Cambodia: (Preăh Réachéa Anachâk Kâmpŭchea) An Assessment of Development Potential



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Health:


Cambodia has made notable progress in health outcomes over the past two decades. From 1990-2006, the infant mortality rate9 decreased from 85 to 65, the under-5 mortality rate10 decreased from 116 to 82, and the adult mortality rate11 declined from 263 to 257 (WHO). During this same period, life expectancy increased from 59 years to 62 years, and malnutrition declined in prevalence in children under age 5 (The World Bank Group).12

Figure 19: Mortality rates




1990

2000

2006

Infant mortality rate

85

78

65

Under-5 mortality rate

116

104

82

Adult mortality rate

263

307

257

Source: World Health Statistics, 2008

Figure 20: Life expectancy (2006) Figure 21: Maternal Mortality Ratio13 (2006)


Source: World Health Statistics, 2008

Source: World Health Statistics, 2008

Despite this progress, Cambodia continues to rank lower than its neighbors on virtually all major health indicators. As shown in Figure 20, in 2006, life expectancy was 10 years less in Cambodia than in Vietnam or Thailand. Women in Cambodia were 3.6 times more likely to die in childbirth than Vietnamese women and nearly five times more likely to die in childbirth than women in Thailand (Figure 21). Similarly, with the exception of Laos, Cambodia had the highest adult mortality rate, under-5 mortality rate, and infant mortality rate out of all of these countries (Figure 22).



Figure 22: Mortality Rates (2006)


Source: World Health Statistics, 2008

According to the World Health Organization, the top five causes of death in 2002 were HIV/AIDS (10%), tuberculosis (8%), diarrheal diseases (7%), perinatal conditions (7%), and lower respiratory infections (5%) (Figure 23). Among children, vaccine-preventable diseases, diarrhea, pneumonia, and respiratory infections are the leading causes of death (Unicef). Among people 15-49 years old, the prevalence of HIV/AIDS has greatly decreased, from a peak rate of 3.0% in 1997 to 0.8% in 2007. In particular, rates of HIV/AIDS have declined among high-risk groups such as brothel-based sex workers (from 43% in 1997 to 21% in 2003), non-brothel-based sex workers (from 18% in 1998 to 12% in 2003), and male police officers (from 4% in 1998 to 3% in 2003). This progress is largely attributed to government initiatives promoting 100% condom use and increasing the availability of services related to the care and treatment of sexually transmitted infections. The Ministry of Health has also introduced voluntary, confidential counseling and testing as an important intervention in HIV prevention strategies. If present interventions are sustained, projections indicate that HIV prevalence should continue to decline, stabilizing at 0.6% by 2011 (World Health Organization).



Figure 23- Top 10 causes of Death in 2002



Source: http://www.who.int/whosis/mort/profiles/mort_wpro_khm_cambodia.pdf

One major health priority is improving the status of maternal health in Cambodia. Each year, approximately 2,900 women and girls die from pregnancy-related complications, and 58,000 to 87,000 Cambodian women and girls needlessly suffer from disabilities related to pregnancy and childbirth (USAID). With an average of four women dying during childbirth every day, Cambodia has the third highest maternal death rate in Southeast Asia, after Laos and East Timor” (WHO). Although progress has been made in increasing the availability of obstetric care, a vast majority of Cambodian women still do not have access to quality, long-term reproductive health care and family planning services. In 2005, only 44% of births were attended by a skilled health professional (The World Bank Group). Twenty-one percent of women receive absolutely no prenatal care. Moreover, there is a significant urban bias in access to safe motherhood services, as shown in Figure 24. The data in Figure 24 come from a 1999 study on maternal and neonatal heath services conducted by 750 reproductive health experts. On a scale of 0 to 100 (with 0 as the worst and 100 as the best), this study demonstrated large disparities in rural and urban access ratings, particularly for the treatment of obstructed labor (8 vs. 90, respectively), 24-hour hospitalization (15 vs. 86), and treatment for postpartum hemorrhage (15 vs. 85). Taken together with Cambodia’s high maternal mortality rate of 540, it is clear that basic maternal health needs are not being met.



Figure 24- Comparisons of access to services for rural and urban areas in Cambodia



Source: http://pdf.usaid.gov/pdf_docs/PNACR871.pdf

Although child nutrition has improved in Cambodia, the prevalence of malnutrition also remains alarming high. As shown in Figure 24, Cambodian children exhibit four times more instances of underweight and nearly 3 times more cases of stunting than children in Thailand. In 2006, 44% of children under 5 years old exhibited stunted growth, and 28% of the population was underweight. Malnutrition is associated with multiple health problems such as delayed mental and motor development in children and increased risk of developing coronary heart disease, diabetes, and high blood pressure as an adult. Because malnutrition compromises the immune system, children who are moderately underweight are more than four times more likely to die from infectious disease, when compared to well-nourished children (United Nations Development Programme). While malnutrition affects all age groups, it is concentrated among poor people and those with inadequate access to health education, clean water, and proper sanitation.



