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 Cambodia - Country Assessment
In 1996, the National Public Health and Research Institute of Cambodia described a system lacking managerial, financial, and human resources. Since then, a comprehensive health-sector reform effort has been implemented in the country, but it has yet to be completed. The SEAM assessment found that rural areas are still underserved by the public and private sectors, with providers overconcentrated in populated areas. Improvements have been evident in demonstration districts or in those facilities with dynamic leaders. Otherwise, few incentives exist in the public sector for providing high-quality health care services, and health facilities are frequently underutilized and understaffed. Where utilization is higher, incentives promote overprescribing of drugs without an apparent link to positive patient outcomes.
Public financing of supplies in Cambodia is heavily subsidized by donor contributions. The value of stock distributed through the public sector has tripled over the last four years, yet this is apparently insufficient to meet demand at the patient level. In lower levels a lack of accountability leads to a significant leakage of public supplies into the private sector. Public-sector medicines are procured through a private intermediary and distributed through a three-tiered supply system to a recently reorganized network of public health centers and hospitals. Although public-sector drug prices are higher than average international prices, some cost-efficiency appears to have been realized. Prices fell from 60 percent above average international prices in 1997 to approximately 14 percent above international prices in the first half of 2001. Patient out-of-pocket payment for health care, including pharmaceuticals, constitutes approximately 80 percent of per capita annual spending on health care and has been a major source of impoverishment of the population. Regulations require licensure for pharmacies and drug depots, but this requirement is not enforced. There has been an explosive growth in unlicensed drug vendors, which, in 2001, outnumbered legal outlets by approximately 3.5 to 1, leading to a fragmented market of wholesalers and distributors, with variable pricing and drug quality. The SEAM product-quality and Ministry of Health/World Health Organization (MOH/WHO) studies confirmed the presence of counterfeit and substandard pharmaceutical products in the Cambodian market. In the SEAM sample, nearly 10 percent of samples were found to be substandard; public facilities had a failure rate of 13 percent and private retail outlets, 9.6 percent. A recent MOH/WHO study found an overall failure rate of 13.5 percent; approximately 50 percent of product samples were not registered in Cambodia. Not surprisingly, unregistered products had a much higher failure rate (22.3 percent) than registered products (5.2 percent). Related Information» View Assessment Report (PDF, 470KB) » View Survey Data (PDF, 741KB) |
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Availability of essential medicines was low at both public and private facilities (59 percent in public facilities, 50 percent at nongovernmental organization [NGO] clinics, 56 percent at private clinics, and 66 percent at private pharmacies). Yet, when essential medicines are unavailable in the public sector, patients purchase them in private drug outlets at exorbitant prices. Whereas a course of the recommended first-line antibiotic treatment for pediatric pneumonia may cost one-quarter of a day's wage (at the lowest-paid government worker's salary) at an NGO clinic, the same treatment may cost three days' wages at a private pharmacy. Private retail drug outlets are the first points of contact for a majority of the population, where the staff often do not have appropriate medical or public health education. A wide range of pharmaceuticals is available on demand in the private sector, where prices are often set by what the consumer is willing to pay.