Review of Literature (Cambodia)
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Contents
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Health Status & Priorities
Health indicators in Cambodia
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INDICATORS DATA Year Source
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Total Male Female
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Area (1 000 km2) 181.04 3
Estimated population ('000s) 13 091.00 6.32 6.76 2004 1
Annual population growth rate (%) 1.81 … … 1998-2004 1
Percentage of population
0–14 years 39.00 41.10 36.20 2004 1
65+ years 4.00 3.30 4.50 2004 1
Urban population (%) 16.00 … … 2004 1
Adult literacy rate (%) 73.60 f 84.70 f 64.10 f 2004 1
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Crude birth rate (per 1 000 population) 25.00 … … 2004 1
Crude death rate (per 1 000 population) 6.70 … … 2004 1
Rate of natural increase of population (% per annum) 1.83 … … 2004 1
Life expectancy (years)
at birth … 56.40 60.30 2001 1
Health-adjusted Life expectancy at age 60 … 9.70 11.00 2002 15
Neonatal mortality rate (per 1 000 live births) 37.30 … … 2000 4
Infant mortality rate (per 1 000 live births) 66.00 … … 2004 1
Under-five mortality rate (per 1 000 live births) 82.00 … … 2004 1
Total fertility rate (women aged 15–49 years) 3.34 2004 1
Maternal mortality ratio (per 100 000 live births) 437.00 2000 4
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% newborn weighing at least 2500 g at birth 77.00 … … 2000 20
Prevalence of underweight children under age 5 45.20 44.30 46.30 2000 4
Percentage of pregnant women with anaemia 66.40 2000 4
Immunization coverage for infants (%)
BCG 95.00 … … 2004 8
DTP3 85.00 … … 2004 8
OPV3 86.00 … … 2004 8
Measles 80.00 … … 2004 8
Hepatitis B III … … …
MCH coverage (pregnancies, deliveries, infant care)
% pregnant women cared for by skilled health personnel 32.97 2004 5
% pregnant women immunized with tetanus toxoid (TT2) 51.00 2004 5
% deliveries, at home by skilled health personnel 16.51 2004 5
% deliveries, in health facilities 16.34 2004 5
% women of reproductive age group using modern
contraceptive methods 19.00 2000 4
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- Source: WHO Western Pacific region health databank 2006 Revision. Data from 2004.
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INDICATORS DATA Year Source
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Total Urban Rural
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% population with sustainable access to improved
water source 44.20 72.00 39.60 2004 1
% population with access to improved sanitation 21.90 55.40 16.40 2004 1
% population using solid fuels for cooking/heating >95.00 2003 8
Human development index 0.57 2003 2
Per capita GDP at current market prices (US$) 306.00 2003 13
Rate of growth of per capita GDP (%) 2.60 2003 11
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Health expenditure
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Total health expenditure (million US$) 469.43 2005 18
Total health expenditure (% GDP) 10.20 2005 18
Total health expenditure (per capita, US$) 4.09g 2005 19
Government expenditure (million US$) 56.45 2005 18
Gov. expenditure (% of total health expenditure) 12.03 2005 18
Gov. expenditure (% of total gov. expenditure) 7.14 2005 18
External source of government health expenditure
Private expenditure (% of total health expenditure) 70.00 2003 est 14
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- Source: WHO Western Pacific region health databank 2006 Revision. Data from 2004.
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Health Care Workforce DATA Year Source
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Total Rate ( per 10 000)
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Physicians 2122 1.62 2004 16
Dentists 241 0.18 2004 16
Pharmacists 577 0.44 2004 16
Nurses 4516 c 3.45 2004 16
Midwives 1754 c 1.34 2004 16
Other nursing / auxiliary staff 4449 3.39 2004 16
Other paramedical staff (e.g. medical assistants,laboratory technicians, X-ray technicians)
160 0.12 2004 16
Other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.)
1638 1.25 2004 5
Yearly new graduates – physicians … …
Yearly new graduates – nurses 280 c 2002-2004 16
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- Source: WHO Western Pacific region health databank 2006 Revision. Data from 2004.
