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Health Systems Strengthening in Cambodia: The Whole Is Greater Than the Sum of Its Parts
The USAID Better Health Services (BHS) and preceding Health Systems Strengthening projects implemented by URC in Cambodia since 2002 provide examples of why the whole is sometimes greater than its parts. These projects used a variety of strategies to improve the quality of care delivered by public health services, increase the utilization of and demand for such services while maintaining the pro-poor goals of the Ministry of Health (MOH), and support on-going and new health reform efforts aimed at increasing the transparency and accountability of health services through decentralized, contractual structures. Activities were aligned closely with and in support of national strategies and plans.
The goals of the second project, BHS, explicitly dovetailed with the mission of the Ministry of Health as stated in the Cambodian Health Strategic Plan 2008-2015: “to provide stewardship for the entire health sector and to ensure a supportive environment for increased demand and equitable access to quality health services in order that all the peoples of Cambodia are able to achieve the highest level of health and well-being.”
After 11 years, the results are significant. Cambodia has now largely met its Millennium Development Goals (MDGs) on child mortality, maternal health, and HIV/AIDS, malaria, and other diseases, as well as the targets in the National Strategic Development Plan. The recent mid-term review of Cambodia’s Health Sector Support Programme 2 (HSSP2) described the progress achieved on these indicators over the last decade as “nothing short of phenomenal.”
BHS played a key role in these achievements by effectively collaborating with the MOH and in coordination with other health partners, particularly under the umbrella of the HSSP2. Illustrative achievements in the project’s focus areas include:
- Service delivery: The project strengthened the capacity of hospitals and health centers to provide high-quality care by improving the quality of service delivery at patient, ward, and facility levels. Onsite training and coaching approaches have resulted in demonstrable gains in midwifery and nursing competencies in the provision of key reproductive, maternal, newborn, and child health and nutrition care and counseling. We introduced tools to routinely monitor the quality of care at hospitals and health centers (Level 1 and Level 2 Quality Assessment Tools). The Level 1 tools (structural aspects of quality) are now routinely used at public health facilities, and Level 2 tools (process or patient care aspects of quality) will be adopted as the new national standard in 2013 and implemented nationally in 2014. Systems for emergency medical care and a Patient Management and Registration System (PMRS) were also introduced, and many MOH clinical practice guidelines and service delivery protocols have been revised or introduced.
- Health workforce: Working with partners, URC introduced innovative learning methods, such as team-based learning, into hospital-based continuing medical education and provincial level midwifery coordination alliance team meetings. The interactive and highly visual training strategies have revitalized in-service training and will be expanded through collaboration with the Medical Council of Cambodia (MCC) with the goal of integrating health partner in-service training into a formal continuing medical education system led by MCC.
- Health information: URC worked with the Department of Planning and Health Information to revise and update the national health management information system (HMIS), formerly a mix of stand-alone databases with a Microsoft Access database at its center. The new web-based HMIS has almost 100% reporting within two weeks of month’s end from public health facilities and many private facilities. The aggregate data in the HMIS are being augmented by the roll-out of the PMRS at the hospital level: the PMRS assigns a unique patient ID and can track individual patient records over multiple visits and different facilities.
- Health financing: URC continued to provide technical assistance and monitoring to strengthen and expand coverage the health equity fund (HEF) system, a pro-poor health financing mechanism adopted as a government strategy in 2003 to cover health care costs for the poorest third of Cambodian households. HEFs currently cover health care for the poor in 61 of 80 health operating districts covering 65% of the public hospitals and 43% of the public health centers. Plans are in place to expand the HEF system to complete nationwide coverage by 2015.
- Leadership and governance: URC also supported government-led health reform efforts, such as special operating agencies (SOAs) and service delivery grants (SDGs). SOAs are operational districts or hospitals that receive limited autonomy from the Ministry to manage their own affairs. They enter into a contractual relationship with various MOH levels to receive an SDG. URC has worked to implement the new structures in six provinces and to introduce elements of pay-for-performance into the internal facility agreements formed as part of the larger overall contractual relationships.
Perhaps most importantly in health systems strengthening, however, has been the ability to forge linkages between these different components for a comprehensive and sustainable approach. For example, because URC was working in both health financing and quality of care, it was able to tie health facility performance on the quality assessments to eligibility for HEF support, resulting in significant improvements in care quality. The project could also link the HEF system data to the national HMIS.
These examples highlight the importance of a health systems strengthening approach: outcomes are synergistic where 1) increased service delivery quality will lead to an increase in demand and 2) health financing mechanisms contribute to the increased demand being distributed equitably across the population. Housing all health system components within one project facilitated coordination and planning.
September 19, 2013