Health Service Access Among Poor Communities in Phnom Penh 2009

PREFACE

The Health Sector Strategic Plan 2008-2015 clearly stipulates that the long term vision of the
Ministry of Health is “to enhance sustainable development of the health sector for better
health and well-being of all Cambodian, especially of the poor, women and children, thereby
contributing to poverty alleviation and socio-economic development.”; and furthermore that
“A value-based commitment of the Ministry of Health is Equity and the Right to Health for
all Cambodians”; and the first of its five Working Principles is “ Social health protection,
especially for the poor and vulnerable groups: To promote pro-poor approaches, focusing on
targeting resources to the poor and groups with special needs and to areas in greatest need,
especially rural and remote areas, and the urban poor.

Through the efforts of the Ministry of Health and health development partners, we have made
important steps forward in recent years in expanding health services coverage across the
country, and in trying to meet the health needs of the poor in particular through
implementation of health financing reforms and extension of health outreach services to the
most remote villages of the country. The results of those efforts have translated into overall
increase in coverage of main maternal and child health care programs as well as
communicable diseases interventions and a significant reduction in the child mortality rate.

However, as Demographic and Health Surveys have demonstrated, there are persisting
problems of inequity of health care access and health outcomes that are related to the
economic status and education backgrounds of the population. Lower levels of income and
education in families means that women and children in these families are more likely to have
lower access to health care and have a higher mortality risk.

Along with the fast growing urbanization in the recent years, we have seen the expansion of
settlement communities in Phnom Penh which consist largely of those families with lower
incomes and levels of educational attainment and poorer living conditions. These settlement
communities have been the source of public health threats such as a circulating vaccine
derived poliovirus in 2006. In 2010 these areas still present a high risk for further
communicable disease outbreaks. Thus, better health services will not only improve the health
status of these poorer communities, but also will help protect the health of the whole
Cambodian population.

This study enables us to understand more clearly the challenges these communities have in
keeping their families healthy and gaining access to health care services. Ministry of Health
wish is that the Ministry of Health, Provincial and District health staff, relevant local
authorities, international agencies and NGOs and community leaders themselves will use
these findings to develop strategies to work together to reach out to these populations for both
better health services and improved health for the more disadvantaged sections of our society.

Phnom Penh, July 9th, 2010






Professor Eng Huot
Secretary of State
Ministry of Health
Health Service Access Among Poor Communities in Phnom Penh 2009



Acknowledgments

The study was designed and conducted by the principal consultant John Grundy in collaboration with
researchers from the Centre for Advanced Studies: Dr. Hean Sokhom, Ms. Bun Malen, Ms. Khun
Chandavy, Mr.Ou Sirren, Mr. Hun Thirith, Ms. Lim Sidedine and Ms. Som Dany.

The National Immunization Programme’s director, Prof. Sann Chan Soeung and other staff, Dr. Svay
Sarath, Mr. Ork Vichit and Mrs. Choun Vuthoeun, as well as the staff from Phnom Penh Municipal
Health Department , Dr. Paou Linar and Dr. Vong Vannak, have provided valuable inputs to the design
and implementation process.

UNICEF staff, Dr Thor Rasoka, Mr. Chum Aun, Ms Julie Forder and the WHO advisor, Dr. Kohei Toda,
have provided technical assistance.

A special thanks to Ms. Diana Chang Blanc, UNICEF-EAPRO, for valuable financial contribution and
technical advice to the study. The study was funded by UNICEF.

And a particular note of appreciation to staff and local authorities for their time and to the children and
their families, especially the mothers who provided valuable descriptions of their lives and the
challenges they face when trying to ensure a better life for their children.
















Contact Information

Ministry of Health
National Immunisation Programme
Telephone: (023) 426 257
Website: www.moh.gov.kh


UNICEF Cambodia
Telephone: (023) 426 214
Website: www.unicef.org
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
CONTENTS


EXECUTIVE SUMMARY ............................................................................................................. V

1. INTRODUCTION TO THE STUDY ......................................................................................... 1
Ethics 2
Objectives 2
Research methods 3
Data analysis 6
Study limitations 6

2. COMMUNITY CONSULTATION FINDINGS .......................................................................... 7
Community profile 1: Trabeng Chuuk 8
Community profile 2: Dam Charn and Dam Slaeng 9
Community profile 3: Borey Kaylah 9
Community profile 4: Tuol Sangkhae 10

3. HOUSEHOLD SURVEY FINDINGS AND OBSERVATIONS .............................................. 11
Community background and family socio-economics 12
Health communication and health knowledge 15
Health service coverage and use 17

4. INTERVIEWS AND FOCUS GROUP DISCUSSION FINDINGS ......................................... 23
The social context for health and health service access 24
Social networks for health 29
Utilization patterns of health care services and access barriers 31

5. RECOMMENDATIONS FOR IMPROVING ACCESS TO HEALTH SERVICES ................. 41
Recommendation 1: Community-based services for the urban poor 43
Recommendation 2: Community-based health monitoring of the urban poor 44
Recommendation 3: Health services quality improvement 44
Recommendation 4: Review of the public health functions 45
Recommendation 5: Review and scale up social protection policies 46

