Government officials readily acknowledge Cambodia has one of the poorest health care systems in the world.
The infant mortality rate is relatively high compared to other countries in the region, at least 750,000 children below age 5 suffer from malnutrition, and about 5,000 people die each year of malaria.
NGOs say the biggest obstacle to improving these problems is the government itself, specifically the way the Ministry of Finance handles the health care budget.
The dramatic differences between the official budget and the amount actually spent make it impossible to bring Cambodia’s health care system up to international standards, NGOs say.
“The lack of possibilities is due to this system,” said Maurits van Pelt, head of the Medecins Sans Frontieres in Cambodia. “You cannot plan and you cannot make progress like this.”
Finance Minister Keat Chhon acknowledged in a speech given Thursday to donors that there remain problems in how the ministry distributes money for health care. “The source of these difficulties can be partly blamed on the central Ministry for Economy and Finance as the full budget is not made available to provinces and at the province level where obstacles are placed in the way of the health departments,” Keat Chhon said, according to a copy of the speech.
However, Suor Victor, undersecretary of state for Finance, says the problem is the Ministry of Health, which he maintained is underspending. “We are not ignoring them, we are pushing them [to spend more],” he said.
But NGOs and Health Minister Hong Sun Huot insist the problem is the lack of available funds.
“The problem is the amount adopted on paper is not the same as the real money given to us,” Hong Sun Huot said.
The shortage brings the average amount spent on health care to $1 per person per year.
“The Ministry of Health has clear ideas of what it wants to do,” said Michael Curtis, the World Health Organization’s budgetary adviser to the Ministry of Health. “If the government wants it to do its job, don’t expect them to do it without the resources.”
Defense and security are the priorities, spending 110 percent to 150 percent of its budget each year, while health usually gets 50 percent or less. In 1998, 6 percent of the national budget went to health care and 40 percent went to defense and security.
In the Finance Ministry budget report for the first six months of 1999, health was able to spend only 13.2 percent of its budget, while defense spent 53 percent.
“We have a lot of things to do,” Hong Sun Huot said. “How can you do it with $1 per person?”
Suor Victor said health care has not always received the funds allocated for it, but said that is going to change with the 2000 budget. The Ministry of Finance has proposed increasing health spending to account for 2.18 percent of GDP, compared to 1.89 percent for 1994-98.
If a ministry presents a package for spending, there is a very good chance it will get the money, Suor Victor said.
In addition to citing a lack of funds, Curtis blames the system of approving expenditures. Every expense, including menial items such as office supplies, has to get at least three signatures before it is finally approved.
That kind of system is susceptible to corruption because people have to rely on several others to get their expenditures approved, Curtis said. “A simple, transparent system and clear accountability for performance are the best controls, not numerous signatures and committees,” he said.
To follow the trail of money going into health care in Cambodia, there are three budgets to examine instead of one.
The first is the official budget that is shown to the international community, what NGOs call the public relations budget.
The second budget is laid out in directives, or prakas, which contain the amount of credit the Ministry of Finance opens in the name of a governor of a province. That amount is always less than official budget figures. It is the governor’s responsibility to divvy up the credit among the different departments. There is no structure to ensure that the governor spends the credit properly for each department.
The third health budget is the actual amount spent by the provinces, which never reaches the amount of credit it is given.
The Ministry of Health’s budget monitoring report for the first six months of this year showed that while the amount budgeted to be spent on health care in the provinces was 14.8 million riel (about $3,900), the amount of credit provincial health departments received was 3.2 million riel and the amount actually spent was 2.1 million riel.
“Health managers operate under full uncertainty because they never know how much they are going to get,” said Stephane Rousseau, executive director of Medicam.
Another problem, NGOs say, is the Ministry of Health has little access to and control over its budget at the provincial level. The Ministry of Health is not informed by the Finance Ministry about the amounts that provinces are given for health care.
NGOs say the system essentially makes the provincial governors the direct managers of the budget of the Ministry of Health, which is not in charge of the governors. “We’re only a technical ministry,” Hong Sun Huot says. “We can only say, ‘Please take care of the budget.’ ”