Although Cambodia has progressively improved some health outcomes and health care services have become more available to the general population during the past decade, the accessibility and low utilization of public health care services remain a problem for most of the Cambodian poor population.

There are various factors contributing to this failure. Those factors could be a lack of interaction mechanisms between providers and clients; clients know little about the availability of health services; clients do not know the working hours of health providers; unfriendly, unethical and uncaring attitude of health providers, unofficial and unpredictable payment for health care which are widespread in the whole health care system of Cambodia; clients do not understand their rights to health care and as well as the providers’ rights-duties; and most importantly, people do not have the proper opportunities to raise their health concerns to health providers, local health decision makers at the operational level or policy makers. All these issues create an unpleasant environment at public health facilities and most people perceive that the public health facilities are not the right place for them to seek health care when they become ill.

MEDiCAM believes that some of the above mentioned issues could be resolved at the local operational health system through Community Health Forum which can bring together for faceto- face dialogue between services providers and clients.

With the support of DFID through Healthlink Worldwide, MEDiCAM has so far conducted two Community Health Fora (CHF) in Battambag province. The first CHF was conducted on 17 November 2008 at Sangkeo Operational district and the second on 16 December, 2008 at Battambang Operational District. The CHF aims to increase communication between the service providers and clients, promote understanding of Client’s Rights and Provider’s Rights-Duties and promote understanding between service providers and clients to improve the operational health system. The forum was held in close collaboration with Battambang Provincial Health Department and NGOs partners who are working in the above mentioned ODs. During the preparation and organization of the CHF in Sangke OD, eight NGOs including MPK, AS, RHAC, TPO, EOC, BFD, CHED and SCC, operating their programs in the Sangkoe OD, and eleven other NGOs , including MPK,BFD,WVC, CCN,KNT, KAWP, TTA,AS, CHED, ILDO, and MHSS, operating their programs in Battambang OD, were actively cooperating to make the two forums happen.

Each forum brought about 500- 600 participants including villagers, VHSGs, HCMCs, commune council, district governor, teachers, students and monks, health service providers and local authority from the above mentioned ODs, the director of the provincial health department, operational district director, hospital director and chief of health centers, NGOs, health partner representatives, media agencies, and relevant health department of MoH (National Center for Health Promotion). The forum offered the opportunity for community and service providers to interact with their perspectives as users and as providers. The discussion panel includes (1) PHD director,(2) hospital director, (3) OD director, (4) health center chief (5) district governor, (6) commune council, (8) MEDiCAM Executive director, and (9) CBO representative. The discussion was facilitated by Dr. Sin Somuny, Executive Director of MEDiCAM. Prior to the debate, Dr. Heng Lim Try, Deputy Director of National Health for Health Promotion (NCHP) introduced and explained the client’s rights and providers’ rights-duty to the audience. Dr. Lim Try told them that they have the (1) Right to equality, and to be free from all forms of discrimination, (2) Right to Information and Health Education, (3) Right to health care and treatment, (4) Right to confidentiality, (5) Right to privacy, (6) Right to choice and informed consent, and (7) Right to express opinion and to participation.

The providers’ right-duties were also explained. He mentioned that providers also have their own rights in providing health care service to clients. Those rights include (1) Right and Duties to ask and to receive information according to medical techniques, (2) Rights and Duties to provide health care and treatment, (3) Rights and Duties in confidentiality, (4) Rights and Duties to decide on intervention. The community members have carefully listened about their rights and providers’ rights-duties.

After the session on consumers’ rights and providers’ right-duties, Dr. Sin Somuny opened the floor for questions and answers by mentioning that this forum is for you to please ask questions and complain about anything you may have encountered in your experience using the public system. He encouraged the audience that this is a very safe environment for all of us to speak out to our panelists who are the medical professionals, medical leaders, local authority representatives, and our CBO representatives. Without having to waste more time, the courageous community members stood up and asked several questions for the panel to respond. The following description captures some key points from the discussion.

Question from a participant: “My name is Seang Phalla, from Prek Chhdoa village, Peam Ek commune. I just learnt from the speaker that clients have rights to equality, and are free from all forms of discrimination, but the health care providers pay more attention only to the rich clients. For example, I recalled that one day I referred a pregnant woman from my village to deliver her baby at the provincial referral hospital and she was admitted to stay on the floor of the hospital’s temporary waiting room for three days without any attention from the health care providers. The next day the woman delivered her baby on the floor”. “Can you explain why the health providers in BTB RH did that and what should you do to solve it”, she asked.