6. CONCLUSIONS .................................................................................................................... 49

REFERENCES .......................................................................................................................... 51

ANNEX 1: RESEARCH INSTRUMENTS ................................................................................. 53
Details of quantitative research instruments 53
Household questionnaire 54
Qualitative research instruments 60

ANNEX 2: LITERATURE REVIEW ........................................................................................... 62
History of urban health service delivery in Phnom Penh 62

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Health Service Access Among Poor Communities in Phnom Penh 2009

TABLES

Table 1: Study communities for household survey 4
Table 2: Communities included in the household survey 5
Table 3: Study sample for interviews and focus group discussions 6
Table 4: Location of previous delivery 21

FIGURES

Figure 1: Hand-drawn map of Dam Charn community 4
Figure 2: Summary of household survey findings 12
Figure 3: Main reason survey respondents moved to the community 13
Figure 4: Income of main income earners 14
Figure 5: Mothers’ knowledge of diseases preventable by immunization 15
Figure 6: Mother’s knowledge of maternal danger signs 16
Figure 7: Mother’s knowledge of child health danger signs 16
Figure 8: DPT-Hepatitis B coverage 17
Figure 9: Reasons for not receiving immunization at the health centre 18
Figure 10: Previous childhood illness 18
Figure 11: First choice of provider for treating child illness 19
Figure 12: Reasons for first choice of provider to treat child illness 20
Figure 13: Services provided during antenatal care 20
Figure 14: Market choices for health care in Dam Charn 32
Figure 15: Analysis of health care costs in the four communities 33
Figure 16: Summary of what is working well in relation to health service access 36
Figure 17: Summary of responses to the fixed-facility site strategy 37
Figure 18: Contrasting perspectives on recommendations for improving health
and health access 38
Figure 19: Frameworks for analysing the social determinants of health 42

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Health Service Access Among Poor Communities in Phnom Penh 2009




ACRONYMS

ADB Asian Development Bank
AFD Agence Francaice de Development
ANC Antenatal Care
ARI Acute Respiratory Infection
CAS Centre for Advanced Studies
CBM Community-Based Monitoring
CPA Complementary Package of Activities
DFID Department for International Development
DPT Diphtheria, Pertussis and Tetanus
EPI Expanded Programme on Immunization
FDG Focus Discussion Group
FHD Family Health Development
GRET Groupe de Recherche et d'Echanges Technologiques
GTZ Deutsche Gesellschaft für Technische Zusammenarbeit (=German
Development Cooperation)
HC Health Centre
HDI Human Development Index
HEF Health Equity Fund
HSP2 Second Health Sector Strategic Plan
HSSC Health System Strengthening in Cambodia
HSUP Health Services for the Urban Poor Project
IMCI Integrated Management of Childhood Illnesses
KAP Knowledge, Attitudes and Practices
MCH Maternal and Child Health
MHD The Municipal Health Department
MoH Ministry of Health
NGO Non-Governmental Organization
NIP National Immunization Programme
NIS National Institute of Statistics
OD Operational Districts
PAC Priority Access Card
RH Referral Hospital
RHAC Reproductive Health Association of Cambodia
RMIT Royal Melbourne Institute of Technology
TBA Traditional Birth Attendant
UHP Urban Health Program
UN United Nations
UNCHS United Nations Centre on Human Settlements
UNDP United Nations Development Programme
UNICEF United Nations Children’s Fund
USAID US Agency for International Development
USG Urban Sector Group
WHO World Health Organization
iii
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009




= study areas
iv
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
EXECUTIVE SUMMARY


There is a long-running problem of poor health service access among populations in the
lowest socio-economic quintiles throughout Cambodia. In 2005 in Phnom Penh alone, the
National Immunization Program identified up to 16 per cent of villages as at risk of outbreaks
of vaccine-preventable disease. One of these at-risk communities had been the source of a
vaccine-derived polio case earlier in the year, which led to a nationwide immunization
campaign and targeted strategies to reach the most vulnerable populations. However, despite
those efforts, concerns remain that coverage has not been complete and that the health care
system is inadequate to reach the at-risk populations.

To improve the quality and coverage of immunization and maternal and child health
preventive programmes for the at-risk populations in Phnom Penh, the National Immunization
Program and UNICEF first initiated a health access study. In collaboration, the Centre for
Advanced Studies (CAS) along with the Municipal Health Department (MDOH) conducted the
study from January through March 2009. The purpose was to identify how communication and
health system strategies could be strengthened in terms maternal and child health care,
particularly preventive care. The study's purpose was to identify the main barriers to service
access and ways to overcome them. The research entailed a literature review, a household
survey, one-on-one interviews and focus groups discussions with mothers (of children
younger than 5 years), health centre staff and local health authorities in four very poor
communities (62 per cent of the households live on US$1–$5 a day).

Although the research was not population based with a sampling methodology that allows the
results to be generalized, it has provided in-depth analysis of what the local residents in a few
communities think of the health service and how access can be improved for populations at
risk.

