Public Perception Survey on Transparency and Accountability in Public Healthcare

Abstract

A nationally representative survey on transparency and accountability in public healthcare in Cambodia. The survey seeks to quantify citizens’ perceptions, awareness and attitudes regarding the transparency and accountability of healthcare in Cambodia, and understand citizens’ experience in accessing healthcare in the country.

Methodology

The research follows a mixed-methods approach, combining qualitative and quantitative data collection, and reconciling primary and secondary data analyses. This is a nationally representative survey, as it has interviewed 1,596 individuals across all 25 provinces of Cambodia who were randomly selected. The survey’s findings were triangulated with findings of previous studies and interviews with some key informants in the field.

Findings

1. Public understanding of price list and fee exemption at public health facilities is low. 65% of respondents did not know that public health facilities were required to publically display their price list and fee exception and 64.5% claimed that they have not seen this information displayed. The exception were people with higher education and income levels who were more aware of this issue. In addition, 92.8% of respondents did not know that health centres were required to publically post the information regarding annual revenues and expenditures, and a large majority supported that public health facilities should post the information about its annual budgets.
2. Informal payments are seen as the most common form of corruption. Although 59.8% of respondents claimed that this was the most usual form of corruption, only 62.2% agreed that informal payments constituted corruption. Many consider informal payments necessary to guarantee a better quality of services. Of those who engaged in informal payments, 78.4% disclosed that they have offered informal payments, even in cases where healthcare providers made no such request.
3. Corruption was most likely to come from a midwife or nurse. 39.7% and 31.8 % of those who experienced malpractice at public health facilities claimed that midwives and nurses are most prone to corruption.
4. Healthcare professionals accredited to public hospitals should not be allowed to work for private practices. The majority of respondents (63.1%) believed this. The most common reasons are: “increasing absenteeism” (53.3%), “they are employees of the government” (47.1%), and “health professionals will neglect public duties” (33.3%). Of those respondents who supported public healthcare professionals to work in private practices (36.9%), 42.4% said that they can only do this after public hours, and 35.3% claimed that their engagement in private practices should not affect their performance at public health facilities or be prioritised over their public work.

Recommendations

1. Address the public knowledge gap concerning price lists and fee exemptions. Although price lists and fee exemptions are usually displayed on boards in public health facilities, most respondents are still unaware of them. In addition, illiterate people cannot read this information. The government should take initiative to make the boards more visible and raise awareness about the price lists in other ways. Patients should be informed in advance about the prices or fees charged for certain treatments or procedures.
2. Eliminate informal or unofficial payments at public health facilities. Informal payments are considered to be the best way to ensure better medical attention. Given that many people are ready to make extra payments without being asked for them, informal payments seem to be entrenched in Cambodia’s culture. Public health professionals should provide medical service with the highest standards without expecting anything in return, as stipulated in the code of conduct for health. The government should raise public awareness about the illegality of informal payments and how they constitute corruption.
3. Tackling informal and unofficial payments at the point of service delivery is very important, as midwives and nurses are perceived to be the most corrupted public healthcare providers. This perception suggests that unofficial payments at the time of birth may be very widespread, and this requires further investigation. Corruption related to birth may hit the poorest the most because they are the main users of public health services.
4. Consider reforming/introducing health policy regarding dual practice. Dual practice in the country is widespread and ubiquitous. Most people agreed that healthcare professionals accredited to public hospitals should not be allowed to work for private practices. The government should take this into serious consideration. The government should either eliminate, or at least strictly regulate, dual practice because it affects the accessibility, equity and quality of public healthcare.

Impact

The impact remains to be seen. TI-Cambodia has presented this study’s findings to other NGOs, development partners and UN agencies. TI-Cambodia will continue to push the government for changes in policy and practice based on this study’s recommendations.

Lessons Learnt

1. Conducting a survey of this scale is challenging. Mobilizing teams to collect data in 25 counties presented TI-Cambodia with various logistics issues.
2. The political landscape was not helpful. TI-Cambodia faced serious threats from the government while running the survey. In addition, the government did not give TI-Cambodia permission to conduct field data collection, although there were no requirements for this before.