Evaluation of Immunization Knowledge, Practices, and Service-Delivery in the Private Sector in Cambodia

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ABSTRACT

A study of private-sector immunization services was undertaken to assess scope of practice and quality of care and to identify opportunities for the development of models of collaboration between the public and the private health sector. A questionnaire survey was conducted with health providers at 127 private facilities; clinical practices were directly observed; and a policy forum was held for government representatives, private healthcare providers, and international partners. In terms of prevalence of private-sector provision of immunization services, 93% of the private inpatient clinics surveyed provided immunization services. The private sector demonstrated a lack of quality of care and management in terms of health workers' knowledge of immunization schedules, waste and vaccine management practices, and exchange of health information with the public sector. Policy and operational guidelines are required for private-sector immunization practices that address critical subject areas, such as setting of standards, capacity-building, public-sector monitoring, and exchange of health information between the public and the private sector. Such public/private collaborations will keep pace with the trends towards the development of private-sector provision of health services in developing countries.

Key words: Evaluation studies; Health services; Health-sector reforms; Health systems; Immunization; Private sector; Quality of care; Standards; Cambodia

INTRODUCTION

In 1993, Cambodia (population 14 million) emerged from a lengthy period of civil conflict that ended when United Nations-sponsored general elections were held. Since then, the country has entered an era of economic and social development. Significant developments occurred within the two main social sectors of health and education. Health-sector reform, begun in 1996, led to the establishment of national health institutions, 24 provincial health departments, 76 operational health districts, and more than 930 health centres, most of which serve the rural communities that comprise 80% of the country's total population. As a result of the developing market economy and rapid urbanization, a professional private health sector emerged in the middle of the 1990s with a range of studies indicating that it is expanding at a rapid rate (1,2). Today, two-thirds of the population turn first to the private sector or non-medical sector for medical care (3).

Established in 1986 with the technical assistance of the United Nations Children's Fund (UNICEF), the National Immunization Program (NIP) manages the immunization of an annual cohort of 372,000 infants aged less than one year (2006) against seven diseases and also against tetanus for women of childbearing age. Demographic health surveys conducted in 2000 and 2005 have seen a rise in immunization coverage rate of diphtheria, pertussis and tetanus vaccine (DPT3) in children aged 12 months. The rates of coverage have increased from 43% in 2000 to 76% in 2005, with associated sharp declines in reported vaccine-preventable diseases (3). Cases of neonatal tetanus have reduced from 169 in 2002 to 68 in 2005 (decline in incidence from 0.05 to 0.02 per 1,000 births). Suspected cases of measles have been reduced from 3,640 in 2001 to 264 in 2005 (decline in incidence from 289 to 19 per million population), and the coverage of measles immunization has increased from 41% in 2000 to 70% in 2005. This programme is administered through the state health system, with most service-delivery taking place at the primary-level health centres through outreach services to the 13,000 villages of Cambodia.

A wide definition of the private sector can be des- cribed as "comprising all providers who exist outside the public sector, whether their aim is philanthropic or commercial" (4). For the purpose of the collaboration discussed in this paper, the private sector is referred to as the private, for-profit medical and professional health sector. …