Findings

This study of selected poor populations in Phnom Penh confirmed that health care access to
basic preventive and curative services for women and children has relatively high coverage,
considering people's capacity to pay. Immunization rates are high and antenatal services are
well used. Mothers have a good knowledge of the risk factors for vaccine-preventable
disease, HIV infection, dengue fever and communicable disease. There is also a wide range
of market choice of health care service providers, covering traditional, private and public
sector services. However, although the quality could not be confirmed, and services come at a
high cost relative to income.

Despite the available access and high coverage of health services, the respondents in the
study reported poor health outcomes. But they attributed their poor health primarily to the
unhealthy social and environmental conditions in which they live.

The four communities selected for the study were chosen through consultations with local
authorities. The communities were generally described as having poor solid and waste
management as well as inadequate shelter and water supply in some locations. Some 57 per
cent of the mothers who participated in the research had completed primary school. They
reported their family had spent an average of $66 on health care during the three months prior
to the research study. Around 53 per cent of the mothers said that they had to pay for their
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
child's immunizations. Despite high health care costs relative to their income, only 14 per cent
of the mothers interviewed (160) held a poverty or health insurance card exempting them from
certain health care fees.

Coverage for immunizations, antenatal care and birth delivery at a facility is surprisingly high,
even in the poorest communities. However, 75 per cent of the interviewed mothers said they
do not know staff in their local health centre very well; and only 19 per cent of mothers had
used the health centre in the previous six months when their child was sick. The private sector
is a mother's first choice for child curative care (50.3 per cent). Health centres and
government hospitals are the first choice for preventive care (79 per cent of immunization
services were provided at health centres and 66 per cent of reproductive health services at
government facilities). Because of the fixed-facility strategy, outreach services have stopped.

Perceptions of quality and cost heavily influence the choice of provider. Quality is defined in
terms of effectiveness of medicines, perceived skills and attitudes of the health centre staff
and the cleanliness and presentation of the facility. Reproductive health services (antenatal
and birth delivery) are well used at a range of providers, but especially health centres and
government hospitals.

Water, sanitation, waste removal, nutrition, security and income generation were perceived to
be the main cause of poor health. There are particular subgroups of the poorest families in the
studied communities that are particularly at high risk of social exclusion and social isolation;
these include single mothers, young school-aged children and teenagers. Social programmes
should target these most vulnerable groups to provide them with a minimum level of social
protection for interlinked issues of health, education and food security. Additionally, in
recognition of the strong interaction among access to health, education, food security,
environmental conditions and income generation, there is a need for wider health public policy
implementation for the very poor that takes into account the social determinants of health.

Electronic forms of media and word of mouth are the main channels for spreading health
information in communities. The study's findings indicate that where health education
programmes of the government and international organizations have been active
(immunization, HIV prevention and care, dengue fever) the very poor demonstrate good
knowledge of the causes of illness and what is required to avoid illness. The interviewed
mothers were less informed on matters relating to maternal health risks, child illness and
reproductive health.

Overall, people identified poor health in the context of the social conditions in which they live
rather than gaps in health service access. This highlights the need to refocus public health
strategies in order to alleviate the daily health and social conditions of the very poor. In some
instances, resident health care practitioners and non-government organization (NGO)
networks are powerful channels for networking health information and health referrals,
especially when linked to local health authorities and local government health services. Local
authorities identified their role in health networking mainly in passive terms relating to the
gathering of population statistics or conducting social mobilization activities for immunization
campaigns. The apparent limited role of local authorities in public health networking for safe
water, sanitation and waste removal was striking. All the respondents in the different research
methods seemed to lack clarity on exactly who is responsible for public health functions and
how to request needed public health interventions.

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Health Service Access Among Poor Communities in Phnom Penh 2009
In Cambodia, there is no single unified health system in the urban context. There is in fact a
health market with a wide range of choice of providers and types of service, even for the
urban poor. A better understanding of the dynamics of this health market for the poor would
guide policy makers towards improving quality health care and social protection for them.
Given the scale of the market mechanism for health care, there is also a strong case for
increasing the market competitiveness of government health centres through the reduction of
client costs (social protection) and improvements in the quality of service. The study's findings
indicate that the very poor pay levels of cost for both preventive and curative care services
that are disproportionate to their capacity to pay. Their willingness to pay by borrowing or
selling personal property reflects the high priority the poor place on accessing health care.

Policies and systems interventions are needed to protect the poor from the burden of the
disproportionate costs through social protection, improvements in public health functions and
the health care system. Although the fixed facility strategy has been successful in maintaining
coverage, there is still concern regarding pockets of non-immunized children in selected high-
risk locations. More investment is required for health centres to micro plan, conduct health
education outreach and build stronger partnerships with local practitioners, authorities and
NGOs in high-risk communities.

Although there is some degree of clarity of role in relation to the medical service provision
through health facilities, the broader functions of public health and primary health care are ill
defined. This leaves communities at high risk of communicable disease outbreak. Essential
functions of public health need to be defined and resourced, with clear lines of accountability
for the Ministry of Health staff, local authorities and communities.

Conclusions

Improving access to health care among at-risk populations means improving access to
healthy social conditions as well as improving access to health care services. The report notes
the following primary areas of action:

x scaling up social protection measures for health care and education in collaboration with
civil society and local authorities;
x implementing health care strategies that focus not only on essential medical service
packages but also on essential public health functions that address the social
determinants of health;
x conducting health surveillance focused on the needs of the poor and not just on their
diseases.

