Cambodia - Health Sector Support Project : social assessment

24918 September 16, 2002 Cambodia Health Sector Support Project Social Assessment The Evidence Base: Key Social Issues Pertaining to Health in Cambodia 1 Poverty:.A nation recovering from over two decades of war and international isolation, Cambodia's economic and human poverty is pervasive. Cambodia is the poorest country in South East Asia and ranks 73 out of 78 on the UN Human Poverty Index. About 36% of the population live below the poverty line', 90% of who live in rural areas2. Hotisehold surveys', participatory poverty assessment4, and longitudinal research' provide qualitative and quantitative evidence of the extent, depth, nature and causes of poverty in Cambodia. 2 War has impacted on the nature of poverty, creating a large number of returnees and internally displaced people, high rates of disability, and a large number of female-headed households. The poor in Cambodia lack food security, access to natural resources, access to physical infrastructure, social infrastructure and services. Chronic and catastrophic illness is a major cause.of indebtedness6, asset sales, and impoverishment, and poverty makes the poor more vulnerable to infectious diseases due to poor nutrition and unhealthy living conditions. 3 Inequities in health: The 1997 Cambodia Socio-Economic Survey (CSES), the Cambodia Demographic and Health Survey (2000), and the Public Expenditure Review of the Health Sector in Cambodia (2002) provide evidence of the large inequities in access to and utilisation of health services according to socio-economic status. Findings from the 1997 CSES show that the immunisation rate for the poorest quintile was less than half of that of the richest quintile (35% compared to 77%), and the richest quintile are 3 times as likely to be admitted to hospital than the poorest. The public health system has failed to target resources to those in most need; recent beneficiary incidence analysis (2002)7 shows that the poorest 20% of the population benefit least from public spending. Rural-urban and regional inequity in health status is significant.' 4 Gender differentials in general health and nutrition are not evident from national household surveys. However widespread and growing levels of domestic violence9 and the scale of the sex industry reflect the imbalances in gender relations and suggest the need for a more disaggregated analysis of gender and health. The high level of maternal mortality and burden of reproductive and sexual ill health among women underlines their large unmet reproductive and sexual health needs, and their particular vulnerability. 1 In 2001, the poverty line in Cambodia was the cash equivalent of Riels 54,050 per capita per month, this was equivalent to USSO.45 per day, considerably less than the World Bank's "dollar a day" adjusted measurement for extreme poverty: PPA 2001. 2 Ministry of Planning with World Bank. 1999. Cambodia Poverty Assessment. Cambodia Socio-Economic Survey 1997, Cambodia Socio-Economic Survey 1999. Participatory Poverty Assessment: Cambodia. 2001. Seng Bunnly and Prapassorn Suthumvijit. December 2000. "Health and Landlessness". Cambodia Land Study Project, Oxfam. 6 Seng Bunnly and Prapassorn Suthumvijit. December 2000. "Health and Landlessness". Cambodia Land Study Project, Oxfam. Undertaken within the context of the Public Expenditure Review of the Health Sector in Cambodia. 2002. See Cambodia Demographic and Health Survey. 2000. PPA (2001), DHS (2000). 1 FILE COPY 5 The Khmer constitute over 90% of the Cambodian. Non-Khmer ethnic groups include Cham, Chinese, Lao, Vietnamese, and indigenous groups living in remote forested areas, known as the hill tribes. Only a partial profile of the health status of Cambodia's ethnic minorities is available, what data is available shows that hill tribes peoples are extremely disadvantaged in terms of health outcomes and access to services. 6 Barriers to accessing appropriate health care: the supply-side. The main barriers that the poor face in accessing public health care are cost, physical availability, and poor quality. High out-of- pocket expenses demanded by the market (public and private), estimated at $33 per capita per yearo, is for many Cambodians unaffordable and impoverishing. Cambodians spend more on health care than most others in the developing world and receive poor quality. Physical access to public health services is constrained for the rural poor. Only a third of Cambodians live within 10km or a two-hour walk of a public health centre". The situation is worse in the remote northeast of the country where the population is relatively small but dispersed over a large area. The quality of health care (public and private) is extremely low, it offers poor value-for-mon*, and wastes scare household resources. For ethnic minorities, language barriers, cultural difference, and latent discrimination towards minority groups compound access. 7 Socio-cultural influences on health seeking behaviour: the demand-side. Research in Cambodia consistently shows inappropriate use of public and private health care, a high reliance on self-medication, and high demand for intravenous infusions, injections, and antibiotics2. Such health seeking behaviour is rooted in traditional belief systems about the aetiology of disease, limited knowledge of modem health care and how it works, and a resulting trial-and-error approach to treating illness. Social organisation based on weak relationships beyond the household reinforce the preference for treatment close to home, where families have greater control over treatment choices. The cognitive drivers of health behaviour combined with the economic reality explain the shopping list approach consumers take to health care, and their simultaneous use of traditional and modem medicine'. 8 Such demand side forces combined with a health supply of poor quality and limited access explains the high health expenditures of households and poor health outcomes. A clear preference for private providers of all income groups exists. The absence of effective regulation of the private sector and the poor quality of care provided's, coupled with inadequate wages in the public sector that drive staff to practice privately, and the non-existence of consumer protection, leaves consumers exposed to poor practices in an unregulated and expensive market. 9 Governance and civil society: Accountability of public institutions and public servants is weak and institutional mechanisms to promote transparency in their infancy. Social capital in Cambodia has been severely fractured by war and genocide. Civil society is not well organised. Decentralisation presents opportunity to increase local accountability and the recent election of Commune Councils is a positive step. Nevertheless capacity building at the local level will be essential for enabling greater local accountability and responsiveness. Within the health sector the Government's policy and '0 See Joint Health Sector Reivew. 2000. 11 The Government's definition of physical accessibility. 12 See Collins et al. 2000. "Medical Practitioners and Traditional Healers: A Study of Health-seeking Behaviour in Kampong Chhnang, Cambodia". Van de Put. 1992. "Empty Hospitals, Thriving Business. Utilisation of health services in two Cambodian Districts." Medicin Sans Frontier Swiss-Holland-Belgium. Magherini. 1998. "Financing and Management of Public Health Facilities in Rural Cambodia. A Qualitative Study on Knowledge Attitude and Practice of the Public Health System. Demand Side and Supply Side." Medicin Sans Frontier Swiss-Holland-Belgium. RACHA Studies Number 4. "Rural Women and Health Centre Use, Staff Employment, and Heath Seeking Behaviour. Sompoav Meas District, Pursat." 