of larvicides for dengue prevention and control. Since a number of other donors were already active in providing support to HIV/AIDS prevention and control activities, including global health initiatives such as the Global Fund, HSSP1 focused on the procurement of ARV drugs for treatment of the syndrome.
Finally, HSSP1 contributed in many ways to institutional strengthening in the health system. Under HSSP1, the MOH first launched the Joint Annual Health Sector Review that was later renamed the Joint Annual Performance Review (JAPR) and merged with the MOH’s annual National Health Conference (NHC). The JAPR/NHC brings together all stakeholders in the sector, including provincial and operational district health units, sister ministries and government agencies, local authorities, community members, representatives of the private sector, and health development partners to review the previous year’s achievements and set sector priorities and targets for the coming year.
At the tail end of the Project, the MOH also inaugurated the Joint Annual PlanAppraisal (JAPA) where the MOH and its partners come together to carry out an appraisal of the sector’s Annual Operational Plan and examine patterns of resource allocation. Project funding and technical assistance contributed to the development of guidelines for the health information system (HIS) and training of health workers at all levels in the compilation, analysis and use of health statistics, development of a sector wide computerized database with provision of computer equipment down to OD levels, development of the monitoring and evaluation framework of the Second Health Strategic Plan, 2008-15, a comprehensive assessment of the health information system, formulation of an HIS strategic plan for the 2008-15 period, and a number of different sub-sector reviews and assessments.
If you may, please share with us the achievements of the HSSP-I in its seven years?
The period of implementation of HSSP1 has seen a dramatic improvement in the health status of our people. For instance, in terms of infant and child mortality impressive achievements have been documented over this period through the CIPS 2004, CDHS 2005, and the Census 2008. From 95 deaths per 1,000 live births in 2000, infant mortality has declined to 60 in 2008 and we are well on our way to achieving both the NSDP and CMDG targets of 50 deaths per 1,000 live births by 2015.
Key output and coverage indicators that contribute to improved infant and child health have also shown sustained improvement from 2000 to 2008: measles immunization coverage has increased from 41% to 91%, children aged 6-59 months receiving vitamin A supplements has shot up from 28% to 79%, and the combined diphtheria, pertussis, tetanus, and Hepatitis B vaccine coverage has improved from 43% to 92%. More mothers of infants are practicing healthy behaviors: the exclusive breastfeeding rate has improved from 11% to 66% over the same period, and we have seen sustained increases in initiation of breastfeeding after delivery and complementary feeding as well.
In terms of the number of maternal deaths, evidence from the measurement of the maternal mortality ratio will only be available from the CDHS 2010. However, dramatic declines in the total fertility rate from 4.0 in 2000 to 3.1 in 2008, coupled with significant increases in maternal health services utilization and coverage indicators, such as improvement in the proportion of deliveries attended by trained health personnel from 32% in 2000 to 58% in 2008, proportion of pregnant women with 2 or more antenatal care visits from 31% to 81%, and proportion of pregnant women receiving iron foliate supplementation at 69% in 2008 suggest that these numbers have declined as well. In terms of infectious and communicable diseases, the number of malaria cases treated at public health facilities per 1,000 persons has dropped more than two-fold from 11.4 in 2000 to 4.4 in 2008, the TB cure rate stands at 90%, and HIV prevalence among adults 15-49 years has declined from 1.9% to an estimated 0.7% in 2008.
Perhaps the most significant contribution of HSSP1 has been in the area of institutional strengthening through the adoption of a sector wide management approach. As I said earlier, HSSP1 pioneered new approaches to policy dialogue and sector wide management including the JAPR and the JAPA, contributed to improved sector monitoring and supervision, supported training of staff in clinical specialties, as well as management and finance, and strengthened the health information system.
What is your view on HSSP2 for improving health status of Cambodian people?
In terms of HSSP2, it is designed so as to build on the achievements and lessons learned from HSSP1 including transiting from a sector wide management approach to many features of a sector wide approach, most notably pooled funding arrangements. I expect that many of the components of HSSP2 including the innovative use of block grants to implementing units termed service delivery grants, the introduction of internal contracting arrangements at provincial and operational district levels, the expansion of health equity funds to purchase health services for the poor and the vulnerable, the strengthening of emergency and referral systems, improvements to the health service delivery network, building capacity at central and local levels through strengthening training institutions and conducting appropriate training programs, and the piloting of community score cards to strengthen accountability and involvement at community levels will all go a long way to improving health service utilization and behavior, and ultimately the health status of our people over the next five years.
What lessons have been learned from the Project?
I should point out that the MOH has recruited an external consultancy team of experts to carry out an end of project assessment of HSSP1, and that they are currently engaged in this task. I am looking forward keenly to their findings. But from our experience in HSSP1 I can say that we have learned that successful implementation of the sector wide management approach can become the basis for the introduction of an overall sector wide approach in the health sector. This is precisely what we have done in the design of HSSP2 where seven health development partners have joined hands with the MOH to introduce pooled sector funding for the very first time, along with non-pooled funding. Second, experience with NGO contracting of health services under HSSP1 permitted the MOH to launch internal contracting with block grants to special operating agencies in line with the RGC’s Policy on Public Service Delivery. Finally, a key lesson learned is that the three year rolling plans and annual operational plans which form part of the planning cycle of the MOH can be successful approaches to improved resource allocation thus contributing to the MOH’s goals of efficiency, equity and effectiveness in service delivery resulting in the improved health status of our people. All these lessons have been applied to the design and implementation of HSSP2 for the 2009-13 period.
(Source: The World Bank Newsletter, Volume 8, January-February 2010)