Recommendations

The five recommendations that are presented in the report cut across three levels of
intervention – i) service delivery strengthening, ii) public health function and iii) social
protection policy – and largely derive from suggestions by local authorities, health centre staff
and mothers. The recommendations speak to two prime needs: making health service more
affordable and of higher quality, and making living environments more conducive to a healthy
way of life.

Recommendation 1: Community-based services for the urban poor
Adequate resourcing of health centres should be introduced for conducting health education
and service outreach to at-risk communities on a regular basis. The purpose is three-fold: i)
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Health Service Access Among Poor Communities in Phnom Penh 2009
strengthen links among health services, community practitioners, local authorities, NGOs and
communities; ii) make contact with and support local social networks for health (formal and
informal); and iii) provide mobile services for the most at-risk populations.

Recommendation 2: Community-based health monitoring of the urban poor
The Municipal Health Department (MHD) needs to undertake a systematic approach to the
surveillance of at-risk populations through support to districts and health centres. In
conjunction with local authorities and civil society partners, the MHD also needs to conduct
regular mapping and micro planning for at-risk populations. The mapping exercise should be
built into the routine functioning of the surveillance and planning system so that surveillance
focuses both on disease and on detecting health risks and health inequities.

Recommendation 3: Health services quality improvement
A combined health education and quality improvement strategy should be adopted so poor
people can access good-quality and more affordable child-illness care at health centres, such
as facility and community-integrated management of childhood illness.

Recommendation 4: Review of the public health functions
A review of essential public health functions for improving urban people's health should
identify the resources required and a capacity-building plan to strengthen the delivery of
services, either through local authorities, NGOs, health centres or a combination of all.

Recommendation 5: Review and scaling up the social protection policy
Social equity funds or 'social-safety net' funds, based on a model of the health-equity fund,
should be established in the poorest communities in Phnom Penh on a comprehensive basis
to ensure very poor people's access to both health care and education services.
viii
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Health Service Access Among Poor Communities in Phnom Penh 2009




1. INTRODUCTION TO
THE STUDY


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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
According to the Cambodian 2005 Demographic Health Survey (Ministry of Planning), people
in the lowest socio-economic quintiles have substantially less access to health services. The
National Immunization Programme (NIP) in 2005 identified up to 16 per cent of villages in
Phnom Penh (109 of 695) as at risk of insufficient coverage (NIP documentation, 2008). One
of the identified communities in the National Immunization Programme research was the
source of a vaccine-derived polio case earlier in the year, which had prompted national
immunization campaigns and other targeted strategies for populations at risk of infection from
vaccine-preventable diseases.

Despite the campaigns and coverage improvements, national and municipal health managers
continue to be concerned that Cambodia’s communication and health system strategies
remain ineffective in reaching the at-risk populations. Thus remains the possibility of repeat
outbreaks of the vaccine-preventable disease as well as inequities in maternal and child
health outcomes.

To improve the quality and coverage of immunization and maternal and child health
preventive programmes for the at-risk populations in Phnom Penh, the National Immunization
Programme and UNICEF first initiated a health access study, incorporating both quantitative
and qualitative components. In collaboration, the Centre for Advanced Studies (CAS) along
with the The Municipal Health Department (MDOH) conducted the study from January
through March 2009 and included observations and interviews with residents of communities
in four operational districts (OD) of Phnom Penh municipality: Cheung, Lech, Tboung and
Kandal.

Specifically, the respondents lived in a selected krom, which is the lowest administrative unit
in the Cambodian system. The krom consists of approximately 50 families and has an
identified krom leader. Each village within an operational district consists of one or more krom.

The study entailed three stages: 1) community consultations, 2) household survey and 3)
interviews and focus group discussions. This report highlights the findings and responses.

A Steering Committee consisting of representatives from the four research partners (the
National Immunization Program, UNICEF, CAS and MDOH) managed the study’s
proceedings.
Ethics

A study proposal was submitted to and approved by the National Ethics Committee of the
Ministry of Health in December 2008. Ethical considerations including obtaining consent and
community participation were discussed during the training of the data collectors from the
Centre for Advanced Studies in January 2009.
Objectives

The study was designed to analyse the situation in selected at-risk communities within Phnom
Penh in terms of health service access. The purpose was to generate sufficient insight for
recommendations on improving the communication and health access strategy for at-risk
populations. Ultimately, the insight and recommendations would help improve coverage of the
Expanded Programme on Immunization (EPI) as well as maternal and child health (MCH)
preventative care.
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009

In particular, the study aimed to:
x identify and describe the main barriers to access of health services, through
conversations and interviews with community members, health centre staff and local
authorities
x identify and describe health system delivery approaches and communication strategies
to improve and sustain health service access for maternal and child health care among
at-risk populations.
Research methods

The study adopted a case study approach to gain the needed in-depth understanding of the
barriers and potential solutions. The study was conducted in three stages:

Stage 1: Community consultations (January 2009): Researchers visited the health
centres in the four operational districts to identify ‘the most difficult’ or poorest populations.
The researchers then travelled to the suggested villages to consult with the village leaders
and explain the objectives of the study. From these consultations, four study communities
were selected for stages 1 and 2 research.