13 Collins et al. op.cit. Ovesen et al. 1996. "Social Organisation and Power Structures in Rural Cambodia". Uppsala Research Reports in Cultural Anthropology. 14 Collins et al. op cit. '5 Phnom Perh Urban Health Project, "Mystery Client Study". 2 strategy includes intent to increase consumer voice and public accountability, but this is not as yet institutionalised and is one of the challenges of sector reform. Social Development Inputs to Project Preparation 10 The project builds on the experience of health projects financed by the three donors -- Asian Development Bank'6, the UK Department for International Development", and the World Bank -- over the past 10 years, as well as other donor-funded projects with Government and NGOs. The project design draws heavily from the findings of the Joint Health Sector Review (2000) and is fully consistent with, and supportive of the Government's recently launched Health Sector Strategic Plan (2002-2007). Project preparation included the participation of a social development consultant during both preparation and appraisal missions, and inputs outside of missions. Institutional analyses of the sector were undertaken by institutional development consultants attached to project preparation and the development of the strategic plan. A study was undertaken by an anthropologist to review the health situation of ethnic minorities in Cambodia'", and a nfre targeted study of the health seeking behaviours and constraints to accessing health services of ethnic minority groups in Kratie and Stung Treng was financed'9. Stakeholders 11 The primary stakeholders of the project are the health consumers that will benefit from the improved accessibility, affordability, and quality of services. Target beneficiaries are the poor, extreme poor, women and children, and vulnerable ethnic minorities, all of whom are exposed to high health risks and are disadvantaged in accessing affordable health care. Health service users and civil society will benefit from the opportunities created to enhance consumer participation in the planning and monitoring of services and to increase public accountability, as well as opportunity for civil society to participate in monitoring sector wide progress. 12 Key secondary stakeholders are Ministry of Health (MOH) policy makers, programme planners and managers that will benefit from systems strengthening and capacity building activities, as well as from the projects design and approach which endorses the MOH's Strategic Plan. Service providers working at all levels will benefit from health systems development: upgrading health facilities, training, salary incentives, management development and change. These initiatives will lead to greater job satisfaction as the working environment and professional benefits improve and quality of services provided increase. The project supports the MOH's deepening of sector wide management and presents a flexible instrument for supporting sector priorities. It will promote improvements in donor co-ordination and reinforce the MOH's leadership and stewardship of the sector. 13 Other service stakeholders are NGOs and private-for-profit practitioners. The project will broaden the scope for NGOs to work as contractors to the MOH. The contractual relationship will carry positive and negative features for NGOs, on the one hand increasing their potential influence on the other, making NGO contractors explicitly accountable to the Ministry. More effective regulation of the private sector will benefit consumers and assist in improving quality standards within the sub- sector. From the perspective of private providers (including government health staff that practice privately) this will strengthen professional standards but tighten the market and so reduce income earning from ineffective, costly, and unethical practice. 16 In particular the piloting of contracting of public health services under Basic Health Services Project 1. 7 Including the work by Thomas (1999) "Health Sector Reform Phase III: Social Development Priorities in Health Sector Reform." ' Helen Pickering. June 2002. "Report on Health Situation of Ethnic Minorities in Cambodia". DFID Health Systems Resource Centre. '9 This study is being implemented by Partners for Development, a health and development NGO working in Kratie and Stung Treng. The findings of the participatory research will enable service planning to be more responsive to ethnic minority needs in the 2 target provinces, and contribute to design of services targeting minority groups in other parts of the country. 3 14 External financiers (the World Bank, DFID, ADB, USAID, GTZ, the Japanese government, WHO and other UN agencies, as well as international NGOs) are others with important interests in the project, and who have much to gain from its success. Other key ministries notably the Ministry of Economy and Finance played an important part in the development of the project design and will continue to do so during implementation and monitoring. Cambodian and international researchers and academics are a further stakeholder group with interests in gaining experience in international best practice for health sector reform, as well as specific programme developments in fields such as TB, malaria and HIV control. 15 Stakeholder analysis: analysis of the health needs of primary stakeholders, and constraints to accessing services relied upon existing literature. NGOs and international donors have undertaken a wide range of consumer-oriented research. Unfortunately this research has generally not been well co- ordinated or utilised. There continue to be gaps in the evidence base. Continuing design and planning of project support will benefit from the findings of the PRSP consultation with the poor on health (2002), and the findings of the ethnic minority health seeking behaviour study, as well as the special studies planned as part of implementation20. Analysis of primary stakeholder interests will continue during implementation through integration in the monitoring and evaluation framework, and the commissioning of demand-side research. The interests of secondary stakeholders was analysed within the context of the institutional analyses21. 16 Stakeholder participation secondary stakeholders participated extensively in the design of the project: MOH, Provincial Health Departments, Ministry of Economics and Finance, Ministry of Planning, international donors, NGOs, Medicam22, research and training institutes. The project sub- components were designed in collaboration with programme managers within the MOH and respective external partners that will lead and implement the components. Participation of beneficiaries was limited in the initial design phase. However, the project will provide the means to mainstream consumer participation into the health sector through various capacity building processes and activities. Increased consumer participation is expected across the sector at various levels, and in core decision-making areas as a result of project support. How Project Design Addresses Social Issues Project approach 17 The project is designed to support the Government's Health Sector Strategic Plan (2002-2007) and has a strong pro-poor focus. It is designed to support the Government's move towards sector wide management of the sector support. Within this framework, the project aims to improve the health of the poor, women, and other vulnerable groups by increasing affordability of, access to, and use of public health services. Two approaches are taken to address social development issues, targeted assistance and mainstreaming. The project will: i) Target primary stakeholder groups by: (1) Strengthening health services in particularly poor and disadvantaged geographical areas to increase access, affordability and quality, (2) Introducing social protection measures to safeguard the most vulnerable from the costs of hospital care, (3) Supporting national health programmes that most benefit the poor and disadvantaged. ii) Mainstream the principles of client-centredness, pro-poor, social inclusion, and stakeholder participation through its support to sector reform and institutional 20 Described in more detail under the monitoring and evaluation sub-component. 