As Covid-19 cases rise, healthcare systems in the most developed nations have struggled to cope. Horn Chanvoitey of Future Forum warns that Cambodia's chronically underfunded healthcare system will also be overwhelmed if an outbreak occurs

This op-ed has been written by Future Forum, an independent Cambodia-based public policy think-tank. The views in this piece do not necessarily reflect those of Southeast Asia Globe.

As Covid-19 cases continue to rise globally, the disease is set to strain public health systems in developed and developing countries alike. Soaring death tolls in countries like Spain, Italy, and Iran reveal that the systems that are currently in place around the world are not ready for this challenge. In that regard, Cambodia may have a daunting road ahead.

Much attention has been paid to the immediate impact Covid-19 is having on Cambodia’s economy. As the timeline for the crisis stretches on, the cost to Cambodia will also rise. But, we must not lose sight of an equally pressing problem – the capacity of Cambodia’s healthcare system to effectively deal with this disease.

This will be a defining moment for the country’s health institutions, which are at the moment, scrambling to gather experts and supplies.

As of writing, 114 people have officially tested positive for Covid-19 in Cambodia. Given the patterns experienced around the world, that number is expected to rise.

A large migrant workforce streaming home across the country’s borders, could serve to further exacerbate Cambodia’s outbreak. In the past weeks, as Thailand began the process of closing its borders, approximately 40,000 Cambodian workers entered Cambodia. Interior Minister Sar Kheng has admitted that the government has neither the capacity to monitor all of the returning workers, nor the ability to quarantine them for the needed 14 days.

The swiftly approaching Khmer New Year celebrations could pose an equal, if not bigger challenge in terms of virus monitoring and containment.

Much now depends on the government’s willingness and ability to pool resources to scale up the country’s testing and treatment capacity. Any further delay in this response can only mean that worse outcomes will follow.

But, the task of safeguarding people’s health rests on a public health system weakened by decades of poor planning and inadequate investment. For these reasons, Cambodia may pay a heavy price.

The first issue the country will have to reckon with is the low level of government spending on health care.

The government spent only 6.6% of the total national budget on health care in 2019, compared to 7.5% in Vietnam. In real terms, $455 million was allocated to the 2019 health care budget, a $30 million decrease from 2018.

And, any spending for this year will be further hampered by the hit the Cambodian national budget has taken since the start of this global health crisis. The government has announced that all ministries and institutions under control of the government will suffer a 50% annual budget cut, with the exception of two ministries – the Ministry for Foreign Affairs and International Cooperation and the Ministry of Commerce. The Office of Council of Ministers will also only suffer a 25% cut.

The government has not yet made it clear if the budget for the Ministry of Health will also be slashed by 50%.

Any cuts in spending would have a particularly stark impact on the underprepared and understaffed rural public hospitals, even with the $30 million the government has promised to allocate to facilitate virus screening and monitoring nationwide.

The second issue Cambodia will have to contend with is the fact that the country lacks the facilities and resources to combat the virus’ spread.

According to Cambodia’s Health Strategic Plan 2016-20, Cambodia has around 1,000 public health care facilities and 8,000 private health care facilities and providers across the country.

Perhaps one of the most serious challenges facing this country is its shortage of health professionals, doctors and nurses. Cambodia has only 1.4 health workers per 1,000 people, a level of shortage the WHO classifies as a ‘critical’

The reality is, Cambodia will not have enough Intensive Care Unit beds for critically ill patients if the number of cases soars.

Countries like Japan and China have made donations to try to address the scarcity of key materials in Cambodia. On February 16, the Japanese government donated 9,360 protective suits, 480 hand sanitisers, 540 protection glasses and 24,400 pairs of gloves.

According to a Ministry of Health press release, its Chinese counterpart donated materials including 7,000 pairs of disposable latex gloves, over 100,000 medical masks, 5,000 N95 protective masks, 5,000 disposable work hats, and more.

And then there’s the high profile donation from Jack Ma, the Chinese billionaire and founder of Alibaba, which included 1.8 million face masks and 210,000 coronavirus test kits as a gift to several countries, including Cambodia, to fight against the pandemic.

