Consultation Meetings with the Poor:
PRSP- Health
MoH, NIPH, MoP, GTZ
November 2002
Consultation Meetings with the Poor: PRSP- Health
Background:
As part of the PRSP process, it is important to meet the poor, discuss their concerns, and understand their perceptions and perspectives. This will help to ensure not only that the Ministry of Health's strategy responds to the realities of the poor, but also that the poor understand and accept the commitment of the Ministry to work for their benefit. Perhaps more important, however, is for the officials involved in the PRSP process to extend and expand their personal perceptions of the needs of the poor and how the PRSP process will directly respond to these.
At the same time, a basic principle of development work is "No survey without service". It is therefore important to provide some simple services to the poor who participate in these meetings.
When planning the meetings included were the provision of simple one-day clinic to treat minor aliments and provide health education for the local community.
Purpose:
q To meet with the poor in villages and communes to listen to their perceptions and perspectives concerning health and poverty, in order to give credibility to the poverty reduction strategy of the Ministry of Health.
q To provide officials working on the PRSP in the MoH to extend their personal perceptions of the needs of the poor and how the PRSP process responds to these.
q To provide simple free services to the poor who participate in these meetings in recognition of their cooperation.
Expected outcome:
i. To understand better the poor’s perceptions of their health needs:
1) Had they always been very poor or did a special event lead them into poverty. If the latter, what was that event?
2) What are the main daily problems?
3) What do they do when they are sick?
4) Use or non-use of health services (Public / private), why and why not?
5) What is their perception of the quality of the services?
6) Costs, exemption or not, under table payments, other costs as transport, opportunity cost, etc.
7) Reproductive health needs – Family Planning, others
8) Recommendations to the health system and the services providers on how to improve
9) Did they know about commune councils? If so, do they think the councils are in place to assist them, and if so in what manner?
ii. A number of poor people treated for common ailments.
Methodology:
q Focus Group Discussions with stratified groups:
· Users which then further split into smaller sub-groups of 5 people in each group women, men, adolescent boys, adolescent girls and community feedback committee for in depth discussions.
· Non Users, the same procedure as the users groups.
q The discussion started by asking for any special experience, emergencies, disease and how this was managed, decision taking, consequences, etc., within the frame of expected outcome of the meeting.
q Community feed-back committee members were organized as one separate group as to avoid bias and domination in the discussion.
q Meetings places were organized at the convenience of participants (close to where the people live)
q The result of the finding will be presented to relevant stakeholders involving in poverty reduction, national, international partners including provincial and municipal health directorate team. So that they can organize afterwards to start Improvement process.
q Simple MPA services, including outpatient and health education were provided both to the participants and to their members of the community from which they came from.
Places of consultation meetings:
q Kampong Thom Province, OD Baray-Santuk (assistance for organization through GTZ-NIPH and Kampong Thom PHD, health centre staff)[1]:
· Treal health catchment areas – meeting in one far away village for non users, another meeting with groups for those who use the services
· Krova Health Centre catchment areas – same approach as in Treal
· Tangkok Health Center catchment areas - same approach as in the above two
q Phnom Penh Slam areas –Anlong Kngan village (users, non-users and Cambodian Red Cross social workers)
Number of poor to be involved:
q 120 in Kampong Thom + 15 FBC members
q Phnom Penh 40 persons + 5 FBC members
Total 180 persons
Focus Group Discussion Team:
From MoH:
· Dr. Lo Vesna Kiry -
· Dr. Sao Sovanrattanak - , Tel: 012-859 134
· Dr. Seng Sokuntheary- 012987305
· Dr. Seng Heng
· Dr. Ben Mony- 12893146
· Chhay Chamnap- 016873146
· Thor Bony- 012937340
From National Institute of Public Health
· Dr. Yen Romany
:From Ministry of Planning
Sujaya Misra, Co-ordinator PRSP, for preparation and dissemination– Tel:012-834-712
1 person
From GTZ:
§ Dr. Gertrud Schmidt-Ehry for preparation only
§ Dr. Chhom Rada -
§ Dr. Him Phanary -
§ Ms. Sarah Martin as intern student to learn about the process –
Summary of the findings
As this study involves only the poor groups, the starting point of the discussion was to discuss a little bit about how they themselves define the poor and why. They define the poor into two categories by using theKhmer word Kror and Toal. Kror means they still have food to eat but are unable to save anything from what they earn, have no money to send children to school, can not afford to pay medical care at hospital, live in a small thatch house etc., while Toal they just simply rely on daily labor, do not have enough food to eat “Ban Preuk Kvas Lngeach” meaning you have enough food for the morning but not enough for the evening. Thus, struggling for food is the main concerns for the toal people. And usually they are in debt.
1. How long have they been poor and what made them poor
1.1. Rural poor
Majority said that they have been poor for a long time, the poverty their only inheritance from their parents and for more than decades. This group was not questioned further about why they were poor. However, those who said that they had became worse (the second majority) within the last 4-5 year were questioned about why and what had been the reason for things to get worse. The answers are ranked in order of frequency as follows:
1.1.1. Ill health and lost land due to illnesses. As they do not have any saving from their earning, thus the only thing they can do to save their live when they get severely sick is to sell out important assets like draft animals, land and eventually houses.