21 See Ian Beach. June 2002. "Strategic Planning for Health Services in Cambodia". DFID Health Systems Resource Centre. 22 A national NGO representing health NGOs in Cambodia. 4 development. The principle channels for mainstreaming will be through building capacity and systems for planning, management, budgeting, monitoring and evaluation, and human resource development. 18 Overall, the project concentrates its support to developing the supply side of health with only minor support of demand side activities (such as health promotion and behaviour change interventions, consumer and civil society voice and participation). In this respect, achievement of project objectives to increase health outcomes through increased use of public health services, will depend on assistance to and adequate financing of demand-side programmes: this has been incorporated into project assurances. Targeting the most disadvantaged geographical areas to increase access, affordability and quality 19 The project targets resources to the neediest geographicAl areas and peoples by: (i) contracting of services to NGOs in the most disadvantaged areas23, (ii) strengthening the infrastructure of the public health service in those areas with greatest health need and highest poverty indicators24. 20 Contracting: Based on the MOH's positive experience of contracting out operational district health services to NGOs, this approach will be supported in 11 operational districts under the project25 covering a population of over 1.4 million. The contracting approach has demonstrated its ability to out perform the standard Government service in terms of coverage and utilisation, and to reduce out-of- pocket health expenditure by the poor. The selected operational districts under HSSP include some of the most remote, difficult to access and impoverished districts in the country26. They include districts with a high proportion of ethnic minority populations, areas that were devastated by the floods of 1999, 2000, 2001 and 2002 and those that are prone to drought, and districts with poorly developed health systems. Poverty is high in all the chosen districts. 21 The contracting model addresses the problem of underpaid health staff charging unofficial fees by introducing transparent user fee systems tied to salary incentives, alongside improvements in quality and management. The contracting approach under HSSP has been revised to sharpen attention to reaching the poorest, and to promote financial and institutional sustainability. The former will be achieved by introducing social protection for the poorest at the hospital level27 (equity funds), and by adapting monitoring and evaluation methodologies to better assess impact on the poorest28. 22 The project will support public health service infrastructure development in line with the Government's Health Coverage Plan. Civil works and equipment will be provided to priority locations based on poverty indicators, health needs, and health systems needs. This will include the provision of health posts in remote areas, a new sub-health centre facility that will increase access of dispersed hill tribes' populations to health facilities29. Training of health staff and managers will also be provided to facilities benefiting from infrastructure improvements. Social protection of the most vulnerable 23 Financed by ADB, DFID and World Bank. 24 Financed by ADB and World Bank. 25 10 financed by ADB and DFID, and I financed by the World Bank. 26 Selection was based on various sources: Keller and Schwartz. 2001. "Final evaluation report: contracting for health services pilot project (CHSSP) - a component of the of the Basic Health Services Project". Cambodia Socio-Economic Survey 1997. World Food Programme 2001. 27 The approach incorporates exemptions from user fees at health centre level. 28 Baseline surveys disaggregate income groups based on assets. 29 Health posts have been shown by NGOs to be more effective in reaching hill tribes peoples in Mondalkiri. 5 23 The public health system is fee paying, both official and unofficial fees. User fees at hospital level are a major barrier to the poor and exemption systems fail to protect them". Hospitalisation places the poor and those lying just above poverty at great risk of losing assets and going into debt. Evidence on whether user fees at health facility level inhibit use by the poor and poorest is mixed. The 2001 user fee evaluation concluded that fees at health facility level are not a barrier to most of the poor. 24 User fees are just one of several potential inhibitors to the poor and poorest using health facilities. How the various factors -- such as access to information, confidence in the health system and providers, cost of services, opportunity costs (transport, childcare, lost earnings), physical accessibility, and perceived quality -- that shape poor people's health seeking behaviour compound each other and result in low utilisation is not fully understood, and has relevance at all levels of the health system. To investigate this problem the project will support research to better understand why the extreme poor do not use public health services. This research will contribute to the design of equity funds, as well as broader pro-poor sector development. 25 Improving the affordability of public health services for the poor, particularly hospital care, will promote equity and contribute to poverty alleviation. The project will support interventions to subsidise the costs of hospital level treatment for the poor in operational districts under the contracting component31 and in selected operational districts with alternative models of quality and management improvementS32: in total 25% of Cambodia's operational districts. Quality and management capacity at the hospital level are a prerequisite to the introduction of hospital oriented social protection mechanisms. The project will experiment with various types of equity funds so that through operational research, lessons can be learned as to their relative effectiveness and efficiency. This will make a significant contribution to the evidence base on which to expand social protection measures in health as the.system develops and resources become available. 26 Experience shows that a major challenge to social protection measures in Cambodia is including and reaching the most disadvantaged. To address this risk, the project funded equity funds will include participatory methods of identification at the community level.33 Experience in Cambodia suggests this is a more effective method of reaching the target group than applying an eligibility test at the hospital34. In extremely poor operational districts, such as Ratanakiri and Mondolkiri, all health services are likely to be provided free of cost. Participatory methodologies will contribute to disseminating information to marginal groups and individuals, and support broader efforts to strengthen social capital. The overall management of the equity funds by a central non-governmental organisation tasked to monitor and support local fund managers will strengthen various forms of participating civil society: i.e. local NGOs, community based organisations, local elected bodies, health committees. 