Cambodia’s health professionals and the ASEAN Mutual Recognition Arrangements: registration, education and mobility

In 2015, the Association of South East Asian Nations (ASEAN) announced the establishment of the ASEAN Economic Community (AEC) [1], loosely modelled after the European Economic Community. The AEC was envisaged as a single market and production base, developing equitably to compete economically in the global economy. Equitable development and the free flow of trade in services and skilled labour were identified as critical to achieving this [2]. Given the extraordinary diversity across ASEAN—with economies ranging from Singapore to Myanmar—Mutual Recognition Arrangements (MRAs) were established in seven key occupations where facilitated mobility, information exchange on standards and qualifications, promotion of best practice and opportunities for capacity building and professional education were seen as prerequisites to regional development. Health was an early focus, with MRAs in nursing (2006) and medicine and dentistry (2009). However, development of the MRAs in health has been cautious: while ASEAN Joint Coordinating Committees (AJCC) have been established for each health discipline, governance remains at the member state level and regional mechanisms such as a professional registry or secretariat have not been created as with other professions [3], resulting in inconsistent implementation of the MRA process [4]. A recent scoping review of the MRAs in health provides broad insight into their implementation, though there is limited documentation of country experience available [5].

Cambodia—the last of the current 10 member states to join in 1999—illustrates both the advantages and challenges of MRA implementation. Despite its recent elevation to low-middle income status, it is clustered with Lao PDR, Myanmar and Vietnam, distinct from the six more advanced economies. With the health workforce decimated during the 1975–1979 Khmer Rouge period, and the decade of international sanctions that followed, the impact on Cambodia’s health professions is still evident [6] and shapes its response to the MRA process. The early initiatives to repopulate the health workforce saw accelerated medical education, with medical assistants and experienced nurses “upgraded”, effectively removing the cohort that could have provided mature nursing leadership [7]. The accelerated education reiterated the hospital orientation and theoretical emphasis of the French curricula of the 1970s, but initially forgoing the thesis. In the re-establishment of educational institutions, French was the preferred language of instruction complemented with Khmer, with French development assistance concentrated in the (then) Université des Sciences de la Santé (now University of Health Sciences) and the Hôpital Calmette, with Dentistry and Pharmacy faculties within the Université. Nursing and midwifery were taught through the École Centrale des Cadres Sanitaires and two regional schools, in courses of between 1 and 3 years. Non-government organisations trained a range of health professionals in border camps, and the integration of demobilised military health staff into the health system left the country with a bloated workforce of uncertain quality.

But the past 25 years have seen rapid demographic and economic transformation in the wake of political stability and international solidarity [8], with Cambodia now emerging as a middle-income economy. The health sector reforms of the late 1990s have set up the infrastructure for universal health coverage; over the life of the Millennium Development Goals, health status has measurably improved. Early experience with contracting out of District Health Services has been extended with direct government funding [9]. Health Equity Funds provide a level of protection to the marginalised. Curricula in medicine, dentistry and nursing have been revised, with nursing now commencing a 4-year Bachelor’s degree programme. Private universities teaching medicine, dentistry and nursing have recently evolved, with English assuming dominance with Khmer as the language of instruction, consistent with Cambodia’s ASEAN neighbours. The timing would appear to be optimal for Cambodia to leverage the MRAs to ensure the quality and regional recognition of its health workforce, to share resources and best practice experience and to explore the potential for capacity building and professional development. This study seeks to provide an overview of the Cambodian experience in its engagement with the ASEAN MRAs in medicine, dentistry and nursing and to analyse its influence on Cambodian registration, education and mobility of health personnel.

This research case study used qualitative research methods combining literature review with key informant interviews to examine the interface between the ASEAN MRAs and the registration of health professionals (doctors, dentists and nurses) in Cambodia, their education and mobility within the region.

Participants were contacted directly by phone or email and provided with an information sheet and consent form in English and Khmer, with written consent prior to interview. Interviews were conducted face to face at a location nominated by the interviewee, usually their place of work, but in three cases, in cafes, one interview was conducted by skype. Participation was voluntary, and participants were advised that they could withdraw at any point and that any information provided would be de-identified prior to publication. The interviews were conducted in English or Khmer and recorded, translated and transcribed for analysis. Three a priori themes were identified by the authors from the research proposal: health professionals’ registration, health professionals’ education and curricula and mobility of health professionals (Fig. 1). Given the limited number of interviews, KL coded the papers manually using a combination of a priori sub-themes from the literature review, and emergent themes arising from the analysis of the interviews. Findings from the narrative literature review and the interviews have been integrated in the presentation of the results [11].

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.

Cambodia finds itself undergoing a series of rapid transitions: substantial demographic and economic growth since its emergence from the Khmer Rouge genocide and subsequent sanctions; increasing health status grounded in comprehensive health systems reform; and educational opportunity enabled by a shift towards increasing English usage and burgeoning private sector.

These changes have been accompanied by increasing regional engagement, though there is caution, particularly within the MoH. This is grounded in concerns around retaining its limited but hard-won local capacity, Cambodia’s vulnerability to its economically aggressive neighbours and the potential for increasing migration as standards become regionally recognised. The outcome is a tension between a conservative and hierarchical public sector and entrepreneurial innovation in the emerging but poorly regulated private sector. With health education now a shared responsibility of the MoEYS and MoH, the result is the application of a series of compensatory initiatives that seek to compensate for the irregular baseline of secondary schooling, and tertiary educational standards, and the lack of adequate enforcement of regulation. Hence, the curricula duration for medicine and dentistry is longer than regional counterparts, though it does not clearly result in equivalent outcomes. Entrance and exit examinations have been introduced because of inconsistencies in secondary schooling and unreliable institutional assessments. Nursing and midwifery education attempts to address both local need and regional demands, with limited technical or financial support. The desire to meet regional expectations in the long term is in tension with MRA guidelines in the short term: MRA acts as an international benchmark but its potential to drive internal change does not seem to have been strategically adopted. While the formal channels for regional mobility are slowly operationalised, informal processes ahead are rapidly emerging, and progress against MRA standards designed to increase inter-ASEAN mobility proceeds slowly, in contrast to poorly documented but increasing mobility beyond the ASEAN region.