Poor on IHR capacity progress in 2019, WHO says Cambodia tops COVID-19 response

Despite being in proximity to Hubei, the original epicenter of COVID-19 pandemic, Cambodia has reported just 226 confirmed cases and zero deaths. After seeing the data, WHO appreciated Cambodia’s healthcare information system but experts doubt the claims.

World Health Organization (WHO) has showered praise on Cambodia’s healthcare information and security system for its ‘robust’ COVID-19 response. “Over the last decade, with the support of WHO and partners, Cambodia has made important investments into the health security system in the country, which has enabled a robust response to the COVID-19 crisis,” said a report of the WHO titled ‘The first 100 days of the COVID-19 response: past investments in health security system pay off, and learning lessons for the future’.

Cambodia identified the first case of COVID-19 on January 27 and had reported 226 cases with no deaths till July 28 out of which 97 cases were on three days – March 23 (33 cases), July 12 (15 cases), July 22 (26 cases) and July 26 (23 cases). With a population of 16.7 million, Cambodia has a tourism-supported economy with big cities as well as remote areas. Though national population density is 95 persons per sq km, the national capital city Phnom Penh has a population density of 5,700 people per sq km. These characteristics along with the fact that the country is in proximity to Hubei make it vulnerable to the COVID-19 outbreak.

However, the achievements of Cambodia, despite these hurdles, prima-facie indicate that a ‘robust health information system’ of the country may have put it among the most successful nations in terms of COVID-19 response. However, the question is – how this system went unnoticed before the COVID-19 outbreak?

IHR (International Health Regulations) Capacity Progress 2019, a mechanism of annual reporting and grading of healthcare systems in member countries by WHO on the basis of 13 IHR capacities and 24 indicators, has ranked most of Cambodia’s IHR capacities much below the regional and global averages. Out of 13 IHR capacities, 11 are related to managing outbreaks of infectious diseases (epidemics or pandemics) but were ranked poorly. The capacities ranked significantly below the average are Legislation and Financing, Laboratory, Food Safety, Human Resources, National Health Emergency Framework, Health Service Provision, and Point of Entry (Airports, ports and territorial borders) while it was ranked slightly below the average in Risk Communication, Surveillance, and Zoonotic Events. Cambodia has been ranked above average only in one capacity – coordination with the WHO (IHR Coordinator and National IHR Focal Point).

Furthermore, a study published in Health Economics Review in October 2019 has expressed serious concerns on data collection, cost per contact of patients with the healthcare systems and quality of healthcare, etc. The GHX Index-2019 has also ranked it at 89^th position, below several countries in the Western Pacific region that are struggling to cope up with COVID-19.

Cambodia indeed has a health management information system in place but experts doubt it’s robustness and role in achieving the success against COVID-19 as claimed through the data. The critics accept some success but credit it to luck as well as the culture of covering face due to previous exposures/experiences of respiratory disease outbreaks. This analysis is an attempt to provide the audience with a window to look into Cambodia’s public healthcare management information system, what public health policymakers can learn from it and where it needs improvements.

Public Health Information System in Cambodia

Cambodia has a three-level healthcare system under the Ministry of Health which constitutes central, provincial, and local (community and district) levels of healthcare institutions. Besides, the Communicable Disease Control (CDC) Department with its parallel system is responsible to control communicable diseases.

It follows a mixed system of publically and privately funded healthcare institutions wherein healthcare in public institutions is subsidized while the healthcare cost of the private setups is paid by insurance schemes and out-of-the-pocket settlements.

The Health Information System Master Plan (2016-20) of Cambodia aims to establish a robust health information system to ensure the availability of high-quality health and health-related data for policy, decision-making, planning and budgeting, performance monitoring, evaluation, and research. Presently, it has several disease/event-based health information projects funded by international funding agencies such as WHO, USAID, ADB, and also by mutual agreements with other countries such as Health Management Information System, Patient Management Registration System, and several disease-based databases. The following are the key aspects of the health information system in Cambodia:

• Surveillance: Cambodia has three major surveillance systems for communicable diseases – CamEWARN, ILI Surveillance (Influenza-like Illness), and SARI (Severe Acute Respiratory Illness Surveillance). While ILI and SARI cover their respective diseases, CamEWARN covers 7 epidemic-prone diseases and syndromes. CamEWARN involves weekly reporting from health centers, referral hospitals, and two pediatric specialty hospitals. ILI is a WHO funded project which monitors influenza from seven sites while SARI has involved eight hospitals. Besides, CDC2 Project in collaboration with ADB and Lao PDR and the WHO-supported National e-Health Capacity Roadmap are also meant for the surveillance of communicable diseases at the regional level.
• Health Security project: This project is aimed at including the marginalized populations particularly in remote areas in the healthcare and healthcare information system for surveillance of communicable diseases.
• Cambodia National Poverty Identification System: Being run in collaboration with Australia Aid and Germany’s GIZ development agency, this program is aimed at identifying poor households and providing them financial assistance to ensure access to quality healthcare services. This system is based on a separate database and funds are primarily used to reimburse the healthcare cost of the poor people.
• Health Information Policy and Advocacy (HIPA): Supported by USAID, this project is focused to improve data completeness, quality, and usability. The study is reportedly aimed at ‘assessment of the current data use and information needs from Health Management Information System (HMIS) to support evidence-based decision making among various health managers and information needs of other external and non-health stakeholders at both national and sub-national levels’. It presents data in two formats – commune council dataset and health decision-maker dataset – with a focus on HIV/AIDS.
• Maternal Healthcare: Cambodia has a separate database for maternity and child healthcare associated with healthcare services for expecting mothers and prenatal care. However, the country faces serious challenges to ensuring good quality maternal healthcare evident by a number of indicators such as - 14% of women between 15 and 49 years of age were underweight, 45% of women were anemic out of the 1% severely, and 69% of households were using salt with some iodine, etc. Furthermore, decreasing the median duration of exclusive breastfeeding is also a major concern in Cambodia for child healthcare. 

