Widespread Graft Hurting Public Health

Several times a year, bags bulging with riel leave Phnom Penh, bouncing aboard cars, motorcycles and boats toward each provincial capital, where the money buys medicine and supplies and pays the salaries of government doctors and nurses.

It is not the most efficient or modern way to move public funds from the National Treasury to provincial governments. The cash system is vulnerable to corruption; small amounts of money are often skimmed off the top with each transfer.

But because Cambodia lacks a network of commercially run and government-owned banks, it is the system that Cambodia’s un­derfunded public health care sector will continue to use in the coming years.

“Having the population in good health is crucial for development. But if there is no microeconomic basis, you can’t develop anything, including the social sector,” said Jean-Francois Frys, executive director for Medicam, an umbrella group of health care NGOs.

The government continues to increase its annual budget for health care and education, while cutting funding for the military.

But as more money becomes available to prevent and cure Cambodia’s illnesses, the question of how to get those bags of cash into the hands of those who run the district hospitals and the commune clinics becomes more important.

Funcinpec parliamentarian Keo Ramy pointed out in December that very little of the budgeted money for social sector ministries finds its way to their operations. In the past, provincial health departments have received less than 50 percent of their allocated budgets.

Lawmakers have asked the Ministry of Finance to consider giving funds directly to the ministries. But this is unlikely to happen soon. Efforts to reform the way public health care is funded have changed little in the last five years, said Henk Bekedam, a World Health Organization official who works with the Ministry of Health.

In most provinces, funding passes from the treasury to the Ministry of Finance to provincial governors. It is only then that money is handed to provincial health directors, who, in turn, send money to the local level. The Ministry of Health has little control over its budget at the provincial level, and is often not told what amounts provinces are given for health care.

And because the government is constantly short of funds, money is sent to provinces sporadically. The first shipment of money for 2002 is only now beginning to arrive in provinces—just ahead of the Khmer New Year holiday.

In recent years, seven provinces have participated in the Priority Action Program, in which spending plans are drawn up and quarterly advance payments are made. Officials hoped this would make funds easier to access and increase transparency.

Eighty-seven percent of funding budgeted for this program was disbursed in 2001. That’s compared to just 56 percent for provinces funded under the old system.

There is a debate going on inside the Finance Ministry about whether to increase the number of provinces using PAP, or whether to use only one budgetary system in order to reduce confusion, health officials said.

“There are people [at the Finance Ministry] who are concerned about the situation,” said Medecins sans Frontieres Holland-Belgium-Switzerland chief of mission Marc Hermant.

There remain many difficulties in the way health care is financed, Hermant said. But with increased funding in the last few years, there has been improvement.

The amount of money spent on health care per Cambodian increased from just over $1 in 1998 to $2.70 in 2001, according to ministry figures. But that is still far short of the $12 per capita that the WHO says is needed.

Disbursement varies depending on the province or district, Hermant said. In one district where MSF works, there is money to buy food for patients and for fuel to run electrical generators. In another district, he said, the situation is still “complicated.”

(Additional reporting by Yun Samean)

 

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