Stage 2: Household survey (February 2009): A standardized household questionnaire
was used to randomly survey 160 mothers of children younger than 5 years in the four
selected communities. The questionnaire enabled the gathering of background
information of respondents and their overall knowledge, attitude and practices regarding
maternal and child health care services (see annex 1 for the questionnaire).

Stage 3: Interviews and focus group discussions (March 2009): To gather more
qualitative feedback, detailed interviews were conducted with 20 health centre staff and
key informants. Four small focus group discussions (FGD) were conducted with health
centre teams and mothers. The FGDs ranged in size from 8 to 20 participants and relied
on open-ended questions. A questionnaire guideline was designed for use with the
mothers and with local authorities and health centre staff (annex 1 provides the framework
for these interviews).

The targeted at-risk population – typically categorized as ‘slum dweller’ – was characterized
as living in the lowest socio-economic conditions: on open land, dikes, sidewalks, the
riverbank, rooftops, along railways and rubbish sites or in clusters of densely occupied
temporary or unstructured housing. The targeted secondary populations were the authorities
and agency staff tasked to provide or facilitate health services to the at-risk population,
primarily local authorities, health clinic managers and workers, and local NGO staff.

The four communities were selected by the following criteria:
x area identified by health managers and municipal authorities as the poorest or ‘most
difficult’ in terms of accessibility and coverage
x willingness of community leaders (head of village and/or krom) to participate in the
study.





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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
4
Table 1: Study communities*
Health centre (HC) catchment and
operational district (OD)
Community
Tec Tlar HC, Lech OD Trabeng Chuuk
Mean Chey HC, Tboung OD Dam Charn and Dam Slaeng
7 Makara HC, Kandal OD Borey Kaylah
Samdach Ov HC, Cheng OD Tuol Sangkhae
*These areas are highlighted on the map on p. ii of this report.
Stage 1: Community consultations
The researchers and the national and municipal health authorities visited each operational
district office to identify the health centres with the most difficult to access or poorest
populations. The researchers then travelled to those identified health centres to target the
areas in their catchment that were the poorest or the most difficult to reach. Then the
researchers headed to those villages to meet with the village chief and explain the purpose of
the research. The village chief identified the krom with people considered the poorest
economically. The researchers then moved to the krom to meet with the krom leader to
explain the objectives of the research and the survey’s timeframe and make observations of
the area based on their guidelines.
Stage 2: Household survey
Eight researchers from the Centre for Advanced Studies conducted the household survey,
with supervision by municipal and national health authorities, a UNICEF consultant and senior
CAS researchers. A two-day orientation with the researchers and one-day testing of the
questionnaire took place to ensure good-quality data collection.

A two-day training with the eight researchers and a testing of the questionnaire in Boeung Kak
community was conducted prior to the beginning the household survey.

In three of the four communities, the krom leaders did not have a tabulated list of all
households or family names. In one village, the chief had an outdated list (according to the
krom leader). There were also inconsistent estimates provided on the numbers of families
residing in each krom. The researchers decided to divide the targeted poorest village areas
into three or four blocks, with 10–15 mothers with children younger than 5 years selected from
each block; the researchers moved from house to house in each block until 40 mothers had
been interviewed. The researchers made their own maps when necessary to ensure that they
were sampling the poorest areas.


Figure 1: Hand-drawn map of Dam Charn community (poorest krom labelled in black, at
the top along the Bassac River)




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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009

Table 2: Communities included in the household survey

Health centre
catchment and
operational district
Community No. of families Sample
household
survey
Tec Tlar HC, Lech OD Trabeng Chuuk 300–400 40
Mean Chey HC, Tboung
OD
Dam Charn & 250 30
Dam Slaeng 50 10
7 Makara HC, Kandal OD Borey Kaylah 2,341* 40
Samdach Ov HC, Cheng
OD
Tuol Sangkhae 89 40
Total 160 mothers
*The sample was selected from all the groups in Borey Kaylah. There are 30 groups in the village, and one group
consists of 75–80 households. Dam Charn and Dam Slaeng are treated as one community in this report.

Stage 3: Interviews and focus group discussions
For the qualitative survey, the researchers were asked to identify mothers and/or key
informants during the community consultations and household survey who could articulate the
social context and barriers to health service that they and their neighbours experience. Thus a
majority of the interviewees were purposefully selected for the in-depth interviews. For the
remainder of the sample, the researchers followed the same process as the household
survey, randomly selecting mothers according to the criteria of having a child younger than 5
years and living in the community.

For the FGDs with mothers, one group was selected from each community. In every case, a
key informant (local authority, resident practitioner or community leader) assisted in the
selection of eight mothers, all with a child younger than 5 years and from a very poor
household. However, the focus groups ultimately ranged in size from 8 to 20 mothers because
they were conducted in an open area and other residents joined the discussion.

