Yesterday, shortly after the noon hour, my flatmate Georg had a realization. "Oh right, you're Canadian."
How did this realization come to be? Well, I was really sick. High fever, body aches, some other symptoms I'd rather not talk about in a blog, for about 24 hrs and ongoing at that point. Essentially, I felt miserable, in no mood of going to work or even getting out of bed.
But what really motivated me to not see a physician was paying for one. I lay in bed thinking "why oh why am i not friends with a physician?" Finally, I succumbed to the fact that I was incredibly sick and made my way to the Intenrational SOS Hospital where most ex-pats go to see physicians.
My hospital bill came to:
Physician Visit - $60
Blood Tests - $19
Medication - $40
Total - $119
Being Canadian, I have the right* to free, at the point of visit, medical coverage. The health care I am provided for, as a result of my citizenship, in Canada adheres to the 5 tenets of the Canada Health Act. It is portable: I can use it in whatever province or territory I happen to be in. It is universal: it covers anything that is medically necessary. It is accessible: I can get it regardless of health status, age, gender or any other demographic constraint. It is comprehensive: so it will cover anything under the sun except for my teeth or drugs. Finally, it is publicly administered: the provincial government pays the doctors - I don't.
Cambodia is my first experience residing for a long term outside of Canada. It's been about 5 months now. For the first time working in the health and development sector, I have the experience of associating cost with health care. This is particularly relevant to the subject of migration and health that I am working in.
While there is publicly administered health care in Cambodia, it continues to be viewed with a lack of trust, according to a colleague. Many Cambodians continue to see private health care providers which cost an arm and a leg...or your home and plot of agricultural land. There are also the cost of drugs on top of that. A leading cause of landlessness, and therefore migration, in Cambodia, is indebtedness as a result of health care costs.
What often occurs among many Cambodian families who live in both the middle class and below the poverty line, is that they make the choice to see the pharmacist, rather than the physician. The pharmacist can make an apparently reasonable diagnosis of the affliction and sell the medication thought to be necessary - oftentimes this is paracetamol. This of course, is not a proper way to make a prognosis, diagnosis and treatment.
In fact, in early March, I will be making one of my first site visits to the border province of Svay Rieng, which sits next to the Tay Ninh Province of Vietnam. Here, I will be conducting a rapid needs assessment of knowledge, attitudes and practices of sexual and reproductive health care seeking behaviour of repatriated trafficked women who come back to Cambodia having worked in the begging and sex-work industries in Ho Chi Minh City. My provincial counterpart has already alterted me that one of the reasons that few women, trafficked or otherwise, see publicly administered health, if at all, is due to a lack of trust in the system. I am hoping that this project will inform a more in depth study that will eventually help guide provincial health care policy makers to improve systems such that public trust and practice would also rise as well.
The Asian Development Bank estimates that an investment of $4/head in Cambodia to contract health services from private providers would ensure that the poorest in Cambodia would be covered by proper and decent medical care**. While I am against the notion of public-private partnerships in health care provision since the have the ability to drive costs higher, this does appear to be a good step towards a publicly administered health care system for Cambodia. I am also against the notion of contracting with NGOs for the provision of health care, which is also a strategy advocated by the World Bank. Cambodia should be moving towards the freedom to provide health care to its own population by its own practitioners. What I propose is a simultaneous and step-wise system. First contracting for health service provision with both internal and NGO providers, technical assistance to develop a funding and public provision system and then a slow conversion to a publicly administered system with all stakeholders, especially physicians and patients, satisfied monetarily. The provincial base of this system would also satisfy decentralization goals of the Royal Government of Cambodia. The system can be strengthenned while aid is being provided such that when such aid begins to leave, the system will be able to run on its own.
Of course, this sounds a tad daunting, but it did take over 30 years for Canada to get its act right, no?
* I believe that health is a human right that should be afforded to all regardless of status, demographic or any other measurable, definitive characteristic.
**http://www.adb.org/Documents/Periodicals/ADB_Review/2004/vol36_3/healing.asp
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