27 Through equity funds the project will subsidise the hospital costs of the poor and poorest in the most disadvantaged areas of the country. However, as currently designed the project does not include interventions to mitigate the impoverishment of the non-poor due to health costs. Experimentation with financing mechanisms to off-set the high costs of chronic and catastrophic illness of the non- poor, such as micro-finance schemes, community based health insurance, savings schemes is required, but is currently beyond the framework of HSSP. National health programmes that target the poor and disadvantaged 28 The project will support key national health programmes that control and mitigate communicable diseases that most affect the poor: tuberculosis, malaria, and dengue. It will also support the MOH 30 Wilkinson et. al. 2001. An Evaluation of the pilot user fee scheme". 31 Financed by ADB/DIFD and World Bank. 32 Such as Kampong Thom where GTZ have been implementing quality assurance models. 33 Financed by ADB and World Bank. 3 See Crossland and Conway. July 2002. "Review of Mechanisms to improve equity in access to health care, Cambodia." MSF Cambodia. July 2002. "The New Deal in Cambodia: The Second Year". 6 nutrition, safe motherhood, and HIV/AIDS programmes." Support to the selected national programmes is justifiable on the grounds that they target disease and morbidity that both cause poverty and hinder the poor from moving out of poverty. Specific examples of how national programmes are working towards a stronger poverty and client-centred focus is presented below. 29 Tuberculosis: the main challenge to the TB programme in Cambodia is to increase the detection of TB cases through increasing public awareness and increasing access to effective treatment. To improve physical accessibility and reduce the opportunity costs of TB treatment the programme is decentralising diagnosis and DOTS16 treatment to health facility level from district hospitals. In remote areas, deeper decentralisation will be required to effectively increase access, and is under consideration. TB diagnosis and treatment is officially free in Cambodia and in the past salary incentives have been paid to district TB staff to discourage the levying of unofficial fees from clients. The implications of decentralising services to facility level where strong incentives exist to charge unofficial fees, requires analysis and monitoring to safeguard broad access. 30 The programme invests considerable resources into information, education, and communication (IEC) activities, aiming to inform consumers of TB symptoms, and the availability of free and effective treatment. However to date, the IEC programme has not targeted IEC to specific target groups nor monitored its effectiveness. Strengthening of the IEC programme to increase and improve the targeting of information in the community, to dispel stigma around TB and increase case-finding, particularly from vulnerable and difficult-to-reach groups such as ethnic minorities, seasonal migrants and HIV/AIDS patients, is a priority. For ethnic minorities this will require translating IEC messages into appropriate languages and tailoring messages to fit with prevailing health beliefs. Women make up 50% of TB patients receiving treatment, and do not appear particularly disadvantaged in accessing services. 31 Malaria transmission in Cambodia is highest in the mountainous and forested areas inhabited by extremely poor, ethnic minority groups. The malaria programme (NMCP) has responded to the needs of ethnic minorities by combining malaria outreach activities (provision of impregnated hammock and bed-nets and information) with immunisations, Vitamin A distribution, and deworming. The programme and NGO implementers report a high demand for hammock and bed-nets and health information among minority groups. Social marketing approaches are used to increase consumers' access to information on how and where to confirm malaria diagnosis, what treatment to take and which to avoid. Social marketing to the private sector and parallel distribution of tests and therapies to the public sector has increased access to testing and treatment and impacted on the number of severe malaria cases, thereby reducing the impoverishing costs of treating severe malaria. Women are at highest risk of developing severe malaria during pregnancy when immunity is lowered. Work is in- progress to assess and design more targeted interventions to pregnant women. Implementation in partnership with NGOs has improved programme coverage and allowed the design of locally appropriate outreach activities. 32 Nutrition: The project will support MOH's nutrition programme by strengthening behaviour change activities within the community and amongst health workers, and supplying micronutrients. As such it will have an important but limited role in addressing the problem of malnutrition. The project does not address more fundamental socio-political issues around food security. Behaviour change communication (BCC) materials targeting women will be developed based on participatory, consultative research. Capacity building within the MOH to undertake such research and apply the findings to nutrition oriented BCC strategies will be an important step forward in strengthening BCC capacity in MOH. Support to increase outreach activities of health workers will increase contact with target women and their families, and contribute to increasing health knowledge and generate important links between families and health centres. 3s Support to the safe motherhood and HIV/AIDS programmes will be designed in 2003. 36 Directly observed treatment. 7 Mainstreaming social development through institutional development and capacity building 33 The project will support the MOH to strengthen its capacity to manage the sector and use public resources more efficiently and equitably. The Health Sector Strategic Plan (2002-2007) and Medium Term Expenditure Framework are tools that will enable improved priority setting and management and opportunity to promote greater equity. The project will support the MOH translate social development policy objectives - pro-poor, gender sensitive, social inclusion (including for example the needs of ethnic minorities), social protection, and stakeholder participation -- into practice through sector reform and institutional development, as well as the piloting and delivery of specific interventions (such as contracting and equity funds). The project's intent to move to a sector programme approach with funding tied to annual plans and emerging sector priorities provides flexibility to design strategies and related inputs during implementation. This approach is particularly appropriate for the social development mainstreaming work. Nevertheless, key activities that will contribute to mainstreaming and that have been agreed with project partners are detailed below. 34 Social assessment capacity of MOH: Within the institutional development sub-component of the project, analysis will be undertaken to assess the existing social assessment capacity of core MOH functional departments and identify how this needs to be strengthened to deliver pro-poor sector wide management7. Capacity building in social analytical skills will be embedded in institutional development activities at the various levels of the health system. Core areas of attention will be planning, management, health financing, monitoring and evaluation, and human resource development. Enhanced social assessment capacity will strengthen the MOH's participation in, and contribution to poverty reduction planning processes, and the integration of health in national poverty reduction plans. Experience from the PRSP process shows that this is an area in need of strengthening. 