Cambodia: Second Health Sector Support Project

Cambodia: Second Health Sector Support Project

Social Assessment. March 2008.

IPP278 v.2 rev.

Cambodia: Second Health Sector Support Project

Social Assessment

March 28, 2008

The Second Health Sector Support Project (HSSP2) development objective is to support the Royal Government of Cambodia’s Health Strategic Plan strategies to improve access to, and utilization of effective, efficient and quality health services to improve the health status of the Cambodia population. The Project’s focus on improved and equitable access to essential quality health care is expected to have a positive impact on vulnerable groups (such as ethnic minorities) women and children, and on poorer households in general.

A social assessment was done as part of Project preparation for the First Health Sector Support Project (HSSP1). The current document updates the previous social assessment, aligning it with HSSP2’s objectives and strategies. This updated social assessment takes into account consultations with stakeholders; recent analytical work on equity, gender issues and ethnic minorities; evaluations and monitoring of HSSP1; and analytical work commissioned for HSSP1. Specifically, the updated social assessment looks at key social issues pertaining to health in Cambodia, discusses development inputs to project preparation, and describes how the project design addresses social issues.

i. Introduction

Considerable progress has been made in poverty reduction and economic growth.

Cambodia has made considerable progress in terms of both economic growth and poverty reduction in the one-and-a-half decade since the Paris Peace Accords of 1991. Between the household survey in 1993/4 and the most recent in 2004, poverty fell by around a quarter (from around 47 percent in 1993/4 to 35 percent in 2004). Quality of housing, ownership of consumer goods and access to electricity have also improved, including amongst the poorest fifth of the population.

Improvements are also seen in terms of non-monetary aspects of welfare.[1]When data from the 2005 Cambodia Demographic and Health Survey (CDHS) is compared to data from the 2000 CHDS, it is clear that considerable progress has been made over a five-year span. Health service coverage and child survival outcomes have increased dramatically, for example, deliveries at health facilities more than doubled from 10 percent in 2000 to 22 percent in 2005, and the antenatal care coverage increased from 38 percent in 200 to 69 percent in 2005.[2] The rise in HIV/AIDS has been contained and reversed; and primary school enrolment has expanded rapidly.

But despite impressive progress, several challenges persist.

Despite impressive progress, however, several challenges persist and new ones are emerging. The health status of Cambodians remains below that of their more prosperous neighbors in Thailand, Malaysia, andIndonesia. Cambodia is number 131 out of 177 on the Human Development Index,[3] after neighboring countries such as Vietnam and Lao PDR[4], but just before Myanmar (132). Challenges persist in particular in terms of high maternal mortality rates, slow progress in reducing malnutrition, in the quality and affordability of the care, and in terms of inequity in access to health services:

Maternal mortality remains unacceptable high:

• At 473 per 100,000 live births maternal mortality remains at unacceptable high level, and has notdecreased since 2000.
• While improving, overall levels of safe deliveries remain low and findings vary significantly by geographic location, education level and income.

The low nutritional status of women and boys is a growing concern:

• The percentage of women who are stunted increased from 5.5 percent in 2000 to 7.7 percent in 2005; female anemia remains widespread with 47 percent of women classified as anemic in 2005.[5]

• Although the nutritional status of children showed moderate improvements between 2000 and 2005, overall levels of anemia (62 percent), stunting (37 percent) and wasting (7 percent) remain high, with higher rates for boys than girls in 2005.[6]

Financial and quality barriers are persistent:

• There are considerable financial barriers to essential services (an estimated 70 percent of total per capita health expenditure of US$36 is funded out-of-pocket). These barriers are particularly difficult for poor and vulnerable households.
• Limited physical access and poor quality of health care, offering low-value for money, result in a low proportion of the people using government provided health services; only 17 percent of the people who fall ill and use health services actually rely on government systems.

Inequity in access to services and resulting health based opportunities do still vary considerable:

• The life chances of a child born into the poorest quintile are significantly reduced even before birth, compared to a child born into the richest quintile, his or her mother is four times more likely to have gone without any contact with antenatal care.
• A child born into the poorest quintile is then over twice as likely to suffer from severe malnutrition; and three times as likely to die before reaching their fifth birthday.[7]

ii. Key Social Issues Pertaining to Health in Cambodia

Growth has been unevenly distributed and there are significant differences between urban and rural populations and rich and poor households’ access to health services and outcomes.