- "Cambodia has the highest rate of amputation due to landmine injury in the world. Currently, there are about 40 000 people with amputations in the population. Since 1995, road traffic injuries have started to exceed those due to landmines. In 2002, the Department of Transport reported a fatality rate of 13 per 10 000 vehicles, one of the highest rates in ASEAN countries."
- No official data available on the incidence of noncommunicable diseases. However, a diabetes survey in 2004 unexpectedly found a prevalence of 5% in a rural and 11% in a semi-urban setting.
- National prevalence of smoking among men of 20 years and over is 54%. On average, Cambodian families spend similar amounts on tobacco as they do on health, and significantly more than on education, housing and clothing. Cambodia ratified the WHO Framework Convention on Tobacco Control in 2005.
Sources
- National Health Statistics Report of Cambodia (2004)
- Cambodia Demographic & Health Survey (2000)
- Cambodia Demographic & Health Survey (2005) (May not be published yet)
- Cambodia Inter-Censal Population Survey (2004) General Report. Ministry of Planning, November 2004
- Cambodia Integrated Fiduciary Assessment and Public Expenditure Review 2003. World Bank and Asian Development Bank.
- National Health Survey (1998)
- Médecins Sans Frontières activity reports on Cambodia
- Engender Health
- World Health Organization Documents on Cambodia
- WHO Framework Convention on Tobacco Control in 2005
- WHO Western Pacific Region Health Data Bank: 2006 Revision. Manila, WHO, 2001
- UNAIDS - Cambodia
- World Bank: Cambodia
- IMF: Cambodia
- UN Development Fund for Women
- UN Development Program
- essay writing
- UNICEF Cambodia
- World Food Program
- Food & Agricutlture Organization of the UN
- Office of the High Comissioner on Human Rights - Cambodia
- UN Industrial Development Program
- UNESCO Cambodia
- UN Refugee Agency
- UN Office for Drugs & Crime
Leading causes of morbidity & mortality
Ten leading causes of morbidity
2004
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Cause Number (000s) Rate
per 100 000
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1. Acute respiratory infections 2 122 728 16 215.17
2. Diarrhoeal diseases 383 118 2926.58
3. Malaria (treated cases) 101 857 778.07
4. Cough (of at least 21 days) 97 122 741.90
5. Tuberculosis 31 105 237.60
6. Road accidents 12 556 95.91
7. Dengue haemorrhagic fever 9 983 76.26
8. Gyneco-obstetrics 8 598 65.68
9. Dysentery 3 622 27.67
10. Measles 1 584 12.10
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- Source: WHO Western Pacific region health databank 2006 Revision. Data from 2004.
Ten leading causes of mortality
2004
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Cause Number (000s) Rate
per 100 000
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1. Tuberculosis 1301 9.94
2. Acute respiratory infections 884 6.75
3. Malaria 382 2.92
4. Road accidents 337 2.57
5. Meningitis 163 1.24
6. Dengue haemorrhagic fever 90 0.69
7. Diarrhoeal diseases 76 0.58
8. Other tetanus 37 0.28
9. Neonatal tetanus 23 0.18
10. Gyneco-obstetrics 8 0.06
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- Source: WHO Western Pacific region health databank 2006 Revision. Data from 2004.
Health priorities outlined by government, NGOs & international bodies
- Source: Health Sector Strategic Plan 2003-07
- Key challenges for the health sector:
- Increasing the utilization of cost-effective health services. The overall utilization of public health facilities is around 0.4 visits per person per year. Except in a few areas where additional resources and semi-autonomous management have been provided, utilization rates are not increasing and, to date, the under-resourced publicly funded health services have had little to offer the rural poor. Most people choose to use legal or illegal pharmacies and traditional healers to access health care.