35 Planning and management: The project will: a Provide technical assistance to assist the MOH move to needs-based budgeting3. This will require a robust measure of the distribution of poverty and health needs linked as far as possible to inter-sectoral poverty monitoring systems. The WFP poverty-mapping project provides a starting point for developing appropriate measures. b Support decentralised annual planning at provincial, district, and facility level39. Decentralisation of annual planning presents an opportunity to strengthen the responsiveness of health services to the needs of local communities, to increase consumer participation (or their representatives), and to move towards greater social accountability at the local level. The project will support the further piloting of decentralised planning and develop modalities for enhancing consumer voice and client-centredness. In addition to building the health system's capacity to carry out decentralised planning, the project will address and strengthen the capacity of the public to participate in this process. The participatory research financed by the project to address the health needs of ethnic minority groups in Kratie and Stung Treng is a case study of responsive, participatory local level health planning and will contribute to the design and capacity building of decentralised planning. c Strengthen management capacity at central, provincial, and district level through management training at the National Institute of Public Health40. Based on the findings of a training needs assessment, management training needs to include social and poverty assessment topics such as pro-poor targeting, client-centredness, gender, social inclusion, transparency, and stakeholder participation. 3 Funded by DFID 3 Financed by World Bank. 39 Part financed by all 3 donors. 40 Financed by AD3 and World Bank 8 d The ADB sub-component of the project includes financing of meetings at the health centre level to encourage community participation in health centre management. Existing Health Centre Management Committees that involve community participation are most effective where external agencies are locally present to motivate meetings. The public participation study, described below, will offer alternative options for enabling effective consumer involvement. 36 Monitoring and evaluation: The project will support the further development and implementation of the MOH's monitoring and evaluation framework for the Health Sector Strategic Plan (2002-2007)41. Of particular significance is the commitment to introduce social. and poverty variables into the monitoring and evaluation system, and to systematically introduce consumer and civil society participation in monitoring programme and sector performance, as a means of increasing vertical accountability. Various studies will also be undertaken to investigate social issues critical to achieving sector objectives. Specifically the project will: I i) Support the MOH in undertaking annual reviews of sector performance based on common core indicators disaggregated by sex, socio-economic status, and ethnicity. The core indicators include measurement of physical and financial accessibility, public satisfaction, client satisfaction, health service utilisation, and impact. This set of indicators represents a significant improvement in monitoring how the health sector serves different social groups, public perception of services, and health status of the various sections of society (including the poor, extreme poor, women, and ethnic minorities). ii) Provide technical assistance to develop a tool for measuring socio-economic status based on household assets. This tool will form the basis for monitoring health improvements by socio-economic status and will be used in planned annual sample surveys that will inform annual reviews. In the medium term, the tool will also have use in decentralised operational planning. iii) Support inclusion of disaggregated data on socio-economic status, sex, and ethnicity in national household surveys, such as the Demographic and Health Survey and National Health Survey. iv) Develop the health information system to include sex-disaggregated data. v) Special studies to address social issues such as (a) Review evidence in Cambodia on the most effective forms of public participation in the delivery of public services. The purpose of the study42 will be to inform the MOH's plans to strengthen public participation in the planning, monitoring and management of services, and increase public accountability. Implementation of proposed modalities resulting from the study are likely to involve partnerships with civil society to build local capacity that can articulate the health interests of the poor and other target groups. (b) Undertake participatory research to investigate the barriers to access and factors that drive demand for public health services of the extreme poor. The research will inform programme planners and managers as to how to better deliver services to this particularly vulnerable group, and more specifically guide the design of social protection measures. 41 Financed by ADB and DFID 42 To be financed under the monitoring and evaluation special studies sub-component. 9 vi) Regular consumer surveys to understand the views of various social groups on health issues and services. vii) Beneficiary and social impact assessment surveys. viii) Advocate for and support, as necessary, the MOH's intention to include NGOs and civil society in joint annual reviews of sector performance. This intent presents an important entry point for strengthening the presence of civil society in high-level, national forum, and will be an important means of voicing civil society interests. ix) Develop modalities for disseminating local health centre monitoring information (financial and non-financial) to the community as a means of promoting public accountability. This will link up with the findings of the study on public participation and may involve support for consumer health networks advocating on behalf of consumers at local, regional, and national leve( 37 Human resource development: The project will support MOH's human resource development capacity through: i) Technical assistance to review human resource policy and strategy. One of the main human resource gaps in the workforce is the loss of trained midwives. The factors behind the gap in practicing midwives is complex, but the fact that midwives tend to be female plays a part in explaining the profession's low status and bargaining-power. Through the lens of human resource policy,43 gender issues relating to human resources and the institutional environment will be addressed. No such gender analysis of the health sector has been undertaken, and it is anticipated that this will lead to additional, focused gender mainstreaming activities. Given the large change agenda of the MOH, and the importance senior MOH officers have assigned to the midwives crisis, human resource development is an appropriate and powerful entry point for initiating attention to gender. ii) Addressing the problem of staffing remote health centres in areas inhabited by indigenous hill tribes' peoples44. The capacity of the MOH to staff remote health centres given civil service pay and conditions and the low number of graduates from hill tribes is limited. As a result, many remote hill tribe communities have no access to public health services. To address this problem the project will support the MOH to develop a primary nurse training course tailored to the needs of the northeastern provinces where there are high concentrations of hill peoples. The course will be offered to students from indigenous communities and entry requirements reduced to broaden access. The project will also provide stipends to hill tribes' students during primary nurse training. Post graduation, the students will be contracted to work in a health centre or post in their community for 3 years. Priority will be given to women applicants who will be able to take on nursing and midwifery functions. iii) Continued piloting of quality assurance methodologies45 that include mechanisms of public accountability and influence: i.e. the community determines whether individual service providers receive salary supplements based on their performance. iv) Training of health workers in selected modules of the Minimum Package of Activities to improve communication and interpersonal skills46. 