Knowledge Brief Health, Nutrition and Population Global Practice 93385 THE ROLE OF THE PRIVATE SECTOR IN REPRODUCTIVE HEALTH SERVICES IN BANGLADESH Ahmed Al-Sabir, Bushra Binte Alam, November and 2014 Sameh El-Saharty May 2014 KEY MESSAGES: The Royal Cambodian Government (RCG) has achieved remarkable progress in recent years in reducing the poverty rate by more than half. However, the majority of those escaping from poverty only did so marginally and remain largely near-poor and still highly vulnerable to the slightest of shocks. One of the most critical factors in enabling the poor to escape from poverty, and not only remain non-poor but go on to prosper, lies in ensuring higher levels of health welfare in these households. This is especiall y important in rural areas, where most of Cambodia’s poor reside and where health indicators show a stark divergence with those for urban areas. If poverty is to continue to decline apace, and the gap between rich and poor is to continue to narrow, then the RCG will need to ensure that poor and near-poor people’s health care is greatly improved such that they can make the most of the new opportunities in education and employment that are now becoming available. With significant improvements in some health indicators over the past decade, the major challenges in health care going forward are now becoming clearer. These include: making a breakthrough in tackling high levels of child mortality and child malnutrition; addressing equity more effectively in health service provision and health spending, through pro-poor targeted programs and improvements in the coverage and rates of use of Health Equity Funds (HEF); and the improved monitoring of unregulated private providers of medication used by the majority of the poor. In addition, another crucial step forward would be providing adequate financing and ensuring the implementation of Cambodia’s first National Social Protection Strategy (NSPS). Introduction towards some of its Millennium Development Goals in health. Despite losing 90 percent of its trained health staff during the Khmer Rouge regime in the late health 1970s, Cambodia For instance, in the decade to 2010, Cambodia’s maternal With significant improvements in some indicators over the past decade, mortality major challenges the (MMR) rate droppedin from care going health437 to 288forward (per has made significant progress since then in re- are now becoming clearer. These include: making a breakthrough in tacklinglive 100,000 high levels of births); child the mortality mortality and rate child for 0-1 malnutrition; month olds establishing its healthcare system. The Ministry of Health addressing (MoH) equity more now employs effectively 19,700 ofhealth staff, in which 3,200provision service are dropped and from 30 to health spending, 25 (per through 1,000 targeted pro-poor live births); mortality programs and improvements doctors and 4,600in the coverage are and midwives. qualified rates of use Health of Health Equity Funds (HEF); and the improved monitoring of unregulated private has rate for 1-12 month olds decreased from 66 to 45 (per become one providers ofof the Government’s medication used by thepriorities majorityand, partly of the poor.as 1,000 In addition, live crucial another births);step forwardrate mortality would be12-60 for month providing olds adequate a financing result, Cambodia decreased from 37 to 22 (per 1,000 live births); measles and ensuringhas made remarkable the implementation progress of Cambodia’s first National Social Protection Strategy (NSPS). Page 1 HNPGP Knowledge Brief  immunization coverage improved from 79 to 93 percent; mortality in Cambodia. While neonatal mortality declined DTP immunization coverage improved from 82 to 92 in urban areas in 2005-10, it showed no improvement percent; and births attended by skilled health staff rose either in rural areas or among the poorest quintile. Unlike from 44 to 71 percent. child mortality (death from 1 to 5 years), which is more influenced by the provision of preventive health services However, despite this good news, some indicators do not and socio-economic factors, neonatal mortality (death show such promising progress. These include malnutrition under 28 days) is strongly influenced by the quality of in children and mothers, equity issues regarding health maternal and child care, including prenatal, delivery, and services and health spending, and the lack of regulation post-delivery care. of private and unlicensed suppliers of medication, from Poor coverage and inequities in primary health which 55.1 percent of the poor seek medical care (against interventions account for most of Cambodia’s child 17.9 percent of the rich). mortality. In 2010, the most prevalent causes of U5 mortality were complications at birth, from diseases that The Issues and Challenges can be prevented by vaccines, and a lack of access to drinking water and good sanitation. 