16 December 2014
In their latest ESID working paper, Tim Kelsall and Seiha Heng explain how Cambodia’s political settlement is limiting progressive change within the health sector to certain ‘islands of effectiveness’.
In ‘The political economy of inclusive healthcare in Cambodia’, the authors explain how Cambodia has made significant progress expanding free healthcare to the poor through a multi-stakeholder health financing mechanism called ‘Health Equity Funds’ (HEFs). While HEF operators have helped expand access to healthcare and incentivise staff, they have not been able to address more deeply entrenched challenges, such as ‘under-resourced facilities, underpaid, poorly qualified staff, and a burgeoning private sector’. The authors argue that, despite these islands of effectiveness, ‘the deeper problems are unlikely to be solved without a shift in the political settlement itself’.
Here are some excerpts:
…HEFs have been a relatively successful mechanism for expanding access to free healthcare to the poor. At the same time, their effectiveness in ensuring quality care, notwithstanding some success in this area, is constrained by prevailing levels of low pay, low resourcing, inadequate training, and burgeoning, unregulated private practice…
…the successes and limitation of HEFs can be explained by underlying characteristics of Cambodia’s political settlement. On the one hand, the settlement, including the role of donors and nationalism therein, creates some pressures for performance legitimacy and some space for multi-stakeholder-supported islands of effectiveness. On the other, the dominant logic of patronage politics serves to hollow out the state, constraining the creation of a more genuinely effective, results-oriented health service…
…According to the ESID framework, given Cambodia’s hybrid political settlement, some reasonably effective multi-stakeholder initiatives in service provision, as we see in the case of HEFs, are to be expected (Levy and Walton 2013). Indeed, they are probably the most that Cambodia and states with similar political settlements can hope for. This is because deeper-seated problems in service provision are unlikely to be resolved until the settlement’s dominant tendency shifts from winning votes through predation-fuelled patronage, to programmatic public goods supply; and this shift is unlikely to take place until the dominant coalition senses that the existing way of governing cannot be sustained.
Interestingly, there are some signs in Cambodia that such a perception is growing. In the 2013 general election, for example, the ruling party received a rude shock when large sections of an increasingly youthful electorate rejected its patronage appeals, and turned instead to the Opposition. Whether or not this will provide the incentive the leadership needs to try to change the nature of the political settlement, and whether it will result in support for even more inclusive and effective forms of healthcare, remains to be seen. Policy-makers need to monitor the situation closely, since it will be important not to overhaul too radically a reasonably effective health financing model, before the underlying political conditions for a better replacement have emerged.