takeo town – Aside from the saffron robe and light blue T-shirt monks gave her to use as a blanket and pillow, Path Mom has nothing.
The 27-year-old tuberculosis victim has no food, no money, no family and no home. Her body is covered in sores and her feet and ankles are so swollen and painful she can barely walk.
“If the police hadn’t brought me here, I’d be dead by now,” Path Mom said recently.
A year ago, it would have been questionable whether the emaciated woman from Neak Loeung in neighboring Kandal province would have received treatment or even been admitted to a public hospital.
Despite purporting to provide free treatment, public hospital staff throughout Cambodia routinely demand hefty bribes which often exclude the poor from receiving medical care.
At the Takeo Provincial Hospital, however, that changed a year ago, when the Ministry of Health installed a financial reform program there that includes, in part, a transparent and modest fee structure and increased salaries aimed at fighting corruption.
Today, Takeo Provincial Hospital is cited as being the frontrunner among the eight hospitals and 37 health centers taking part in the reform program.
The financial reform has had varying results in the limited number of hospitals where it has been installed. But Takeo’s
program has succeeded in raising salaries for its 150-plus employees and diminished the need to seek bribes from patients, who are receiving more affordable treatment, health-care officials say.
Corruption has been reduced, public trust is being established and patients are coming from far away.
In Phnom Penh, Ministry of Health officials in charge of the national reform process cautiously agree that Takeo is outperforming other public general hospitals in Cambodia. The Takeo hospital will be among the health-care centers thoroughly evaluated early next year.
Health officials emphasize that Swiss Red Cross budget support has given Takeo Hospital an opportunity to succeed that many hospitals in Cambodia haven’t had.
The caution from Phnom Penh about the reform initiatives in Takeo hasn’t dampened enthusiasm here.
“There is only one hospital in the Kingdom of Cambodia” with such a successful reform program, Takeo Hospital’s director for the last 12 years, Dr No Samith, said last month. “And it is mine, I think.”
The 54-year-old who sports a gold tooth in front and otherwise looks 20 years younger, then crisply writes the words “transparency” and “confidence” on a piece of paper and draws arrows pointing between the words.
“This is the secret” to successful reform, he said.
Not Like Other Hospitals
One look at the cheery white buildings cloistered around its grassy square shows that Takeo Provincial Hospital is not like most other public hospitals in Cambodia: It’s full of patients.
A volleyball game picks up in late afternoon on the sandpit in the grassy center and a little later a team of blue-clad kitchen workers wheel around a cart of bamboo soup and steamed rice.
Family members of the sick spring up from the benches and steps around the buildings to grab a bowl and plate.
The 180-bed hospital is running at a 130 percent occupancy rate, a sign that people trust the hospital’s ability and commitment to treat them, health officials say. “Everybody is more conscious of their duty,” No Samith said.
By boosting staff salaries, the financial reform aims to fight the shortcomings currently crippling the nationwide health network. Each employee at the Takeo hospital has signed a contract pledging not to steal medicine, bribe patients, refuse care to the poor or refer patients to their private clinics.
Takeo Hospital’s services are about five times cheaper than private hospitals or the bribes normally demanded by public hospital staff, health officials say. Half of the money the hospital garners supplements staff incomes, the other half pays for running costs like electricity. Staff salaries generally fall between $75 and $200, employees said.
Twice the number of beds are occupied each month since the program was installed; August’s numbers were three times that of August 1996.
Some of Cambodia’s larger general hospitals normally run at 50 percent or less occupancy, health officials say. Health officials attribute the low numbers to the people’s distrust of public hospitals and belief that they cannot afford the bribes informally required for treatment.
The outdoor mess hall at the Takeo hospital has been transformed into a ward for recovering surgery patients to accommodate overflow, which occasionally reaches 250 patients.
The hospital receives public feedback from citizens’ representatives on a 26-member management committee. A 2-meter-by-2-meter blue-and-white information display outside the reception center lists the fee for every hospital procedure or service.
No one pays more than $40, including major surgery, X-rays and medicine. An initial exam by a primary care doctor is 5,000 riel.
Everybody, rich or poor, receives equal care, hospital staff say. Everybody fills out a standard of living questionnaire to judge whether or not they can pay. Those whose house is poor and who do not have household items, land to cultivate or livestock are generally excused from paying for their medical care.
Occasionally, a client lies about their income in order to receive free care, an administrator said. But a staff subcommittee attempts to investigate people’s claims of poverty to verify whether they have told the truth.
One woman, Mom Sophal, said the hospital wasn’t charging her for a pint of blood given to her snake-bitten husband. “We are poor, that’s why we pay less,” she said.
