In 2016, the Cambodian MoH released its third Health Workforce Development Plan . It dealt with the key issues addressed by the MRA—concerns with education standards, the quality of education and appropriate clinical exposure and the challenges with regulating a growing and diverse health workforce—but without specific reference to ASEAN processes. But Cambodia’s ASEAN neighbours remain an immediate frame of reference—with Thailand and Vietnam (#005) and the Philippines (#012) providing relevant benchmarks:
Most of them, when they start to develop their guidelines will… look across – particularly across ASEAN in the first instance and across the region. (#002)
Despite ASEAN’s colonial, cultural, ethnic and economic diversity, the two decades since Cambodia’s admission in 1999 have been characterised by increasing convergence: transitioning economically from post-conflict donor-dependence to middle-income status, engaging increasingly with regional development partners (especially Japan, Korea, China) and reorienting from French towards ASEAN’s preference for English in education, diplomacy and commerce. In this, the Cambodian MoH has been a lead ministry in terms of internal reform, and potentially in international developments.
Registration in Cambodia and the MRAs
With the universities—including the flagship University of Health Sciences—now accountable to the Ministry of Education, Youth and Sport (MoEYS), and the introduction of the new law on Regulation of Health Practitioners in late 2016, responsibility for registration is a shared responsibility between MoEYS and MoH. The five professional councils set the Scope of Practice for their profession and propose competencies for graduates: Medical Council of Cambodia (MCC), Dental Council of Cambodia (DCC), Cambodian Midwives Council (CMC), Cambodian Council of Nurses (CCN) and Pharmacy Council of Cambodia (PCC) . Maintaining independence is difficult, given the multiple roles played by some key actors across agencies:
…there’s been huge difficulty in separating the difference between a regulator and an association that advocates for the health profession… Nursing and medicine are the two that are struggling the most to separate council and professional association. (#002)
The MRAs currently include medicine, dentistry and nursing: there is no separate MRA for midwifery. Compliance with the MRAs in terms of registration is an acknowledged goal:
We’ve tried to align more with Asia than with the West for the reasons you’d expect, because it’s the region in which they’ll operate and work. So, registration, license to practice are a model for the region... (#002)
But while the values implicit in the MRAs are shared, the specific mechanisms of professional registration appear driven by internal histories and local commitment to improve standards, rather than a strategic use of the MRAs to drive reform from outside. The 2016 law on the Regulation of Health Practitioners makes registration compulsory for doctors, dentists and nurses, though registration of medical practitioners does not currently differentiate specialist practitioners. Awareness of the new requirement is high:
Recently we all hear about registration. Everybody had to register. Every profession, nurse, midwife, medical doctor, everybody had to be registered with their actual council. (#013)
Despite severe sanctions of up to 2 years imprisonment and US$2500 fines for failure to meet the requirements of registration [13, 14], enforcement mechanisms are inadequately resourced. Continuing Professional Development (CPD) is a requirement for ongoing licence renewal for all health professionals, but also is being used by both medicine and dentistry as an incentive for promoting registration to existing practitioners. The introduction of CPD is also consistent with MRA requirements.
Medicine used it as a mechanism to drive registration. Because people were saying what’s in it for me, why would I get registered, why would I want to be a member of a council? So, they have been going around the country running CPD sessions. Now that’s been quite successful. (#002)
The Dental Association has a meeting every year with overseas speakers, plus some local speakers, and these are inexpensive, with lots of sponsorship from companies that help support it, you see. And then the Dental Council has another conference later in the year, and there’s a lot of short courses in various areas, like implants or orthodontics. There’s a lot offered with visiting overseas speakers and so on. So for dentists, there’s lots of opportunities for continuing education. (#011)
The Nursing Council has been less successful in establishing CPD, given the lower incomes of their members, and limited donor or commercial support, but the recently created Nursing Midwifery Education Society of Cambodia, an active, voluntary initiative of 30 internationally trained graduate nurses, is offering biannual seminars:
This is the association that we provided. We would like to support our society—we promote nursing promotion. Our vision is to train nurses. Every year we have two seminars conducted by this group. (#006)
Health professional education in Cambodia and the MRAs
Within the expanding education sector, the Accreditation Council of Cambodia (ACC), reporting to the MoEYS and MoH, accredits public and private education of health professionals, focusing on the foundation year programme and the quality of higher education institutions . At review, its procedures were considered adequate, though clinical competence is not assessed in accreditation:
the documentation is very good, you know; it’s very similar, from what I’ve seen, to other accreditation processes overseas. (#011)
Education for doctors and dentists and degree courses for nurses are concentrated in the capital, with a strong hospital focus and limited clinical placements. To safeguard clinical standards, the MoH retains a direct interest. For medicine and dentistry, this has resulted in curricula longer than those of their ASEAN counterparts: “an eight year program for a medical doctor,” (#005; #008) when
many countries like even Malaysia, Singapore, and Australia and New Zealand, all of them, they have very short programs. (#004)
Concerns over clinical standards at registration have seen the introduction of national entry and exit examinations for medicine, dentistry and degree students in nursing, in addition to university certification. The National Exit Examination is managed by the National Examination Committee, chaired by the Council of Ministers with members from MoH, MoEYS, ACC and all public and private education institutions. It comprises both multiple choice and objective structured clinical examination (OSCE) and is required for registration. The heavy resource demands saw the OSCE suspended in 2017, amid concerns among regulators: “multiple choice questions cannot test the student competence—we need OSCEs.” (#008).