1.1.2. The second cause mainly cited by women and girls was widowhood and separation. Men play a very important role for family economics in the peasant communities. A household without men is seen as a big problem ( May be interesting to link with HIV mortality?)Poor harvest due to floods are the causes that make the poor family become even worse within the last 3-4 years. Credit/loan schemes are few and far between, so the poor are at the mercy of money lenders who charge interest between 20-30% per month, taking land title deeds as collateral up front. Some families went into debt, lost land and migrated out as their land was flooded for 2 to 3 consecutive years.
1.1.3. Too many children are also perceived as the causes of poverty (this was cited with the same frequency as poor harvest). The explanation is children consume a lot of women's time which otherwise women could use to help in the field. Children get sick very often which again costs time and resources . Thirdly children consume food as well, which becomes a big problem, especially when they are many.
As poor harvest was the main concern of the peasant poor we interviewed, we elaborated a little bit on this issue . The results are seen in the poverty circle as illustrated in Figure 1.
The story starts from the poor harvest. As these poor rely entirely on the harvest, the consequences of the flood have a tumultous effect on their family food security situation for the whole year . When they face a shortage of food, the poor borrow food from better off families, who often charge high interest rate. Nevertheless they have to borrow by hoping that next year they will have a better harvest so that they can pay back all the debt. But unfortunately they got hit by floods again. So to avoid accumulation of the interests and debt they resort to selling draft animals. If they are lucky at this stage (no flood) they still have their land but they have to spend double labor forces in exchange for borrowing the draft animals from others. But if the flood occurs again then they have no other option but to pawn land and sell labor for food. With diminishing food and weakened immunity, they get sick and are unable to work, then there is no food, so they sell land for food and for health care. If the situation does not get better they sell houses. At this stage some of them may end up living in a small hut boat relying on daily fishing subsistence, some migrate to Phnom Penh, to Koh Kong and eventually to Thailand, and the story goes on and on!.
Figure1. Poverty circle
1.2. Urban poor
Based on the scope of the study we did not ask poor people the long story how they end up living in the poor society but we did ask what make them worse and why? Most of these people formerly lived in the urban slum areas "Front Bassac" in Phnom Penh, which area caught fire. The municipal authority re-allocated these settlers to a new place which is now called Anlong Kngan commune. Anlong Knang is outside the city; about an hour away in the dry season. Roads leading to the commune are not tarmac and so during the rainy season access becomes a problem. Most of the houses are made of thatch. The concrete ones made earlier, presumably by government stand without their roofs—some of the people said that the people had pulled the roofs off and taken them back to Phnom Penh. This was not made clear. It is not astonishing that most of them cited that:
1.2.1. Their family economic got worse after their houses got burnt down(7-8 months ago).
1.2.2. The new place makes life even more difficult as they have little or no opportunity for income (like running motor taxi, selling daily labor and selling grocery etc.)
1.2.3. With less income (6000 to 7000 riels per days) they have to pay expensive electricity (1,500 riels compare to 350 riels in Phnom Penh) and water
1.2.4. Interest rates are high e.g A $300 loan for a water pump to raise money by selling water at 500 riels (12cents) a barrel, was being repaid at $60 a month (20% per month) This groups falls between the gaps of agencies set up to assist them. Agencies like Acleda refuse them loans as they are considered high risk, whilst the NGO's apparently told them they needed a proper house.
2. What are their daily problems or concerns?
2.1. Rural
When we asked this question to them they often comeback to the very basic human need which is:
2.1.1. The Food. The food is their main daily concerns. The usual agenda for the day “Am I going to have enough food for today or not? ” and “Will we have rice or rice soup?” This all depend on the daily earning opportunity, said the people relying on daily subsistence.
2.1.2. The second concern is the sickness. They said that they often get sick because they do not have enough to eat and at the same time they have to work hard.
“Every time I or my family member gets sick I am very afraid as it costs a lot for us”. Cost number one is the loss of work opportunity and cost number two is expenses on health care cost, said one of the young people in Taing Kork commune.
Two of them said that their sisters worked too hard even during her pregnancy and because of that they both started bleeding and lost their babies.
“She lost her land for the surgery in the hospital, now her economic situation is very bad”
“My father and I experienced cough with blood; I think may be because we have worked to hard in the field” said another young boy. (TB?)
From this story we could summarize the inter-link between the sicknesses, hard work and poverty as shown in figure 2 below
Figure 2. Sickness and poverty
2.2. Urban
The urban poor people have the same concerns as the rural people as well but in addition they find the following as the main problem too:
2.2.1. To cope with the family economic situation they are facing now, all members of the family have to find work regardless of the children. “I have to stop my children from going to school now because we can not afford any more”. “One of my sons dropped his grade 5 school to work as a shoe shine boy, earning between 3000 to 5000 riels a day”.
2.2.2. Toilet, or lack thereof, is considered a priority and almost every single person said they would willing give their labour if someone with technical exptertise could provide toilets. They said that when they lived in Phnom Penh they never had such problems. Even though they have some problems to earn the living over there. Now they face both problems, earning to eat and to go to the toilet. “We don’t know where to go if we feel like to going to toilet during day time as we live in the open air areas”. This is true from our point of views (the study team). There is shit every where in the village. According to the interview about 5% of the total households have their own toilet. Currently the UNCHS and/or Municipality have provided one toilet for 10 families. No one was willing to clean them, so they have backed up and are not being used. They don’t believe that setting a public toilet will work in this society.