43 Financed by ADB. 44 Financed by ADB. 45 Financed by World Bank implemented through GTZ. 46 Financed by ADB and World Bank. 10 38 Stakeholder participation: The project, embedded as it is within the MOH's Health Sector Strategic Plan, and designed to strengthen the Ministry's capacity to move towards sector wide management will require broad stakeholder participation if it is to be effective. Examples of how the project will encourage and demand stakeholder participation are: (a) project management will be mainstreamed into the line management of the MOH; no separate management unit will be created. The project will be managed and implemented by existing, though strengthened government structures, and will involve the various programme managers affected by the project. (b) Monitoring of the project will be subsumed into the agreed common sector monitoring process with no separate project monitoring activities. The annual review process in particular will ensure broad stakeholder participation in monitoring progress: MOH, donors, NGOs, and civil society. (c) Institutional development support to the planning, monitoring and evaluation, and management systems will assist MOH in defining how it can achieve its objective of increasing and mainstreaming consumer participation. (d) Participatory planning approaches will underpin the innovative elements of the project to be implemented parallel to MOH, such as contracting and equity funds. 11 Safeguarding the Health Rights of Ethnic Minorities: A Health Development Plan Introduction 1. Over the past few years the Cambodian Government has taken important steps to recognise and protect the identity and rights of ethnic minorities47 and promote their participation in and benefits from social and economic development48. Poor health status and lack of access to affordable, appropriate health services are characteristics and causes of poverty among ethnic minorities as defined by ethnic peoples themselves. This health development plan draws upon the findings of a participatory poverty assessment of indigenous peoples (200 1)49 and complementary project financed research to study the health seeking behaviours and constraints to accessing health services of ethnic minoritiesso. The development plan targets those ethnic minorities that are vulnerable to poverty and ill health, and embraces various strategies to meet the needs&of different ethnic groups within the local, socio-economic, political and health contexts in which they live. Basic information on ethnic minorities in Cambodia 2. The Ministry of Interior estimated that in 1995, there were 442,699 ethnic minority peoples, some 3.83% of the population, the majority population being Khmer5l. Ethnic minorities include Chain, Chinese, Vietnamese, Lao, and indigenous groups known as the hill tribes. Out of the ethnic minority groups, the Cham are the largest. They are Cambodian Muslims and account for 50% of the total non- Khmer population in Cambodia. The Chinese population is the next largest ethnic minority, though they are technically classified as foreign residents and not a national minority, in practice many have Cambodian passports. The Vietnamese population can be divided into 4 groups with separate immigration histories: rice farmers, urban population, fishermen, and rubber plantation workers. A 1982 policy directive gave Cambodian citizenship to long-term Vietnamese residents that arrived before 1970; many have been excluded from citizenship. 3. There are 15 groups of hill tribes and they make up about 0.95% of the Cambodian population; they are the fourth largest minority group. The hill tribes are distributed throughout the country, but concentrated in the northeast. They form a majority in the provinces of Mondolkiri (75%) and Ratanakiri (66%) and less than 10% in the adjoining provinces of Kratie and Stung Treng. The hill tribes are probably the most disadvantaged Cambodian population. They live in isolated areas, characterised by poor road infrastructure and poor communication facilities. Livelihoods based on traditional swidden farming and forest harvesting practices are being destroyed, as rights to land are lost to mining and logging concerns and to plantations of rubber, coffee and cashew nuts. Rapid social change is being imposed on the hill tribes. Education levels are low among the hill tribes and access to health services extremely poor. Legal framework and policies 4. The Cambodian Constitution respects the rights of ethnic minorities, Article 32 states 4 Ethnic minority is used to define a social group with a social and cultural identity distinct from the dominant society. Ethnic minority is used interchangeably with indigenous peoples. 48 Legislation has been included within the draft Land Law and Forestry Law to recognise and protect the immoveable property of ethnic minorities, and their customary user rights and management of community forests. 49 ADB. 2002. draft report "Capacity Building for Indigenous Peoples/Ethnic Minority Issues and Poverty Reduction". 5o Partners for Development. 2002. forthcoming. 5 Demographic information on Cambodia's various ethnic groups is not regularly collected by the Government, and data available is of questionable reliability. 12 Khmer citizens shall be equal before the law and shall enjoy the same rights, freedom and duties, regardless of their race, color, sex, language, beliefs, religions, political tendencies, birth origin, social status, resources and any position. 5. The definition of Khmer citizens is however controversial. The National Assembly's interpretation during debate in 1995 restricted the term to include some of the country's ethnic minorities, including the hill tribes and Cham, but excluded others such as the Chinese. The country's signature to several human rights conventions however means Cambodia is legally obliged to protect and respect the rights (as covered by the various conventions) of all peoples. 6. The Inter-Ministerial Committee for Ethnic Minorities Development (IMC) is the lead Government body responsible for ethnic minority development. It has selected the four northeastern provinces of Mondolkiri, Ratanakiri, Kratie, and Stung Treng as priority development areas due to the large and diverse concentration of ethnic peoples. A draft policy on the development of hill tribes' peoples is waiting for approval by the Council of Ministers.ffhe vulnerabilities and social exclusion of ethnic minorities is recognised by the Government in national poverty reduction frameworks, and consultative mechanisms are currently being developed to enable stakeholders to engage in and influence the design of the PRSP. The draft Land Law and Forestry Law are key laws for protecting the livelihoods of indigenous groups and both incorporate sections on their rights. Health status and access to public health services 7. Comprehensive information on the health status of ethnic minorities, their health seeking behaviour and use of health services is not available. Government health information is not disaggregated by ethnicity. Health information available on ethnic minorities is mainly drawn from NGOs that have been working with specific ethnic groups. 