1. INEQUITIES IN CHILD MORTALITY Child deaths increase when births are attended by As in many developing countries, child mortality in unskilled personnel. Data analysis suggests that the risk Cambodia is closely correlated with wealth, especially of death increases when births are attended by traditional for children 1-12 months old. Although the country as a birth attendants compared with trained personal; and whole is on target to meet the MDG for U5 mortality by among trained personnel, the risk of death was higher for 2015, children in the poorest quintile are 3.3 times more births attended by nurses and midwives, compared with likely to die before age five than children in the wealthiest qualified doctors. This highlights the need to further quintile—a ratio that has remained unchanged since increase the percentage of births attended by trained 2005. Child mortality for rural children is 3.0 times than for providers at health facilities, and improve the knowledge urban children. Education of mothers is also closely and skills of midwives and nurses. correlated with U5 mortality: children born to mothers with no education are twice as likely to die compared with 2. GROWING BURDEN OF NON- those born to mothers with secondary education or COMMUNICABLE DISEASES (NCDS) IS higher. And poor mothers are less likely to be educated: AFFECTING THE POOR the poorest quintile of girls is twice and five times less likely to attend primary and secondary school, Cambodia faces the dual burden of both respectively, compared with the wealthiest quintile. communicable and non-communicable diseases. According to the WHO, even in 2004 NCDs had Figure 1. Mortality rates for children aged 0-5 years by overtaken CDs as the major source of mortality. This year, Cambodia trend towards NCDs is expected to increase going forward, and increasingly affect the poor. Chronic Source: CDHS 2000, 2005, 2010 diseases such as hypertension, diabetes and cancer affecting the poor will have major consequences for Neonatal (from birth to one month) mortality is now health outcomes and put many Child (12-60 mo) Postneonatal (1-12 mo) Neonatal (0-1 mo) poor and near-poor at risk of Deths per 1,00 children 120 impoverishment due to health spending. A focus on primary prevention and treatment will be 80 necessary to reduce the disease burden and reduce the costs, not 40 only for individuals but also for the health system as a whole. 0 3. INEQUITIES IN THE Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5 PROVISION AND USE OF HEALTH SERVICES 2000 2005 2010 the predominant source of child mortality for both Coverage remains highly inequitable for some rich and poor. Neonatal mortality has seen the least preventative interventions, especially those that improvement across all income groups, dropping from 37 require multiple visits. For example, while 89 percent of (per 1,000 live births) in 2000, to 28 in 2005, and then the poorest women had at least one antenatal visit in only to 27 in 2010. It is now the main type of child Page 2 HNPGP Knowledge Brief  2010, only 40 percent of poor mothers attended the incurring debt because of health expenses. Medical normal four antenatal care visits compared with 80 expenses are also a major burden for the almost 10 percent of the richest mothers. This means that poor percent of households in Cambodia where at least one mothers fail to obtain essential nutritional support, which family member is chronically ill or injured. Poor families affects the quality of the subsequent delivery. with at least one household member with a long-term illness or injury spend about 25 percent of their per capita The poorest still suffer from lower immunization income on such illnesses and injuries, while in rural areas rates. Despite a dramatic increase in vaccination rates the average spending rises to a crippling 125 percent of over the past two decades, only 65 percent of the poor at per capita income. fully immunized compared with 88 percent in the richest quintile. Ensuring higher vaccination coverage for the Coverage and use of Health Equity Funds (HEFs) poor and remote communities would help to reduce remain low. Despite the introduction of HEFs in the late mortality from pneumonia and measles, ranked third and 1990s, in 2013 they still only operate in 44 out of tenth among the top causes of U5 mortality, respectively. Cambodia’s 77 operational health districts, leaving about one-third of the poor uncovered. The Government is Figure 2. Access to key health interventions, Q1 and