Presentation given by Andrew Morse,

Essential Drugs Officer, UNICEF Cambodia

　

　　This is just an add-on to my UNICEF colleague. There are just a few points I want to add in the context of Cambodia, and I'll try to keep it very brief.

　　Many of the countries here today are in very similar situations, where the public sector system is not really in a position to meet the needs of the population, particularly at the community level, while the private sector has a number of problems related to quality of drugs, availability, and costs in a very unregulated environment. These are common problems. But if we're really looking at meeting community needs, we need to address what kind of system we can develop to meet these needs. In most cases it will be a mixture of both private and public sector services.

　　Many countries in this region have to rely, at least for the moment, on developing a public sector system to the point that minimum needs can be met. Certainly, the strategy for Cambodia is to strengthen the public sector supply system with an emphasis on management of drug supply and drug use, while at the same time continuing to address private sector issues (since it won't be too far in the future when the private sector will actually be able to come into play in a regulated environment and perhaps take on some of the drug supply burden).

　　One thing I like to say to most people that I meet is that it's important to make sure that every single dollar which comes into the system is used to improve efficiency. This is important. An example would be the ways in which drugs are delivered to a community health center; it is convenient to receive deliveries in Bamako Initiative boxes, which are transported by an organization, packaged outside of the country and in kit form. There comes a point, however, when you have to consider the sustainability issue, and when an opportunity presents itself, we should do everything we can to put into place a system that will ensure deliveries in the future.

　　Another example would be the verticalized supply system. I know there are countries represented here today who still to a large extent have a system like this, where at the central level, different warehouses, different stores, and no doubt separate Bamako Initiative storerooms exist, each with drugs for malaria, TB, and EPI, and each with separate record keeping from the central level right the way down to district and health center levels. This is a nightmare. This kind of system is very difficult if your purpose is to ensure a sustainable drug supply system. In terms of management, operational costs, and supervision, it is very hard for this kind of system to work. And adding on another Bamako Initiative or whatever vertical system won't help you.

　　In Cambodia, this was the situation after almost three years of an essential drugs program. The Ministry of Health, who are not here today, had great will-- great political will-- to actually improve the situation. The result is basically a very integrated supply system with a public sector medical store handling all supplies from all programs, which in turn allows provincial and district level integrated warehouses to integrate record keeping. At the health center level, since no one is interested to know how many penicillin tablets were used or given to a patient from the Bamako Initiative program, another donor, or from the government budget, many systems fall down when people try to maintain vertical record systems-- a nightmare for health workers who have so many other things to deal with.

　　An integrated system of course needs a lot of input, training, and supervision. Basically, in Cambodia, the national supply system was rewritten and redocumented from top to bottom. If we look at the percentage of health budget used for drugs, it's just over 35%. And as my colleague had mentioned, this together with salaries is always a large component of the health budget. Therefore, every effort must be put into maximizing efficiency, right the way through the chain from selection, procurement, through to drug use. When we look at some financing issues, we'll realize that when we try to finance the drug supply while 35% of our health budget is handled by a system which is very inefficient, we're actually never going to reach the point where we can truly have a sustainable system with a proper level of government health allocation. The issue is too great to ignore.

　　In Cambodia, the health budget of US$17 million is less than US$2 per person. At the first level of care, that is less than half a dollar per person. We calculate that US$5 is needed to deliver a basic packet of services-- the minimum services, so this level of health financing is totally inadequate.

　　If we look at the supply of funds, however, the situation in the short term is actually not too bad. Of the US$10 million needed for the country's needs, the government has committed approximately 30%, and several million dollars of external aid is available, certainly for this year and next year, thanks to the progress the government has made in developing its program, particularly the drug supply system. Donors have responded very well. Until now, there has been no official community input, though unofficial fees for service is very common. When you see 70% of the drug budget is external aid, and even the government's central budget is approximately 45% external aid, the issue of financing becomes one that Cambodia must address now.

　　Turning to household health costs, results from a socio-economic survey showed that in rural areas an average of US$16 per person is spent on health care, much of it in the form of self-medication. This means basically that US$180 million of health costs are covered by households, versus only US$17 million by the government and approximately US$35 million by external support, revealing the possibility of channeling community contributions into health services in an organized way. But there remains the fundamental problem that the government allocation is very low-- 0.7% of GDP. With this kind of level, it becomes impossible to expect communities to ever cover costs when the real basic need is not only to address this issue through community cost sharing but also through a fair government budget allocation.

　　Despite the many issues that have been raised or we have noted during the presentations, there hasn't been very much discussion on the government budget, or at least the government budgets in the countries here today. It is so easy to jump straight to the issue of community cost sharing and to forget the government input. This of course goes hand in hand with the improved efficiency we've talked about; so much of the government budget may find its way to patient care if efficiency is high on the agenda. After we've achieved an adequate government budget, helped by an efficient system, then we can really start looking at community cost sharing in the true sense. We're looking for sustainable systems, not for drug kits arriving for three years while there is a special donor fund.

　　In Cambodia, the MOF has just made the commitment to increase the health allocation through the year 2000 up to 2% of GDP, which would actually give around 10% of the government budget to health. This should help. The commitment in terms of guaranteeing the drug supply, improving management, and improving drug use has been there, as demonstrated through the efforts of the last two and a half years. The essential drug policy, officialized in 1995, has done that. Donor support is very good. The drugs pledged by donors in response to government commitments to improve the system gives Cambodia necessary breathing space over the next few years. That breathing space must be used to define long-term strategies. If they miss this opportunity, it will be a much more difficult situation to deal with in the future.

　　The last thing we need to consider is the dynamics at the community level. We can't only consider health center drug supply and service. Most of the population is self-medicating. If we're really looking at community health systems at that level, we've got to encompass both private sellers and self-medication issues. The survey in Cambodia, which certainly must reflect situations in other countries, makes evident the fact that health costs is actually a major contributing factor to rural poverty. When we're talking about US$16 per person per year, mostly for self-medication, it becomes apparent that these issues must be addressed alongside the health center revitalization process.

　

　　This was an add-on to the presentation of my colleague, and no doubt in the working groups there will be the chance for further discussion of some of these points.