8. From the information available we know that the hill tribess2 are highly vulnerable to disease and ill health. Malaria rates are higher in the northeast than in other parts of the country, and malaria is a major cause of mortality. Diarrhoea, acute respiratory infection, tuberculosis, and intestinal parasites are also major diseases. Limited health knowledge and lack of access to reproductive and safe motherhood services exposes women to unacceptably high maternal health risk. 9. The remote living conditions of hill tribes' peoples makes accessing health care expensive and physically difficult. This is further compounded by the underdevelopment of the public health service in the four north-eastern provinces, characterised by: a. Too few health facilities located far from the populations they serve, b. Scarcity of health workers at health facilities, c. Lack of trained health workers from local ethnic groups, d. Services that are unresponsive to the health beliefs, language and cultures of the indigenous populations, e. Detachment from indigenous medicine and healers. 10. Health status data on the Cham and Vietnamese is not available. Participatory research findings suggest that both ethnic groups face barriers in accessing health services due to language and cultural factors, though the nature of the barriers varies according to the local context and livelihood patterns: such as Vietnamese floating populations, Cham rural dwellers, brothel based Vietnamese sex workers. Chinese communities tend to live in urban areas; they are not particularly vulnerable to poverty or ill health, nor experience significant cultural barriers to accessing health. Strategy to Assist Ethnic Minorities 52 See ADB. 2002. draft report "Capacity Building for Indigenous Peoples/Ethnic Minority Issues and Poverty Reduction". 13 11. The health development plan for ethnic minorities focuses on those ethnic groups that are vulnerable to ill health and poverty. The plan aims to increase the health status of vulnerable ethnic peoples by increasing access to appropriate, quality health services, increasing health knowledge to promote health, and ensuring the participation of ethnic groups in the planning and monitoring of service delivery. The plan rests on a two-pronged strategy. a. Targeting health development activities at the four northeastern provinces as recommended by the Inter-Ministerial Committee on Ethnic Minority Development. b. Mainstreaming attention and responsiveness to the needs and constraints of ethnic minorities through institutional development and capacity building across the public health service, specifically through improving the provision of appropriate information, inclusion of ethnic minority voice and interests in service planning and monitoring, and strengthening the sector's monitoring and evalotion system. Social assessment and design of project support 12. Social assessment of the health needs, health seeking behaviour, health beliefs, and constraints to accessing health services of ethnic minorities was initiated during project preparation and will continue into implementation. Initial desk review and rapid assessment" work fed into project preparation. In Mondolkiri and Ratanakiri where services will be contracted to NGOs, contractors will undertake situational analysis and health needs assessments once project implementation begins. The contracting approach includes checks to promote inclusive and responsive health services, therefore parallel social analysis, and assessment to influence the design of services in these two districts is not necessary. In contrast, in Stung Treng and Kratie, where services and project support will be mainstreamed through the public health service, key issues were identified for more detailed study to inform the development of local participatory health development plans. Partners for Development, an international NGO operational in Stung Treng and Kratie was contracted to undertake participatory research to inform project design. This research will underpin local health plans in Kratie and Stung Treng, and start to identify approaches to targeting vulnerable ethnic minorities outside of the northeastern provinces, and highlight additional gaps in knowledge. The research will be completed prior to project implementation. Targeted Assistance to Mondolkiri, Ratanakiri, Stung Treng and Kratie 13. The project's support to the four northeastern provinces attempts to address the health problems identified in the recent participatory poverty assessment54 and support the measures for improving health identified through the consultation exercise55. DFID and ADB will finance district health services contracted to NGOs in Mondolkiri and Ratanakiri, and World Bank will mainstream project inputs to Stung Treng and Kratie into the Provincial Health Departments. Targeted local health development planning will be undertaken during implementation, and the table below gives a preliminary picture of how key constraints will be addressed. Constraints Remedial Measures Project Plans in Project Plans in Stung Identified by Hill Proposed by Mondolkiri And Treng and Kratie Tribes Peoples Stakeholders Ratanakiri s3 Pickering. 2002. "Health Situation of Ethnic Minorities in Cambodia". DFID Health Systems Resource Centre 54 ADB. 2002. draft report 5 National Workshop on Capacity Building for Indigenous/Ethnic Minority Issues and Poverty Reduction, organised by the Ministry of Rural Development and ADB. 56 Including indigenous peoples 14 Constraints Remedial Measures Project Plans in Project Plans in Stung Identified by Hill Proposed by Mondolkiri And Treng and Kratie Tribes Peoples Stakeholders56 Ratanakiri Physical access Introduction of Health posts, and Options for improving health posts and/or flexibility for outreach to be designed mobile services contractors to design based on participatory appropriate outreach research, likely to include services mobile/boat services. Costs are Ensuring that the Options under Improved outreach will unaffordable poor are not charged. consideration: reduce opportunity costs contractors will be of some services. Equity obliged to either funds are not planned. provide completely Affordability is likely to free services, or remain a major barrier to introducaquity hospital services. funds at hospital level to exempt the poor arenotchard poor. Lack of participation Indigenous Situational analysis Participatory research in health community and needs assessment undertaken to assess development participation in surveys. Contractors health needs and health designing and obligated to foster seeking behaviour and making decisions and support constraints to accessing about primary health community health services. Research c are participation in will form the basis for planning and participatory local health monitoring service planning and monitoring. level_to_delivery. Health workers Strategy to retain Contractors will Project supports nurse absent from facilities, health workers in introduce training of indigenous highland areas management and people for northeastern quality provinces. No targeted improvements, human resource financial incentives management strategy for good included. performiance. Project will support nurse training of indigenous people Health workers are Recruiting personnel Development of a Primary nurse training not from local hill from indigenous primary nurse- course available. tribes communities groups training course Additional measures to tailored to the needs promote indigenous of hill tribes' health workers to be populations. Stipends identified and agreed. for hill tribes' students. Poor quality services