gap committed to achieving national coverage of HEFs by with Q5, Cambodia 2010 2015. In those districts covered, the poor are identified by a national ID Poor system, but there appear to be gaps in the system. To illustrate, the 100% 2011 Cambodia Socio-Economic Gap Q1-Q5 Survey (CSES) found that 80 80% percent of the poor did not make Q1 (poorest) 60% use of free or subsidized treatment when seeking health 40% care. Only 10 percent of the poor reported using HEF cards to 20% receive free or subsidized 0% treatment, another 10 percent reported using their ID Poor cards, while 4 percent reported having an HEF card but never using it. Meanwhile, about 5 rd percent of households in the 3 th and 4 wealthiest quintiles Pre-natal Birth Post Natal reported using the ID Poor or HEF cards to obtain Note: ORT + feeding refer to treatment of diarrhea Source: DHS treatment, suggesting significant inclusion errors in the ID 2010. Poor system. Over 90 percent of the poor seeks medical care when While generally pro-poor, government health sick, but the majority goes to unlicensed drug shops spending could be made more equitable and efficient, and markets. This contrasts with the richest quintile of reducing reliance on out-of-pocket payments. A recent which 75 percent seeks care in private pharmacies, World Bank public expenditure analysis in health found clinics, or hospitals. The problem is that unlicensed drug that (i) primary care and preventative spending is pro- shops and their products are not monitored or regulated, poor, while spending on hospitals is not pro-poor; (ii) the shop owners have no medical training, and the resource allocation among provinces lacks transparency, medications are prone to counterfeiting. and could use poverty as a better criterion for allocation; (iii) too many resources (70 percent) are managed 4. INEQUITIES IN HEALTH SPENDING centrally; and (iv) the Ministry of Health spends more than half its budget on pharmaceuticals, and pays more than is Health spending is a major source of debt and necessary for drugs. Savings made here could be used to impoverishment for the poor and near-poor, and the scale up and deepen coverage of priority equity- chronically ill. Despite an overall decline in health enhancing interventions, such as HEFs. spending and catastrophic spending as a percentage of income in recent years due largely to rising incomes, an Figure 3. Source of health care financing, 2011 estimated 2 percent of Cambodians fell into poverty in 2011 due to health costs. Health spending remains a significant burden on the poor, with about 18 percent Page 3 HNPGP Knowledge Brief  60% of malnourished women are more likely to die in infancy. While child malnutrition is correlated with socioeconomic % of households 50% status, other key determinants are maternal malnutrition, 40% uneducated mothers, lack of breastfeeding and open 30% defecation in the community. Analysis also shows that 20% stunted women are more likely to have malnourished 10% children, indicating the inter-generational impacts. 0% Despite progress, more attention is needed to Q1 poor Q2 Q3 Q4 Q5 rich promote breastfeeding and reduce open defecation. Savings Borrow with interest In 2010, 70 percent of communities still defecated in the Borrow no interest Sold assets open and only 50 percent of households in Cambodia had Health E. Funds Community insured access to drinking water. Thirty percent of mothers did not Source: CDHS 2010 practice exclusive breast feeding, 20 percent were underweight and 45 percent were anemic. In addition, 76 5. POOR LEVELS OF MATERNAL AND CHILD percent of children did not receive a minimum acceptable NUTRITION diet. These recent statistics highlight how much remains to be done to improve health welfare in Cambodia. Women continue to suffer high levels of malnutrition and anemia. About 20 percent of all women of Figure 4. Children stunted by wealth, mother education childbearing age are underweight on the body mass index and breastfeeding and open defecation (BMI), a prevalence that has failed to improve over the past decade. This has serious implications for their Source: DHS children, starting with low birth weights. While Source: DHS 2000, 2005, 2010 2000, 2005, improvements have been seen in levels of anemia, high levels of anemia are still found in mothers with many children, 50% uneducated mothers, and women in poor % of Stunnted Children households and in rural areas. 