In a further effort to reach out to the public, administrators are spending more money to improve the food cooked for patients and their families. They also keep a confidential complaints box on the hospital grounds and have appointed a subcommittee to investigate each complaint received.
Staff members report many patients come from as far away as Kompong Cham province. Prak Bun, 46, who is suffering from severe stomach pain, came from Kompong Speu’s Baset district.
“Over there, there isn’t as good a hospital as this one,” Prak Bun said recently from his wooden bed in the surgery ward.
Reform is the Way
Ministry of Health and World Health Organization officials tout the reform as the way to revitalize Cambodia’s decrepit and underfunded network of about 55 general hospitals.
Takeo Hospital is one of about 20 hospitals nationwide that is equipped to safely perform emergency surgery and one of about five that offers the range of services expected of a general hospital in an industrialized country.
The Ministry of Health aims to create a network of at least 72 general hospitals that are up to international standards.
The government, through the Ministry of Health, is supposed to chip in $8,000 per month to cover patients’ food and medicine and the 30,000 riel monthly base staff salary. But so far, the government is living up to only a fraction of that, Takeo staff say. Health Ministry officials say the government is not providing them enough funds to carry out their responsibilities.
In September, the hospital took in $14,500, or more than its share of the approximately $22,000 monthly operating costs. The Swiss Red Cross, which helped financially support the hospital and train staff for 12 years beginning in 1985, has pledged a modest fund to help plug the holes in the budget. The fund started at $11,000 in June and will decline by $500 every month until it is depleted.
The Swiss Red Cross spent about $400,000 per year on materials, renovation and training before it pulled out over the past year and left behind 48-year-old administrator Chukmel Santepheap as its delegate.
Despite the aid assistance, corruption flourished at the Takeo Hospital. The problem continues to plague the nation’s health-care system, where employees are paid less than $10 per month.
While most of Takeo’s wards have either been built or renovated by German, Swiss or Norwegian money, health officials debate whether the funds plugged temporary holes or left a long-term mark on the hospital.
Many health officials believe a longtime NGO commitment of money and training to a particular hospital can turn it around. Few hospitals in Cambodia receive such attention.
Dr Mean Chhivun, deputy director-general for the Health Ministry, said last month that Takeo’s short-term success is “a little bit different” from hospitals that do not have an NGO budget to help them when the government comes up short.
He said the hospital’s progress will be evaluated next year by the World Health Organization and Ministry of Health.
Asked how the rest of the country’s hospitals can learn from Takeo’s success, Chukmel Santepheap said the staff’s willingness to change has been the catalyst for success.
“Sometimes money can’t do anything,” said Chukmel Santepheap, who has worked for various Red Cross organizations since 1990. “We just respect what we learned in school. Maybe we respect it better.”
Earlier this year, a panel of staff representatives fired two staff members implicated in separate incidents of taking bribes from patients.
One of the sacked is related to a top provincial official, which in Cambodia generally precludes a person from losing their job. The management committee treated the situation as a test of the commitment to banish corruption from the hospital.
“We said, ‘If we cannot do this, our system will collapse,’” Santepheap said.
Chukmel Santepheap acknowledged that the hospital cannot stamp out 100 percent of corruption inside of its walls, but it is trying.
Staff members up and down the structure report that they like the reformed system better, although the primary medical staff say their salaries are not radically different from when they charged under-the-table fees.
Chukmel Santepheap said staff members are relieved that they don’t have to “put the knife to the patient’s neck as before” the reform was installed.
“Under this system, the staff is proud,” said Dr Kol Navoeun, 29, one of four surgeons at the hospital. “In the old system, we could make a little money, but our reputation was bad.”
The Cost of Success
Hospital officials and health experts in Takeo are beginning to look toward the future and wonder how the hospital will accommodate the flood of patients.
The hospital has no money to build new wards or to take on the additional staff that would be needed to support an expansion.
Officials also worry what will happen when the Swiss Red Cross money runs out and the government remains behind on the $8,000 monthly support it has pledged to the hospital.
Yogendra Thami, the Nepalese provincial health adviser from the World Health Organization, suggested money-making ventures like converting hospital space into expensive private rooms for the wealthy or renting out space to private businesses.
Dr No Samith, the hospital’s director, said the hospital will attempt to reduce patient stays from the current seven-to-10 day average to free up bed space.
But a long-term solution has not been formulated.
“We don’t know exactly,” said Chukmel Santepheap, the Swiss Red Cross delegate.
For now, the hospital’s only recourse to expansion may be to wait for the government to improve its revenue collection and fulfill its commitment to health projects, Santepheap said. “The people may have to wait for the government to provide.”
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