- Improving the quality of care in both the public and private health sectors. Poor staff attitudes and practices in the public sector, uncertainty about user charges and lack of knowledge about available services are factors that contribute to the low utilization of health services. A number of initiatives have been introduced to promote a client-centred approach to service delivery in health staff training programmes, and the newly established Medical Council is introducing a code of medical ethics in an attempt to improve professionalism among medical practitioners.
- Improving the distribution of staff, particularly midwives. Currently, many referral hospitals and health centres, particularly in rural areas, have insufficient midwives to provide safe coverage for emergency obstetric care. A functional analysis process, initiated in 2002, has focused attention on the need to develop policy to address the maldistribution of staff. There has been an increase in the number of midwifery trainees in recent years.
- Improving reproductive and adolescent health services. The main focus of reproductive health services is fertility control and antenatal care. In remote rural areas, however, the fertility rate has increased.
- Note: No mention of Tobacco or STI/HIV at this stage.
- Ministry of Health's strategic objectives for 2003– 2007. Its eight essential objectives (strategies) are:
- To improve coverage and access to health services, especially for the poor and other vulnerable groups;
- To strengthen the delivery of high quality basic health services;
- To strengthen the quality of care, especially that of obstetric and paediatric care;
- To improve the attitude of health providers to enable them to communicate with customers effectively;
- To introduce a culture of quality in the public health services;
- To increase the number of midwives through training and capacity-building;
- To ensure a regular and adequate flow of funds to the health sector, especially for service delivery, through advocacy, and to increase financial resources and strengthen financial management; and
- To introduce organizational and management reform of structures and procedures to respond to change.
- Key challenges for the health sector:
These strategies are expected to result in
- reduced infant, child and maternal mortality;
- improved nutritional status among children and women;
- a reduced total fertility rate;
- reduced household health expenditure, especially among the poor; and
- a more efficient and effective health system.
Questions
- Quality limits of the data (generalizability across time, location, social class, gender etc.)
Perspectives
- Cambodian citizens (across gender, religion, class, age, urban vs. rural)
- Cambodian government
- NGOs/aid organizations
- on-the-ground volunteers
Sources
Health & determinants of health
Theoretical foundations
- Health
- What does health mean to residence of Cambodia?
- Determinants of Health
An analysis of the state of determinants of health in Cambodia
Nutrition
- Source: Cambodia Report on Nutrition (2004), Cambodian Government.
- Overview: Nutritional problems in Cambodia are closely related to the poor general health status of the population. The leading causes of mortality are acute respiratory infections, diarrhoea, tuberculosis and malaria. Undernutrition is still a major problem.
Nutritional Problems
- 'Birth weight: (CDHS) as few births take place in medical facilities data on low birth weight prevalence is unreliable as it relies mainly on the mother's perception of size. The National Health Statistics of Cambodia 2000 reports that:
- 23% of babies were born with a low birth weight <2500 g.
- 21% of mothers had a BMI below the cut-off of 18.5, indicating chronic energy deficiency.
- Infant feeding: (CDHS 2000)
- 96% of women in both the rural and urban areas of Cambodia were breast-feeding, 50% did so for two years.
- only 11% of infants started breast-feeding within an hour of birth, and 24% within one day.
- only 5% of children aged 4-5 months were exclusively breast-fed.
- most infants were being introduced to other liquids and foods before six months of age.
- 6% of children less than two months of age consumed other liquids and 2% drank milk other than breast milk.
- About two thirds of children were consuming cereals, grains and solid or semisolid foods by 6-7 months of age.
- Child growth (CDHS 2000)
- high level of protein/energy malnutrition among children under 5-years
- stunting prevalence rate of 44.3% (severe stunting -3SD, 20.2%).
- prevalence of wasting was 15.0% (severe wasting -3SD, 3.8%)
- prevalence of underweight was 45.3% (severe underweight -3SD, 12.5%).
- high level of malnutrition is reflected in the high infant mortality rate, 95 per 1000 live births, and in the
higher mortality rate among children under five years of age, at 124 per 1000 live births.
- Nutritional anaemia:
- 63% of children 6-59 montha are anaemic.