While the country’s economic growth is impressive, the benefits of this growth have been unevenly distributed. In 2004, the living standards of the poorest fifth in the population were only 8 percent higher than they were a decade earlier; over this same period, the living standards of the richest fifth rose five times as fast (45 percent). Similarly, rural living standards rose more slowly than those in Phnom Penh and other urban centers. The result has been a rise in the Gini coefficient, from 0.35 in 1993/4 to 0.40 in 2004.[8] On the Human Poverty Index, Cambodia’s ranking in 2007/08 is 85 among 108 developing countries.[9]

The rise in total inequality in Cambodia can be attributed primarily to widening differences in standards of living in the countryside. But in rural areas, the rich initially made rapid gains while others lagged; later, improvements were spread more evenly across the population.

Table 1: Greater poverty in remote villages with less connectivity

Village size / Distance to the nearest all-weather road
Less than 5km More than 5 km
More than 1,000 persons / 33% population are poor / 38% population are poor
Less than 1,000 persons / 43% population are poor / 53% population are poor

Source: SESC 1993/4, CSES 2004

With public spending on health too low to play an effective compensatory role, an individual’s access to quality healthcare closely tracks his of her level of income, savings and consumption. And poorer households – who tend to be located in remote areas – invariable have less access to health services and outcome. Consequently, chronic and catastrophic illness is a major cause of indebtedness, asset sales and impoverishment.[10]Studies have found that half of all distress sales, or around 40 percent of cases of once-landowning families losing land, involved health crises.[11]

Women and men have different health needs and face different challenges.

Women and men face different health problems, for example, men are twice as likely as women to suffer from injuries, accidents or physical impairment, and are more prone to engage in risk-behaviors. Men are also more likely to experience public violence from male gang members, peers, and authorities. Women are more likely to experience sexual violence and assault, including in particular domestic violence from men. Women also have a very high risk of illness or death due to pregnancy and childbearing.

Several key indicators for women’s health have shown improvement, such as contraceptive prevalence, a reduction in unmet need for family planning, improved access to antenatal care, and more deliveries by trained professionals and in health facilities. However, the maternal mortality ratio remains at unacceptably high rates and highlights the importance of continuing the efforts to upgrade both the accessibility and the quality of health services, particularly reproductive health services.

In many cases, women’s bargaining power within the household about decisions about her health is weak and there is a need to both raise awareness and empower women in making informed decisions affecting her (and her family’s) health needs. Due to cultural and gender norms it is still common that men play a dominant role in making decisions affecting women’s sexual and reproductive health, as well as child survival. In most cases, such behaviors are the result of lack of awareness and understanding of how men’s roles can be re-oriented more usefully towards equitable individual and social development goals.

Low nutritional status among women and boys is a growing concern.Moreover, the reproductive health of Cambodia’s sizable youth population is an emerging issue. Young people in general, and young men in particular, are engaging in high-risk sexual behavior with weak knowledge of the risks.

Ethnic minorities tend to be particularly vulnerable to poor health and poverty.

Ethnic minorities face particular challenges in accessing health serves and tend to be particularly vulnerable to poor health. Many minority groups live in rough-terrain highland and border areas that are hard to reach and generally poorer than average. The sheer physical geography of these settings pose special challenges, as well as costs, in terms of accessing, providing and maintaining health care services. Geographic isolation coupled with language and cultural barriers, and generally poorer human development indicators, make reaching these groups a particular challenge.

The Cambodian Government recognizes the Hill Tribes and the Khmer Cham as Cambodian minorities. The Hill Tribes are mainly concentrated in the north eastern provinces, where they comprise the majority of the population in both Rattanak Kiri (66%) and Mondol Kiri (75%) and less than 10% in the adjoining provinces of Kratie and Stung Treng. The Cham, who speak Khmer, constitute about half of the ethnic minority groups and are widely distributed throughout the country.The Cambodian definition of ethnic minorities does not include Vietnamese, Chinese and other groups who are considered “migrants” even though they have lived in Cambodia for generations. With a wider definition of “ethnic” groups also including Cham, Lao, Vietnamese and Chinese, the proportion of ethnic minorities is approximately 6%.Many of the Vietnamese are fishermen living along the rivers and on the Tonle SapLake, while artisans and traders are found in all large towns.

The hill tribes in Mondol Kiri and Rattanak Kiri are among the poorest groups in the country.[12] Literacy rates in these provinces are less than one third of the national average. Women are even less likely to be literate and speak Khmer. This creates extra barriers for women,who have a high need for reproductive health, birth-spacing and child health services. Furthermore, infant and child mortality are particularly high in the easternmost region of the country. The percentage of infants reported smaller than average is 26.6 percent in Mondol Kiri and Rattanak Kiricompared to 14.5 percent as the nationas a whole.[13]

In general, health indicators for ethnic minorities are low compared to the rest of the country, although it is difficult to develop an accurate understanding of health status as Cambodia does not collect disaggregated data by ethnicity. Statistics on ethnic groups are scare and mainly based on estimates.[14]