Loopholes in the Healthcare Information System of Cambodia

The evaluation studies conducted on Cambodia’s healthcare information system have shown significant improvements in digitization and inclusion of poor in the healthcare system in the past couple of years, however, there are still some glaring loopholes that need to be plugged.

• Multiplicity of Database Systems: As discussed above, the multiplicity of database systems is one of the biggest problems in Cambodia’s healthcare information system. These loopholes were also highlighted in several documents including SWAT analysis of Cambodia’s Health Information System Master Plan 2016-20. The country is largely dependent on foreign funding for its health information system which has resulted in several joint projects being run with different database systems. Besides, there are separate databases for different diseases and schemes. There isn't any department or central agency to ensure coordination amongst them.
• Disparity: The healthcare services in Cambodia are considered discriminatory as public healthcare services are generally used by low-income people while high-income people prefer private healthcare services. Besides, the lack of adequate healthcare insurance scheme is also considered a major hurdle to ensure equitable healthcare services for all.
• Low-Quality Healthcare Services: Quality of healthcare services in Cambodia remains low particularly in remote areas. The private sector and informal healthcare providers account for 61% and 26%, respectively, of all service provisions which are either unaffordable or filled with low-quality healthcare providers. Studies suggest that the out of pocket payment accounts for about 60% of the total healthcare expenditure.
• Poor Data Quality: The inaccuracy and duplicity of healthcare data are one of the major problems in Cambodia. This was also highlighted in the Country Cooperation Strategy (CCS) of Cambodia submitted to WHO as part of the IHR 2005 and HIS Master Plan 2016-20. Besides, data collection from the private sector is a difficult task which constitutes about 67% of the first treatments in Cambodia.
• Lack of Real-Time Data: Despite claiming to have integrated information technology in the health system, Cambodia follows a weekly reporting system of communicable diseases that too lacks accuracy and timeliness. In the weekly report for the week June 29 to July 7, six centers had submitted only 30 to 75.6% of the expected reports. Besides, several centers were not sending reports on time in the past as well and two could not send even a single report before the deadline.
• Electronic Health Record: Various hospital groups and agencies in the country have Electronic Medical Record (EMR) of their patients but they are not interlinked, accessible, and interoperable between hospital groups.

Cambodia’s COVID Response

Cambodia’s perceived success in combating COVID-19 is credited for its effective contact tracing and testing mechanism. The WHO report,  credits CamEWARN, national toll-free hotlines for COVID, rapid response teams (RRTs), and efficient testing.

Interestingly, CamEWARN and ILI Surveillance have also been covering diseases having similar symptoms to COVID-19 which has made experts doubt that mild COVID cases may have been counted under ‘influenza-like illness’ or other similar diseases. Given the problems of accuracy in data collection in the country, these doubts can’t be ignored completely. However, COVID-19 is also yet to be fully controlled in the country and the daily surveillance reports are not available after July 1. This raises doubts about the claims of ‘real-time data’ collection and information dissemination.

The preexisting systems of CamEWARN and ILI coupled with their previous experience of SARS and MERS may have put Cambodia and other countries of the Western Pacific region ahead to the Euro-American countries in controlling this pandemic associated with respiratory illness. Cambodia’s COVID-19 response has primarily been focused on imported cases coming through aerial routes. In pursuance to this policy, it also issued a controversial order asking tourists to deposit $3,000 as part of COVID-19 healthcare facilities including funerals which has triggered criticism from the tourism and hospitality sector. 

Conclusion and Agenda for Discussion

The World Health Organization (WHO) seems to be in a hurry to credit or discredit the health systems of its member countries. In this hurriedness, the health body seems to discredit its own standards of assessment for the healthcare management information system.

Though the pandemic is completely new for the Europe and Americas, the countries in the East and South Asia have previous experience of controlling similar outbreaks such as SARS, MERS, and influenza-like illness. Therefore, they have a better mechanism in place and their citizens are more aware of such diseases in comparison to the rest of the world. This experience gives them an added advantage in controlling cases and fatalities. However, merely the low number of COVID-19 cases in a country should not be the sole basis to prove the robustness of the healthcare management information system of a country.

Furthermore, WHO needs to develop well-defined criteria for assessing successful COVID-19 response. This is because, though Cambodia claims to have a low number of COVID-19 cases and zero deaths, various reports suggest a rise in other diseases. Estimates suggest an increase of 35% in child mortality along with other problems associated with healthcare as all the resources were put to control COVID-19. An ideal health system should follow an integrated and holistic approach to public healthcare. It should not thrive by shifting the burden of diseases across categories, regions, and age groups in the population.

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