- children under 2 were more likely to be anaemic than older children.
- high prevalence of anaemia (90%) was found in the age group 10-11 months, an indication of poor complementary feeding practices.
- 58% of non-pregnant women and 66% of pregnant women were classified as anaemic.
- only 4% of women were taking iron/folate supplements for at least two months during pregnancy. This contributes to the high maternal mortality ratio, estimated at 437/100 000 live birth.
- Iodine deficiency: The First National Goitre Survey was completed in 1997 and estimated a national total goitre rate of about 12% in the 8-12 age group, with a rate of 45% in some areas. The survey recorded a total goitre rate of 17% in a sample of over 35 000 children.
- Cambodia began salt iodization in 1998 and iodized salt domestically produced is distributed to all provinces. Four remote provinces receive most of their iodized salt from neighbouring countries. While iodized salt can be found in the main provincial towns, coverage throughout many provinces remains low (CDHS 2000 found only 12% of households with adequate iodized salt).
- The target set by the Cambodia Nutrition Investment Plan (CNIP) is to increase the percentage of households consuming iodized salt to 80% by 2007. Recent campaigns have increased awareness of the importance of iodized salt, but further work is required to increase iodized salt coverage.
Overall local production of iodized salt increased from 6750 metric tons in 2001 to 13 000 metric tons in 2002. Production still has a long way to go to reach the 65 000 metric tons required to meet the estimated national iodized salt requirement.
- Vitamin A deficiency: (Cambodia National Micronutrient Survey 2000)
- The prevalence of night blindness among children aged 18-59 months was above the WHO cut-off (1%) in seven of the 10 provinces surveyed, as well as among the lactating mothers (range: 1.1-6.8% in the 10 provinces) and during the mother's most recent pregnancy (range: 2.0-9.3%). T
- less than 10% of women and children meeting their recommended daily intake of vitamin A.
- During national immunization days (NIDS) from 1995 to 1998 and subnational immunization days (SNIDS) in 1999,
vitamin A capsules were distributed to children aged 12-59 months together with oral poliomyelitis vaccine. An estimated 90% coverage was achieved during the campaigns. In 1998, vitamin A capsule distribution was fully integrated into the routine expanded programme on immunization (EPI). Vitamin A capsules are distributed to children of 6-59 months twice yearly with the routine EPI and during special supplemental campaigns, such as SNIDS and measles outbreaks responses.
- only 29% children aged 6-59 months had received a vitamin A capsule within the previous six months. (CDHS 2000)
- Vitamin A capsules are also provided for postpartum women within eight weeks of delivery, through the routine monthly outreach activity. Only 11% of women, however, reported receiving a post-partum capsule (CDHS 2000).
Policies & Programs directed at nutrition
- The National Plan of Action on Nutrition (1996-2000) was approved by the Council of Ministers on 8 January 1997 and a multisectoral National Nutrition Council was established in 1998 with the task of coordinating its implementation, monitoring and evaluation.
- In 1998, the Cambodian Nutrition Investment Plan (1999-2008) was adopted (revised in 2001-02). It proposes an investment of US$ 41 million in nutrition over a five-year period (2003-2007) and is structured to contribute to Cambodia's Social and Economic Development Plan II, The Health Sector Strategic Plan 2003- 2007 and the National Poverty Reduction Strategy Paper 2003-2007.
- The Cambodian Nutrition Investment Plan (CNIP) focuses on children under 5-years and pregnant women. Community growth monitoring systems and the development of village action plans are recognized as being key strategies for the CNIP. Donors and nongovernmental organizations have already provided technical input and made some investment to support implementation of nutrition-relevant actions in the directions recommended in the CNIP.
- Anemia: Ministry of Health completed a pilot programme to test weekly iron/folate supplementation for women of reproductive age in 2001-2002... now developing ways to introduce this on a national scale. A similar pilot project for children <2 years is planned.