Figure 24: Country Comparison of Malnutrition prevalence (2006)

Source: World Development Indicators, 2009

*All values given for the year 2006, except for Lao PDR, which is from the year 2000.

This intersection between poverty and poor health is apparent in Cambodia’s existing health disparities. In particular, vast health disparities exist by income, geographical location, and education. For example, an examination of child mortality rates reveals significant differences across each of these measures. According to the World Health Organization, the under-5 mortality rate was 111.0 in rural areas, as compared with 75.7 in urban areas in 2005. When comparing levels of education and wealth, the under-5 mortality rate was 2.6 times higher for mothers of lowest educational levels when compared to mothers of the highest education levels, and 3.0 times higher when comparing mothers of lowest and highest income levels (Figure 25). This means that before a Cambodian child even reaches the age of 5, her health will be influenced significantly by such factors as where she was born, what her parents earn, and whether her mother had the opportunity to pursue an education.



Figure 25: Under-5 mortality rate by income, location, and mother’s education

Under-5 mortality rate:

Highest and lowest quintiles












Wealth/asset quintiles

Lowest

Highest

Ratio




127.0

43.0

3.0

Urban/Rural

Rural

Urban

Ratio




111.0

75.7

1.5

Mother’s education quintiles

Lowest

Highest

Ratio




135.7

53.0

2.6

* All values for the year 2005 (Source: World Health Statistics 2008)

Location is also a powerful determinant of health, in terms of access to clean water and sanitation facilities. In 2006, only 28% of the population had access to improved sanitation facilities.14 These facilities were available to 62% of the urban population, as opposed to only 19% of the rural population. Similarly, 80% of urban residents had access to an improved water source,15 in comparison to only 61% of the rural population. In the absence of potable drinking water, villagers in rural areas must often resort to drinking water from lake and rivers, increasing the risk of acquiring diarrhea and other preventable water-borne illnesses (Figure 26).



Figure 26: Access to sanitation and drinking water

 

%

Population with sustainable access to improved drinking water (% rural)

61

Population with sustainable access to improved drinking water (% urban)

80

Population with sustainable access to improved sanitation (% rural)

19

Population with sustainable access to improved sanitation (% urban)

62

* All values for the year 2006

Source: World Health Statistics, 2008

Currently, the Cambodian health system lacks funding and health care personnel, which severely limits people’s access to adequate health care services. Although there is no universal standard that can be used to assess the size of the health workforce needed to address the health care needs of a given population, it is estimated that countries with fewer than 25 health care professionals (physicians, nurses, and midwives) per 10,000 people fail to achieve adequate coverage rates for primary health care interventions that have been prioritized by the Millennium Development Goals framework (World Health Organization). As shown in Figure 8, in 2000, Cambodia had only 2 physicians, 9 nursing and midwifery personnel, and <1 dentistry personnel per 10,000 population in the year 2000 (WHO).



Figure 27:

Health Care Workforce

Value

Dentistry personnel density (per 10,000 population)

<1

Number of dentistry personnel

209

Nursing and midwifery personnel density (per 10,000 population)

9

Number of nursing and midwifery personnel

11,125

Physician density (per 10,000 population)

2

Number of physicians

2,047

Source: World Health Statistics, 2008

In 2005, total health expenditures per capita (PPP $ international) were $167. Of these health expenditures, government expenditures accounted for only 24.2 percent, out-of-pocket expenditures accounted for 60.1 percent, and 15.7 percent were accounted for by other private sources like NGOs (Figure 28). Comparably, individuals therefore pay a disproportionately high amount of out-of-pocket expenses to cover health care costs. With 68% of the population living on less than $2/day, health costs therefore pose a massive barrier to health care, indebting many who receive health services and deterring others from seeking out any type of health care.



Figure 28: Total Health Expenditures in 2005

Source: World Health Statistics, 2008

Taking into account present data, the health status of Cambodia is in poor shape. Not only do Cambodians lack access to clean water, proper sanitation, and adequate health care services, but they lack a public health system to cover the few health care costs they may incur as well. Despite improvements in life expectancy and infant mortality, Cambodia’s health status trails far behind its Southeast Asian neighbors and remains among the lowest in the Asia-Pacific region. Most importantly, any progress that has been made has been uneven. Children from lower-income, less educated backgrounds suffer much worse health outcomes, and health disparities in rural versus urban areas persist.



Our development approach is based on the premise that every person has the right to a long and healthy life. An individual’s health should not be determined by his or her level of education, income, or geographical location. In a world where obesity has become epidemic, it is inexcusable that malnutrition continues to limit the educational and physical capacities of Cambodians. Addressing these fundamental health issues is therefore a crucial element of our development proposal.
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