Health workers Training in specific Training in specific trained to offer MPA modules of MPA, modules of MPA based based on needs on needs assessment. assessment.ractor 15 The above table shows that the project will make a significant effort to increase access of ethnic groups to health services in the northeastern provinces. Project support to Mondolkiri and Ratanakiri is more intensive than in Kratie and Stung Treng, and it is to be expected that the contracting approach will deliver faster health systems and health outcome benefits than the mainstreaming approach in Kratie and Stung Treng. The project's institutional development activities will strengthen capacity for lesson learning across the sector, and this will be particularly relevant for replicating good practices vis-A-vis ethnic minorities. Mainstreaming Safeguards for Ethnic Minorities 14. Integrated into the institutional development and capacity building activities of the project are measures to enhance attention to, and the inclusion of ethnic minority concerns. The mainstreaning of safeguards across the sector is necessary to support the targeted interventions in the four northeastern provinces, but also to capture and respond to the interests ofvulnerable ethnic minorities living in other parts of the country. Pathways for mainstreaming are: a. Strengthening the social assessment capacity of the MOH. b. Improving delivery of appropriate targeted information and behaviour change communication. c. Local ethnic minority participation in designing and monitoring health development plans. d. Monitoring, evaluation and the annual sector review process. e. Human resource development. 15. Social assessment capacity: Within the context of institutional development, the project will strengthen the social assessment capacity of the MOH. This will include capacity building in social analytical skills at various levels of the health system, and the introduction of safeguard checks in key sector management processes such as planning, the allocation of resources,'monitoring and evaluation, to direct attention to the inclusion of ethnic minorities. 16. Access to appropriate health information: Language is a barrier that excludes ethnic minorities from participating in development processes. Lack of information and educational materials in the languages of ethnic minorities is a major constraint to health promotion. The project will through its support for key national programmes57 ensure that behaviour change communication (BCC) strategies and materials take into account the specific needs of ethnic minorities and communication approaches and materials are developed that are appropriate for the needs of target minority groups. This will require increased understanding of the health beliefs that influence ethnic minorities in order to design appropriate materials. NGOs are already using a range of BCC approaches and materials in their work with ethnic minorities, and this is an important resource that needs to be better used by MOH. Where appropriate consideration will need to be given by MOH and Provincial Health Departments to sanctioning the use of local translators in health facilities and during outreach activities. 17. An important gap in strengthening national BCC capacity to safeguard the interests of vulnerable groups is the lack of support for the National Centre for Health Promotion (NCHP), the MOH lead agency for BCC and demand generation. Without strong and capable leadership there is the risk that BCC approaches and materials will continue to be developed without the benefits of co-ordination across agencies and technical and social monitoring (ethnic minorities, gender, vulnerable social groups, participation). This is an institutional weakness recognised by MOH and likely to receive further attention under the project's institutional development activities. Capacity building of NCHP has not been prioritised as a project supported activity in the initial project years; this may change as the project shifts to supporting annual sector plans. " malaria, tuberculosis, dengue, nutrition, safe motherhood, HIV/AIDS. 16 18. Local participation of ethnic peoples will be encouraged through the development of more participatory planning and monitoring processes at local, district, provincial and the national level. The project will support the MOH's efforts to strengthen the planning process to be more responsive and participatory. This will include strengthening the participation of a diverse range of the community, including ethnic minorities, and undertaking an analysis of the health situation and needs of the catchment population at the local level. NGO participatory planning experience is valuable and provides examples of workable methodologies in Cambodia that could be adapted and scaled up. The presence of NGOs in particularly disadvantaged areas working with difficult to reach social groups, such as ethnic minorities is also a resource for local health managers. 19. The MOH is committed to increasing the participation of all sections of society in monitoring services as a means of enhancing public accountability. The project will support this objective by undertaking research to inform the design of participation mechanisms, developing mechanisms in consultation with target social groups, and monitoring the effectiveness of different forms of consumer participation. In all of this work, attention will beggiven to vulnerable ethnic minority groups and communities. 20. In the four northeastern provinces, participatory approaches are likely to take different forms than in the rest of the country where ethnic minority populations are less concentrated. It is likely that the targeted support in Mondolkiri and Ratanakiri will provide models of good practice that can be adapted and used in other areas. To raise the profile of ethnic minorities in planning and monitoring processes throughout the country, the planning and monitoring frameworks will include specific questions on ethnic minorities, training to implement the revised methods will include attention to the health of ethnic groups and methods to promote their inclusion, and guidelines for establishing consumer participation will include representatives of ethnic minorities where they are present in the local population. 21. Sector monitoring and evaluation: The project will assist the MOH reform sector wide monitoring and evaluation to include civil society participation in the process, and to introduce social variables such as ethnicity. Annual reviews of sector performance will disaggregate achievements in accessibility, public and client satisfaction, and health utilisation by ethnicity: this will significantly increase knowledge on the health and access to health care of ethnic minorities. The participation of civil society in annual sector reviews will also allow ethnic minority interests to be heard at the national level. The means to enable broad based civil society presence are still to be developed. 22. Human resource development: lack of trained health workers from the ethnic minority population is a major constraint to offering responsive services to ethnic groups. The MOH with support from the project has agreed to develop a primary nurse training course tailored to the needs of hill tribes' peoples and targeting students from the four northeastern provinces. Entry requirements will be reduced to increase access and students from the northeast offered stipends, women will be given priority. In addition, the project will support a review of human resource policy and within this, consideration given to how human resource development needs to adapt to embrace the needs of ethnic minorities. 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