The FGDs with health centre staff were conducted in the health centre closest to each of the
four communities. Participation was limited to the workers with employee status of the health
centre, with a specific request for the health centre manager, an immunization specialist and
an MCH provider. The FGDs ranged in size from 6 to 12 participants, depending on the size of
the facility and the staff’s willingness.

The interviews and focus group discussions were conducted by the Khmer researchers in
Khmer. Permission was requested from the participants for recording each conversation.
Representatives from the National Immunization Programme and UNICEF observed the
process.

Given the limited scope of the survey, men (aside from the local authorities) were not
purposefully targeted for interviews, although discussion took place with women on the role of
men in seeking health care (see annex 1 for more details on the research instruments,
methods and content).

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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Table 3: Study sample for interviews and focus group discussions
Health centre
catchment and
operational district
Community In-depth interviews Focus group
discussion
Tec Tlar HC, Lech OD Trabeng
Chuuk
Mothers, local authorities, health
centre staff
Mothers
Health centre
staff
Mean Chey HC, Tboung
OD
Dam Charn &
Dam Slaeng
Mothers, local authorities, health
centre staff
Mothers
Health centre
staff
7 Makara HC, Kandal OD Borey Kaylah Mothers, local authorities, health
centre staff
Mothers
Health centre
staff
Samdach Ov HC, Cheng
OD
Tuol
Sangkhae
Mothers, local authorities, health
centre staff
Mothers
Health centre
staff
Total 8 focus groups

Data analysis

Following the collection of data through the household survey in stage 2, debriefing meetings
were conducted in the CAS office. Responses to the few open-ended questions were recoded
before the data was entered into the SPSS program (statistical analysis software).
Interpretation of the findings was further debated and validated with the team of researchers
at a follow-up meeting. The data was analysed again in the SPSS program and entered into
the Excel format for graphic presentation.

Interviews and focus group discussion analysis

Following the interviews and focus group discussions in stage 3, the researchers recorded the
summaries into thematic areas. The summaries were recorded in Khmer and were typically
five pages in length. Following those interviews and FGDs, the researchers met to discuss the
main findings and the implications for recommendations.

The outcomes of the analysis were organized into three sections, based on the three stages
of research. The findings from the three research method were cross-referenced for
consistency in themes. Finally, the overall findings were compared and contrasted with
analysis in national and international literature to arrive at a representation of the situation and
the recommendations on strategy for improving health service access.
Study limitations

The research is not a population-based survey with a sampling methodology that produces
generalised results regarding health status, knowledge or behaviours which is representative
of at-risk populations in Phnom Penh. Rather, it provides an in-depth analysis of four
communities in terms of how community members, health staff and local authorities perceive
their access to health services and their opinions on how to improve that access among
marginalized populations. Further, the research is not a quality assessment of health service
provision, although it seeks to understand community members’ perceptions of the quality of
the service available to them.
- 7 -
Health Service Access Among Poor Communities in Phnom Penh 2009






2. COMMUNITY
CONSULTATIONS
FINDINGS

- 8 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Community profile 1: Trabeng Chuuk

Trabeng Chuuk is located in the catchment
area of Tec Tlar Health Centre, in the Lech
Operational District. The community
members originally resided near a lake a
short distance away. However, ten months
prior to the study research, a large fire
destroyed their housing and the residents
relocated to Trabeng Chuuk, which is an
empty building site about 1.5 h in size.
Different estimates were given for the
number of families residing here, ranging
from 300 to 500 families.

The environmental conditions are very
poor. According to interviews and
observations, there is one toilet for the entire community – at least 300 families. Because of
the recent relocation due to fire, most of the families are still living in plastic shelters; others
are living under coconut palm- or tin-roof structures. Liquid and solid waste are visible in most
pathways and roadways, with uncollected rubbish heaped in one corner of the site. Drinking
water is piped to the site, and large water containers are available.

Various NGOs are helping the community. Hope Hospital provides a once-weekly service for
medical curative care. CARITAS brings water supplies. World Vision provides for home-based
care for people who are HIV-positive. The staff of the Tec Tlar Health Centre comes to the
area if called, but there is no consistent mobile health service.

Some of the community members work as builders and market sellers. But incomes are very
low. Families do not have health insurance or ‘poverty exemption cards’, which exempt them
from certain health care fees. Many children are not attending school. Many of the families
reported that they were waiting for the local authorities to permit them to return to the original
housing site, which was being redeveloped. But the community members are unclear on the
timing of the return or if there will be any compensation if they are unable to return.












A mother’s story in Trabeng Chuuk

“My father had many wives and children. My mother was from a remote province. She was very
beautiful. My father drove the boats up and down the river and was away a lot…. I have no
education. I came to Phnom Penh to work in the garment factory. But then I started also working
in the beer halls and karaoke clubs. Then I met my husband; he was a much older man. And he
was a drug [addict]. The [police] caught him, and now he is in prison for two years. I do not want
to see him again. I [was pregnant]. I tried to drink a lot of alcohol so the baby would abort. But
this did not happen. They said that they would take my baby for $100. But after I delivered the
baby, I loved the baby and now I am keeping him. It cost me $100 to deliver the baby at the
hospital. I cannot return to my mother. I am too ashamed. I am alone now and I have nothing. I
work for $2 a day washing the clothes of the people who live by me. I receive no help from the
outside – but the people who live nearby me, they help. I have nothing.” – the young mother was
living with her newborn under a tarpaulin in a space 2 x 2 m
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Health Service Access Among Poor Communities in Phnom Penh 2009

Community profile 2: Dam Charn and Dam Slaeng

Dam Charn is a village in the catchment area of Mean Chey Health Centre, in Tboung
Operational District. The community was established here in the early 1980s. A large fire
several years ago destroyed most of the community, but the people recently returned to live
along the bank of the Bassac River. The community is of mixed Vietnamese and Khmer ethnic
origin. There is a Khmer village chief and a Vietnamese community leader. One NGO
provides on-site bilingual education programme for the children.