Key constraints identified by ethnic minorities in accessing health care include:[15]

• Poor physical access to health services: Only a third of Cambodians live within 10 km or a two-hour walk of a public health centre. The situation is worse in the remote northeast areas, home to many ethnic minorities, where the population is relatively small but dispersed over a large area.Many minority groups live in remote highland areas with rough-terrain highland which makes both access and provision of health services challenging. According to the most recent Health and Demographic survey, rural women are more than twice as likely to deliver at home, compared to women in urban areas.[16]
• Costs are unaffordable: High out of-pocket expenses are for many Cambodians unaffordable and impoverishing. Given that poverty rates tend to be high among ethnic minorities, costs are particularly unaffordable for these groups. As health costs can be large and unforeseen expenses, many families find they do not have enough money to pay for the care they need.[17]
• Health workers absent from facilities and poor quality services: Absent health workers, limited opening hours and generally poor quality services make health facilities a less desirable option, offering low-value for money and wastes scare household resources.
• Health workers are not from local communities: In cases when health workers are not from the local communities, language can become an issue as different ethnic groups speak different languages and thus have a hard timecommunicating. Also, cultural difference may reduce trust in the health workers and the health workers may have a weak understanding of the communities’ cultural norms and practices, and vice versa.
• Lack of participation in health development: Limited indigenous community participation in designing and making decisions about health care, may result in the health care offered not fully reflecting the communities’ needs, and limit the communities’ ownership of the health services being offered.

Many of the above constraints are relevant not only to ethnic minorities but to poor women and men in general. For ethnic minorities, however, languages barriers, cultural difference, and in some cases discrimination towards minority groups further compound access.

Demand for health services are also related to socio-cultural influences.

Research in Cambodia consistently shows a high reliance on self-medication.[18] Such health seeking behavior is rooted in traditional belief systems about the disease, limited knowledge of modern health care and how it works, and a resulting train-and-error approach to treating illness.[19] Beliefs about the connections between the spirit world, magic, sorcery and illness, disease and healing tend to be particularly wide-spread among ethnic minorities in Cambodia and the Greater Mekong Sub-region in general.[20] These socio-cultural influences have an impact on the demand for health care.

Community participation in health service delivery and management is limited but decentralization presents an opportunity for increase participation and accountability.

Accountability of public institutions and public servants is weak and institutional mechanisms to promote transparency are still in their infancy. Social capital in Cambodia has been severely fractured by war and genocide. In general, civil society is not well organized. On the Government’s side there is also limited capacity to respond to and effectively engage with the community and civil society.

Decentralization, however, presents an opportunity to increase local accountability and the election of Commune Councils is a positive step. In the most recent Commune Council election in 2007, more citizens stood as candidates than in any other election in Cambodian electoral history. The elections were a significant improvement over Cambodia’s first local elections held in 2002, and there was a considerable decrease in the level of violence and intimidation during the election period. At the same time, the Government is keen to increase people’s participation through decentralization and de-concentration of services, and towards this has been working on the Organic law which is hoped to be tabled before elections this year.

iii. Social Development Inputs to Project Preparation

The project builds on the first Health Sector Support Project, and further draws on the experiences of the donors financing HSSP1 and 2, including the UK Department for International Development, AusAid, the World Bank, and the Asian Development Bank, as well as other donors, UN agencies and NGOs engaged in the health sector in Cambodia. The design is fully consistent with and supportive of the Government’s Health Strategic Plan (2008-2015).[21]

Project preparation included the participation of a social development consultant/senior gender specialist. A social assessment was conducted for the first phase of the Health Sector Support Project. An Ethnic Minorities Development Strategy (EMDS) and Framework for Land Acquisition Policy and Procedures were also prepared for HSSP1 to address ethnic minority and resettlement issues respectively. These documents have been updated for the Second Health Sector Support Project to reflect HSSP2 ’s focus, as well as current Cambodian laws and regulations and current World Bank safeguards policies.[22]In terms of the EMDS, it has been developed into an Indigenous Peoples Planning Framework (IPPF).

The updated documents take into account consultations with Ministry of Health officials, Development Partners and NGOs (such as Medicam); recent analytical work on equity, gender issues and ethnic minorities; evaluations and monitoring of HSSP1; and analytical work commissioned for HSSP1, including a study analyzing the health situation of ethnic minorities in Cambodia[23] and a more targeted study of health seeking behaviors and constraints accessing health services of ethnic minority groups in selected areas.[24] Both these studies included consultations with and visits to ethnic minority communities. But none of this work focused specifically and explicitly on ensuring that consultations were “free, prior and informed,” or on demonstrating that broad community support exists for the project.