Response from the panel: The Provincial Heath Department (PHD) and Hospital Directors admitted the health care service providers’ ignorance and accepted those complaints raised by the community and they finally commited to resolve the matters for further improvement.

Question from a participant: “I would like to learn on TB treatment policy. Do clients have to pay for TB treatment?”, one participant asked.

Response from the panel: “Based on the National Policy, TB treatment is free of charge. Moreover, TB patients are provided with additional food during the course of treatment”, the speakers explained.

Question from a participant: “I am from Kompong Chlaong village. I would like to share my experience with hospital service. One day I brought my child to the hospital for high fever. I was charged 150,000 riels (about US$ 47) for one night hospitalization of my child. I begged to pay only 70,000 riels, but they denied my request”.

Response from the panel: The hospital Directors explained that the fee for emergency service is correctly mentioned by the participant, but there is an exemption system and flexible rates for the poor. He promised to improve the hospital management system to ensure that the poor will either receive equity fund or be exempted from user fees.

Community raised the issues regarding the poor referral system and they proposed for further improvement:

Response from the panel: PHD Director informed that Battambang PHD will receive 13 Ambulances from the government. These Ambulances will be distributed to all ODs for referring patients from their respective ODs to Provincial Referral Hospital. However, the referral systems from the community to the health centers remain problematic with further arrangements need to be made with full participation from the community.

Comments from participants: the community members proposed that health providers provide services firstly according to what they need , and not according to what they have the ability to pay. “Survival first, and money later”. Public providers always think money first—no money, no service.

Response from the panel: PHD and Hospital Director agreed to accept the community’s complaints and promised for further discussion at the Hospital Management Committee.

Question for a participant: “Why health care providers and doctors at the referral hospitals did not want to provide good health care services at the facility?, the community asked, adding that maybe because they often tried to bring patients with them to their private clinics. If they continue doing so, how can we improve the health service utilization at the public health facility?”.

Response from the panel: Hospital Director agreed on the issues raised by the community. He admitted that the issues have occurred almost at every public hospital. Some health providers poach the patients from the public health facility to their private clinics. To deal with the issues, PHD and Hospital Directors explained that this is the issue which requires higher policy change about dual practice.

Question from a participant: “I am from Svay Por commune. I have a question. Why do the health centers have different charge rates for user fee?” e.g. Svay Por health center charges 2000 riels for consultation, whilst others charge only 500 – 1000 riels.

Response from the panel: The Chief of Svay Por Health Centre explained that according to the National Charter on Health Financing of the Ministry of Health (MoH), the public health facilities are allowed to charge for

services. However, the rates have been specially adapted for the living condition of the people. The rates of 2000 riels, which has been applied in Svay Por Health Center, were fully consulted with the Health Center Management Committee (HCMC). He also said that most incomes from the user fees are used to purchase additional drugs and supplies due to miss-match between demand and supply.

Question from a participant: “I am a VHSG (Village Health Support Group) member. I suggest that the Ministry of Health (MoH) set up a support policy or incentive scheme for us (e.g. free health care service or reward)”.

Response from the panel: responding to this proposal, OD Director emphasized that the VHSG members would be given health care services at the health centers and at the referral hospitals free of charge, including other incentives. “In addition, this needs to be further discussed at the higher level”, he added. These are just some examples of the discussions which have been raised by the community and the responses from the providers. If you prefer to listen to more details of the community health forums, please obtain a copy of CD or DVD from MEDiCAM or go to MEDiCAM’s website (available soon.)

Dr. Nhek Bun Chob, PHD director of Battambang, during the interview with the media (right after the forum), felt excited about the forum because he said: “the forum has provided a great opportunity for both consumers (the community) and supplier (Operational Health System) to get

better understanding. Communities have an opportunity to complain about the health care services they receive and we (the suppliers) can explain to them what our constraints are. There are also areas of misunderstandings which have been clarified such as the free treatment of TB, HIV/AIDS, the exemption for the poor, and the equity fund”. He said “our long-term and sustainable development must start from understanding each other. This forum is a good start and we need to do more at the health center and at the hospital level”.

In summary, he said that the Community Health Forum has resolved (1) some good practical solutions to the communities, (2) the community understands the client’s rights and providers’ rights-duties, (3) improved understanding between clients and services providers, (4) increased inter- action between clients and providers, and (5) collecting communities’ voice to influence policy changes for better health care in Cambodia.