Despite requests for curriculum review that would shorten both medical and dentistry curricula, the MoH has remained conservative, concerned that clinical standards not be further risked, with review committees proceeding cautiously. A shared mandatory Foundation Year for all health professional students seeks to redress uneven secondary schooling and establish a common platform for the health workforce, but lengthens overall course length. Policy and review processes appear to be aware of MRA standards, but direct application has proved difficult to achieve with current resources:
We discuss the ASEAN full competency for a professional framework… We sit together, but before that they, every country select their own competency and then we… make the framework for ASEAN countries, for the 10 countries and we’re clear on that we have 5 domains… but each of the domains must be determined by the context of the country. (#012)
The core competencies we’ve developed are a little bit high and… still too low to compare with other countries. (#012)
Q. Was the MRA taken into consideration when designing your first draft?
A. Maybe no. I have no idea of these things. (#013)
Within the university sector, curriculum exploration is proceeding independently: the University of Health Sciences offers an international programme, with intensive courses in English and French and exposure to international academics ; the private dental schools are in dialogue with regional partners—though not through MRA mechanisms—seeking to secure MOH action to review their 7-year programme:
The review came about, actually, because we wrote a letter to the Ministry and we asked for a review of the curriculum, so they set up a technical working group and invited members from each university to be in that group and so it is under them; it is their group, and it’s their review. (#011)
Nursing faces particular issues in complying with the MRAs. With the additional mandatory Foundation Year, the 4-year degree course is effectively 3 years—a year less than the ASEAN 4-year degree standard. International cooperation is increasingly supporting nursing with strategies to bridge the MRA requirements, with the Japanese International Cooperation Agency (JICA) funding senior 30 nurses to complete their Bachelor’s degree in Thailand, providing a small but critical mass of experienced and ASEAN standard qualified nurses. The impact of this initiative has been reflected in increased activity through the Nursing Midwifery Education Society of Cambodia, but there is an emerging tension between mature diploma-trained nurses and the emerging cohort of degree qualified, but as yet less experienced graduates. The Korean International Cooperation Agency has supported bridging course to upgrade nurses, but is “only training the lecturers first”, (#006) as faculty staff are themselves mostly 3-year diploma-trained.
Although nursing education within the capital is delivered through the universities, “the regional training sectors work directly through to the ministry.” (#007). This ambiguous positioning of regional nursing education compounds the impact of the hierarchy of professions and institutions—with medicine dominating, followed by pharmacy and then dentistry, with nursing and midwifery education only recently being upgraded to university degree programmes.
Faced with the challenges of high maternal and neonatal mortality, Cambodia has launched a package of successful interventions , among them the introduction of the Associate Degree in Midwifery, with a degree programme in preparation . However, in contrast to other ASEAN states where nursing includes midwifery, in Cambodia, midwifery and nursing have discrete pre-service education and two separate professional councils. This misalignment excludes midwifery from the MRA framework, with little obvious political leverage for change (#002).
In all health disciplines, the rise of the private sector has resulted in a surplus of graduates and uncertain standards on completion of education, with the National Exit Examination and further public service entry examinations used to control entry into the public sector. In nursing, in particular, there is an excess of graduates, but with little impact on the staffing deficits in rural Cambodia and no regional recognition of their qualifications:
Cambodia has a surplus of nurses at the moment with the proliferation of schools of nursing, and the number of graduates was huge over the last few years. I haven’t seen a massive exodus. (#002)
Cambodian health professionals, the MRAs and mobility
Within ASEAN as a whole, there is no record of physicians or dentists relocating under the MRA provisions . For nursing, mobility within ASEAN is more apparent, though no instances of Cambodian migration recorded , but current ASEAN health workforce migration patterns are primarily to non-ASEAN countries for all groups . Interviews suggested that for doctors and medical students, institutional and personal links provided the basis for most (temporary) international placements—with stages in French hospitals relatively unique in offering clinical practice experience. Anecdotally, securing international qualifications enhances this possibility, as happened with JICA sponsored bridging course for nurses: “I’ve seen some invitations to me to join—to work in that hospital in Thailand” (#006). But more common is international recruitment to positions below their Cambodian status:
I heard that they are not allowed to provide direct care to the patients. They just go to assist the nurses in Thailand. (#006)
The growth of medical tourism, with private entrepreneurship in transnational provision of health care, may feed a trend towards regional mobility, recruiting Cambodians to facilitate communication with Khmer clients. In Phnom Penh, international clinics and hospitals import clinical staff—with varying degrees of compliance regarding local registration:
The new law says welcome to the real world. Everybody gets registered, everyone who needs to practice, wants to practice, has to have a license... (#002)
So every foreign nurse has to have a licence, a valid licence from the host country... the diploma, an official translation by the embassy, and also the higher level degree, but I think… nobody respects that... (#012)
We have a lot of foreign owned hospitals and health facilities and they are totally ignorant… ‘we’re better’ and therefore we don’t need to be registered in accordance with the law in this country… (#002)
But the increasing shift towards English as a primary language of instruction, economic growth and the increasing regional engagement in education are key enablers for regional and international mobility.