40% Maternal support through nutrition and education is crucial for both mothers and their children. One example is iron 30% supplements, which protect both women and infants against anemia. One-fifth of 20% prenatal mortality and one-tenth of None Q2 Q3 Q4 Q5 Never Ever 1-6 years Q1 poorest >50% HH's <50% HH's > 6 years maternal mortality are thought to be attributable to iron deficiency worldwide, while anemia is a common cause of premature delivery and low birth weight. Wealth quintile Mother's education Breastfeeding Open defecat. Intervention can make a crucial 2010 difference. In Cambodia in 2010 only 45 percent of mothers reported receiving a Vitamin A-iron-folic acid 6. THE NEED FOR A NATIONWIDE SOCIAL supplement in the six weeks post-delivery. Hence there is PROTECTION SYSTEM significant scope for reducing maternal and prenatal mortality by improving the coverage of micronutrient The National Social Protection Strategy (NSPS) has supplements in Cambodia, possibly through cash still to be implemented. In 2011, the Government transfers to poor pregnant women to encourage earlier approved the first NSPS for Cambodia. However, since antenatal and postnatal care. then the implementation of the strategy has been slow Improvements in child malnutrition have stagnated and there have only been a few new initiatives to date due and wasting has increased since 2005. In 2010, the to inadequate financing and a lack of coordination across the various government agencies involved. With the prevalence of stunting, underweight children and wasting erosion of traditional family-based safety-net systems due were 40, 28, and 11 percent, respectively, while anemia to urbanization, there is an urgent need to adequately was at epidemic proportions of 55 percent for children under 5. The long-term consequences of child finance and implement the NSPS to protect households malnutrition are severe: as adults they die younger and vulnerable to financial shocks. suffer higher rates of chronic disease, while children born Page 4 HNPGP Knowledge Brief Conclusion of ID Poor and HEFs, while maintaining low user- fees in the public sector. Strengthened implementation and monitoring of the ID Poor and Despite some dramatic improvements in health outcomes, HEF systems would help ensure all eligible poor significant gaps remain between the poor and better-off, receive HEF cards and are made aware of the reflecting gaps in coverage and also quality of care. The benefits. Also consideration should be given to COMMUNITY barrier of social exclusion means that some of the most expanding HEFs to the near-poor, urban settings needy are systematically missed from most interventions. and individuals without a permanent address. The Government needs to prioritize closing this equity MIDWIFERY gap in life-saving coverage indicators, including antenatal  Prevention of chronic non-communicable and postnatal care, ensuring adequate financing for diseases (NCDs): In the future, the burden of EDUCATION outreach services to remote communities, and improved disease will shift towards NCDs. Thus, prevention service coverage in remote areas. Demand-side and promotion programs, such as anti-smoking PROGRAM IN interventions such as HEFs should be improved, and campaigns and tobacco taxes, should be targeted interventions such as conditional cash transfers increased and screening and treatment for NCDs (CCTs) further piloted and scaled up. AFGHANISTA should be integrated into primary health care provision. Extending the coverage for priority N chronic diseases into HEFs and social health Recommendations insurance benefits should also be considered. Sameh El-Saharty and Khalil Mohmand  Improve the quality of health care: Most poor  Multi-sector approach to reduce maternal and May 2014 people opt to use the private sector for health child malnutrition: to be targeted aggressively care, indicating some level of dissatisfaction with on the poor and in rural areas. The monitoring of the public sector. Improvements in the child growth in health centers should be effectiveness of the public health sector should be strengthened and should trigger response made, such as increasing the availability of drugs, mechanisms for moderately and severely reducing waiting times, and improving the patient- malnourished children (e.g. micronutrient clinician relationship. The training of medical supplements and feeding practices counseling). personnel and equipment available should also Maternal health monitoring should also be be improved. strengthened and nutritional status and counseling for pregnant women improved.  Enhance financial protection for the poor: This Community-based programs should be scaled to should be achieved through improved coverage improve sanitation and eliminate open defecation. The Health, Nutrition and Population Knowledge Briefs of the World Bank are quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, please contact Miguel Sanjoaquin, Health Economist (msanjoaquinpolo@worldbank.org) . Page 5