In the latest of a series on volunteering abroad in the health service, Patricia Sloan talks about the drive to reduce health inequalities in the Cambodian health system

The public health statistics for Cambodia remain challenging despite major improvements in overall mortality rates. Life expectancy is 60 years for men and 65 for women. The infant mortality rate is 66 per 1,000 live births and maternal mortality rates remain high, contributing to 17 per cent of all deaths among women aged 17-35.

New health problems are also emerging alongside rapid socio-economic development, with an increase in the prevalence of diabetes, hypertension and road traffic accidents requiring even more complex responses from an already beleaguered health system.

A key area for action in relation to the health profile of Cambodia is improving coverage and access to health services, especially among the poorest in the community. The Cambodian government has stated its commitment to improving equity in health, but barriers to achieving this persist.

While demand management was the bread and butter of my role in the UK, in Cambodia, demand management means stimulating increased demand for health services. The hospitals where I am working are in very different situations in relation to demand stimulation. In Mongkol Borei referral hospital, there is a successful health equity fund, operated by a local Cambodian NGO and partly funded by the World Bank and USAID.

Working towards equity

The health equity fund acts to promote demand, especially among the poor. Where possible, the poor are pre-identified in their communities and, on presentation to the hospital, they get full or partial support to cover their hospital fees, transport costs and other expenses.

In Mongkol Borei referral hospital, the fund is directly linked to a quality improvement scheme that assesses the quality of clinical and general management in the hospital. If the required score is achieved, the hospital retains the fund. The hospital and its staff are motivated to continuously improve the quality of care to maximise their provision of care to the poor and increase the revenue available to the hospital. Fees generated from the fund are used to reinvest in quality care (39 per cent), to enhance staff salaries (60 per cent), and returned to the health ministry (1 per cent).

My role in the hospital is to coach and support the hospital director and management team in attaining higher quality scores and working with the health centres to improve referrals to the hospital. Health equity funds have improved access to care for the poor, but coverage of health facilities with the funds is not universal across Cambodia.

Management support

Conversely, Thmar Pouk referral hospital lacks the incentive of a health equity fund linked to a quality incentive scheme to drive up standards and improve access to care. People living in the district may purchase community health insurance to prevent impoverishment due to health costs. However, uptake is variable, with the poorest unlikely to be able to buy health cover.

My role in VSO is to mentor and support the director and the management team (senior doctors) to implement the concept of continuous quality improvement in clinical care and overall patient experience, with the objective of enhancing the reputation of the hospital in the district and thus increasing hospital revenue.

Both Mongkol Borei and Thmar Pouk referral hospitals will also be part of wider project supported by VSO and funded by Astra Zeneca UK. The hospital staff will have the opportunity to go on training programmes, have clinical learning sets and visit centres of best practice in Cambodia and nearby Thailand. This work will enhance the clinical capabilities of staff and form the basis of a clinical network between the three hospitals involved. There will also be a focus on improving general management systems in the hospitals. Outcome measurements for this project will include an increased uptake of services in the three hospitals by the poor. The project starts in September 2008.

About VSO

VSO is an international development charity that works through professional volunteers who live and work at the heart of communities in 34 countries around the world. Working in partnership with local colleagues, they share their skills and expertise to help find long-term solutions to poverty.

The charity recruits skilled and experienced professionals from a wide range of backgrounds, including health, education and business. Health management professionals are needed to develop hospital management systems through staff development, budget planning and resource management, particularly in Cambodia.

VSO volunteers usually have a professional qualification in their field, as well as a minimum of at least two years' experience. As well as professional skills, they must have the right personal qualities, which include confidence, flexibility and the ability to work effectively with others. Volunteer placements can last from two weeks to two years, with shorter-term assignments aimed at those with a high level of experience.

In return, VSO offers a comprehensive volunteer package including return flights, basic accommodation, a local living allowance, national insurance contributions for the period of service (or country equivalent), insurance, comprehensive pre-departure and in-country training, as well as support from a dedicated VSO team on the ground.

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