Dam Charn’s population is unclear. No one had any accurate figure or household listing. Many
children were observed at home with elders while the parents were away working. The
researchers reported there is no waste removal system or system for managing liquid waste
for people living closer to the river. There are no toilets or safe water supplies in the area.

Dam Slaeng village was originally part of Dam Charn village until they were separated in
2007. According to the local authorities, some of the poorest residents in Dam Slaeng (in krom
8, located in the cemetery) had recently migrated from other provinces (such as Prey Veng
and Takeo).The krom consists of approximately 50 families. Six families are living in an
unused building. Here also the environmental conditions are very poor, with crowding and lack
of solid waste disposal. As well, many children seemed to be not attending school.

Due to the proximity of these two communities to each other and their historical connections,
for the purpose of this study, the communities were studied jointly using one sampling frame.
Community profile 3: Borey Kaylah
The Borey Kaylah community is located in the catchment area of 7 Makara Health Centre, in
Kandal Operational District. The residents began moving here in the early 1980s, setting up
temporary homes. In 1993, the community received official status, and the district (sangkhat)
authority appointed a village chief. Between 2003 and 2007, formal building structures were
established in some spots, and a total of 30 krom were recorded. The groups in total entail
some 1,779 families and a population of 9,979 people. The krom leader was unclear on the
number of residents or families but said that the village chief’s list was probably outdated.
Each krom in this location contains 79–80 families. Three health volunteers cover the
population. Some of the families live in high-rise tenement blocks, while others reside in more
temporary single-level dwellings.

The standard of living is very low. According to the village chief, people do not live day to day
but moment to moment. The residents typically earn money as construction workers, rubbish
collectors and market sellers.

There are many health service outlets near the community. These include the referral hospital,
the 7 Makara Health Centre, Hope Hospital (an NGO) and other government hospitals. The
staff at the health centre report that they are unclear on current service use by Borey Kaylah
community members because they are so mobile and there is no structured outreach health
service programme. The researchers verified that many of the community members have
health insurance cards.
- 10 -
Health Service Access Among Poor Communities in Phnom Penh 2009
g
Community profile 4: Tuol Sangkhae
Tuol Sangkhae is a village in the Samdach
Ov Health Centre catchment area, in
Cheng Operational District. The community
members live alongside a narrow gauge
railway track with a train running through
twice daily to transport fuel to a nearby
depot.

Tuol Sangkhae consists of 19 krom, with a
total of 367 families. Of them, 153 women
have children younger than 5 years. This is
also a mixed community, with people of
Khmer and Vietnamese ethnicity. Most of
the population are factory workers, builders
and motorcycle taxi drivers. A few better-off
families live further away from the railway track, having moved here since 1988; some have
been selling land at the railway site to others and moving on. This area has formed its own
community association.

The houses appear to be temporary and are crowded close to the railway track. There are
obvious problems with solid and liquid waste and mosquito control. A private doctor operates
a clinic along the track and assisted the researchers in contacting households for the study.
Some community members reported experiencing economic hardship associated with the
recent closure of factories. Community members said they are using the health centre for
vaccination services. For other health services, they go to private providers and government
hospitals.




















A migrant’s story in Tuol Sangkhae

“I have been here for two years. I moved from another temporary location after [the
authorities] wanted to relocate the homes. Where I was staying was too crowded.
There was no room. So we moved here. I had my baby one month ago. The birth was
quick – it took only ten minutes so I delivered the baby myself. [Someone] contacted the
private doctor and he came quickly and cut the cord.

I left my province ten years ago. My family’s land is in the higher country. There the
soil is dry and sandy. Without a well you cannot make a garden – you cannot make a
living there. So we came here to earn income. But now the factories are closing, and
it’s harder to find money. If I stay here long enough, maybe we can get some money …
and we can go back to the province and make a well.” – the woman and her family live
in a space 2 x 3 m, roughly 8 m from the railway track
- 11 -
Health Service Access Among Poor Communities in Phnom Penh 2009








3. HOUSEHOLD SURVEY
FINDINGS AND
OBSERVATIONS

- 12 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Figure 2 provides a snapshot of the household survey findings and observations the
researchers made during their visit to the four targeted communities and the 160 households.