- Iodine deficiency: A national Sub-Committee for the Control of Iodine Deficiency Disorders established in 1997, chaired by Ministry of Industry, Mines and Energy and includes eight ministries. In 1998, two Prakas, “Measures to Control Iodine Deficiency”, were developed for the Ministry of Planning and the Ministry of Industry, Mines and Energy, and signed by the respective ministries. To accelerate efforts to achieve universal salt iodization a Sub-Decree on The Management of Exploitation of Iodized Salt was approved in October 2003 by the Prime Minister.
- Vitamin A: MoH adopted National Vitamin A Policy Guidelines in 1994 (revised 1999). Agencies involved in vitamin A distribution are working together to strengthen the National Nutrition Program and improve vitamin A capsule coverage.
- Breast-feeding policies: National Policy on Infant and Young Child Feeding (IYCF, 2002). MoH is the focal point for coordination and implementation. Between 2000-2003, 197 (45 trainers and 152 participants) health staff at national and provincial levels were trained in the 40-hour breast-feeding counselling course. Ten teachers from the regional training schools have been trained to teach an adapted breast-feeding counselling course, which has been included in the country's pre-service training curricula.
- The Health Sector Strategic Plan 2003 –2007 has committed to achieving three Baby-friendly Hospitals by the end of 2004 and an additional four by the end of 2005. As the majority of the women deliver at home, Cambodia is keen to develop a Baby-friendly Community Initiative.
- A draft (2003) of regulations on the Marketing of Products for Infant and Young Child Feeding is slowly making progress towards becoming law. In 2002, MoH adopted an interim directive, including relevant articles from the International Code of Marketing of Breast-milk Substitutes, for health facilities to end the availability of free or low-cost supplies of breast-milk substitutes and related products in all hospitals, as well as advertising or direct marketing to mothers, distributed to all provinces, operational districts and health centres.
- The Cambodian Government has developed a National Policy on the Prevention of Mother-to-Child Transmission of HIV, which recommends exclusive breast-feeding in all situations, but leaves the choice to parents after they received adequate counselling.
- Maternity leave is three months in both the public and private sectors.
- Monitoring and surveillance of nutritional status: The nutritional status of children aged 0-5 years is only monitored in some areas through child health cards (yellow card). which include a growth chart, information on immunization and vitamin A capsule receipt. The yellow card was updated and approved by the Ministry of Health in 2001.
- Besides growth data, information on nutrition during pregnancy and infant feeding has been collected through a number of studies.
Tobacco Use
- Smoking
Education
- Education
Poverty
- Poverty
Sanitation
- Sanitation infrastructure
Gender inequality
- Gender inequality
Environement
- Environmental sustainability
- Identified DoH and quantification/analysis
- Review of the state and needs for each identified DoH
Demographics
Gender
Perspectives
Sources
Provision of health care
Questions
- Available resources
- economic resources (internal and external)
- direct healthcare infrastructure
- primary, secondary, tertiary
- public health infrastructure
- child health
- educational infrastructure
- human resources
- Paradigms of health care
- Western-style medicine
- Numbers: practitioners, patients, infrastructure, control system, accessibility, conditions addressed
- What kinds of problems do peopel go to wesetern style physicians for?
- Pharmacies:
- Numbers: practitioners, patients, infrastructure, control system, accessibility, conditions addressed
- What kind of problem do people go to pharmacies for?
- Public health/sanitation
- Numbers: practitioners, patients, infrastructure, control system, accessibility, conditions addressed
- Midwifery
- Numbers: practitioners, patients, infrastructure, control system, accessibility, conditions addressed
- Special purpose healers? (are there any?)
- Western-style medicine
- what is each system best at providing? What are each systems deficiencies?
Perspectives
- providers on their own practice
- providers on other providers within same practices
- provider on other practices
- patients (gender, class, education, religion, age etc.)
- administrators
- policy makers
- exernal policy makers (NGOs etc.)
Sources
Interventions
Questions
- What factors determine use of the various systems?
- posibilities: trust? effectiveness? cost? distance? knowledge? other?