Cambodians are thankful for these donations, but the bigger problem is that this country’s hospitals are starting out at a disadvantage. They are coming at the problem with a lack of necessary knowledge, specialists and equipment to handle a Covid-19 outbreak. Therefore these donations may be far from enough if the pandemic continues to spread quickly in the Kingdom, especially given Cambodia’s insufficient health facilities in rural provinces.

But perhaps one of the most serious challenges facing this country is its shortage of health professionals, doctors and nurses. Cambodia has only 1.4 health workers per 1,000 people, a level of shortage the WHO classifies as a “critical.”

And there are no official statistics that tell us exactly how many of these health workers are lung specialists skilled in treating respiratory illnesses.

Even with the team of seven experienced Chinese doctors who came to Cambodia to share their expertise, the country is far behind in terms of the personnel needed to fight a disease like this one.

Chinese medical experts walk from a plane at Phnom Penh International Airport on March 23 as they prepare to help local authorities deal with the virus. Photo: Tang Chhin Sothy/AFP

Indeed Secretary of State at the Ministry of Health, Dr Heng Taikry, has admitted that although some hospitals, such as Phnom Penh’s Calmette, are equipped with the kind of advanced facilities like those found in Singapore, for the most part, Cambodia’s health institutions lack qualified and skilled staff to ensure a high level of treatment.

It is simply not possible for the government to transform this country’s health care system overnight.

What has the government done to prevent further spread? The Cambodian government has set up a national committee to fight against the Covid-19, headed by Prime Minister Hun Sen, which consists of several ministers, the heads of the armed forces and police, the governors of all provinces and Phnom Penh municipality, and other relevant officials.

The government has also announced it will devote $800 million for the next six months to lessen the economic repercussions from Covid-19. If the pandemic lasts for a year or more, the allocation will increase to $2 billion. This is not counting the previously mentioned $30 million that is set to be spent on screening and monitoring.

The government has also banned public gatherings, closed schools, closed some border points, as well as some businesses, including KTV, clubs, cinemas, theatres and museums. In addition, it was right to ban all religious ceremonies and only allow family gatherings during the upcoming Khmer New Year celebrations.

Although it is a traditional practice to go to the pagoda and bring offerings such as food and dessert to the monks, for the time being such gatherings should be prohibited as a preventive measure, especially considering the overcrowded inflow of Cambodian migrant workforces. Some backlash to a measure like this is to be expected. But one should remember that although Buddhism is the state’s religion, the religion should not be put above the lives of people.

In addition, in mid-March the government issued a statement to ban the entry of travellers from five countries, including the United States, France, German, Spain, and Italy for a period of 30 days, which went into effect March 17.

Recently, the Cambodian government has been in a position to make a clear signal as regards the Kingdom’s relationship with China. Although China’s outbreak of Covid-19 is under control, Cambodia’s government has recently enacted stricter inbound travel measures that apply to Chinese nationals, as well as all other kinds of travellers apart from those holding A and B tier visas.

In considering its close economic and political ties, the Royal Government of Cambodia may wish to examine the immediate implications of such a move upon bilateral support in the form of healthcare specialists and specialist Covid-19 treatment and testing equipment from China. In any case, it would be of public interest to make a statement on the support Cambodia can expect from its main economic benefactor.

What more can the government do? First, Covid-19 testing should be a priority for the government, particularly for the country’s garment workers as they are the backbone of our economy.

Given their working conditions, they are also particularly vulnerable to the spread of viruses if even one worker is infected. These workers will be among those heading home to the provinces during the Khmer New Year, which will add another layer of pressure to the effort to prevent virus’ spread.

Secondly, the government must transparently release information about any decisions it takes in the coming months, particularly regarding its preparedness, and its progress, so as to enable the public to understand more about the situation on the ground.

Given the fragility of the health care system, it would be wise for Cambodians to prepare themselves for the worst. This last suggestion goes out to all citizens and residents of the country: In the coming weeks, stay at home for yourself, your family and this country. Don’t wait for the government to lock you down.