Figure 2: Summary of household survey findings










































Community background and family socio-economics



Sample size
x A total of 160 mothers with children younger than 5 years were randomly selected from the four
communities.
x In most cases, there was no household list; so the random selection was done by dividing a
community into ‘blocks’, with ten mothers selected randomly from each block.
x The communities were identified by operational district officers and health centre staff as the ‘most
poor’.
x The questionnaire of mostly closed but also open-ended questions covered family socio-economics,
health knowledge and communication and service coverage and use.

Socio-economics and environment (survev and observation)
x All respondents reported a low income (62 per cent had an income of $1–$5 per day from the main
income earner) and a low education level (57 per cent had not completed primary school).
x There are high health costs, with families spending on average of $66 in the previous three months
on health care costs.
x The communities suffer from poor solid and liquid waste management.
x In some cases, there is inadequate shelter.
x The respondents noted a lack of social mobility; they had been in the four communities on an
average of 7.6 years.
x The respondents also cited lack of social protection; despite being the four poorest communities
identified by health district officers, only 14 per cent of the respondents have health insurance of
any kind.
x The respondents reported a sense of physical insecurity, especially at night.

Health communication and knowledge
x Mothers have good knowledge of EPI.
x The mothers retain their children’s yellow immunization card (63 per cent) despite their difficult
housing conditions.
x Electronic media (TV) seems to be effective in reaching mothers.
x Knowledge on danger signs in pregnancy and warning signs for child illness is limited.
x Local health educators/communicators are not very visible.

Service coverage and use
x Coverage for EPI, antenatal care and birth delivery at facility is good, even in the poorest
communities.
x The population prioritizes health care.
x Health centres are used for prevention programmes, such as EPI and reproductive health awareness.
x Outreach services have stopped, and 75 per cent of the survey respondents said they do not know
staff at the health centres very well.
x Some 19 per cent of the 160 mothers had used the health centre in the six months prior to the
survey for a child health consultation.
x The private sector is the first choice for child curative care (50.3 per cent) and Kantha Bopha
hospital (20.8 per cent).
x Health centres/government hospitals are the first choice for preventive care (EPI: 79 per cent and
reproductive health: 66 per cent at government facilities).
x Some 53 per cent of the mothers said they have to pay for immunizations.
x The use of provider is driven by perceptions of quality, cost and trust.

- 13 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Of the 160 survey respondents (women with a child younger than 5 years), the mean age is
29 years. The mean size of household is 5.8 persons. Some 84 per cent of the respondents
are Khmer and 13 per cent are Vietnamese; 93 per cent are Buddhist. The Vietnamese
respondents resided predominantly in the Dam Charn community.

Around 71 per cent of the respondents identify themselves as migrants, and 29 per cent
identify themselves as ‘mobile’ (respondents were requested to self identify as mobile – this
commonly means that they are frequently coming and going and also residing in other
locations). On average, the respondents have lived in the community for 7.6 years. Some 38
per cent of them moved to their current location from another area in Phnom Penh; 55 per
cent came from other provinces. Figure 3 highlights the primary reasons the respondents
moved to the community.

Figure 3: Main reason survey respondents moved to the community



















Environmental conditions: Observations made during the community consultation and
household survey detected immensely poor environmental standards. Trabeng Chuuk, in
particular, resembles a humanitarian emergency community. Most shelter here is plastic
sheeting or makeshift materials. There is one pit toilet for at least 300 families. There are open
drains and waterways and no collection of rubbish. Mosquitoes and dengue fever were
mentioned as common problems. Although the average household size of 5.8 persons is
similar to the national average, in slum conditions this represents overcrowding. The
researchers observed that many families live in 2 x 3 m living spaces.

Social problems: Other problems noted during interviews in the community include physical
insecurity at night, social isolation of single mothers, gambling and alcohol consumption, non-
school attendance and increasing unemployment due to the economic crisis (specifically, loss
of work at garment factories).

Socio-economics: Most professions of the main income earners in each respondent’s family
are construction (22 per cent), home or market selling (19 per cent) and motorcycle taxi
driving (17 per cent). Other work includes carpentry and electrical repair (11 per cent),
secretarial (8 per cent) and government jobs (7 per cent).
What was the main reason you moved to this community?
(N = 160)
Economic reason,
74 (46%)
Family reason, 62
(39%)
Others, 3 (2%)
Land or home lost,
21 (13%)
- 14 -
Health Service Access Among Poor Communities in Phnom Penh 2009
At least 300 families share this one toilet in Trabeng
Chuuk community

Only 57.5 per cent of the respondents had
completed primary education. Given the
low education levels, it is not surprising
that the income levels in the families
surveyed are also low. Some 62 per cent
of the respondents stated that the
household income is between $1.25 and
$5 per day
1
(figure 4). Although this is in
line with the gross national income for
Cambodia (at $591), these respondents
need to support an urban cost of living.
City costs tend to be higher than in rural
areas, particularly for health care. In the
three months prior to the survey, the mean
expenditure by households on health care
was $66. Some 25 per cent of the
respondents’ households spent $100 or
more.

When balanced against the income and other family necessities of education and food, the
health care costs are clearly very high.

Some 53 per cent (148) of the mothers surveyed reported that they paid for their child’s
previous immunization, although no specific information was collected on how much each
paid. Only 14 per cent had a ‘poverty card’ or ‘insurance card’, which exempted them from
fees for certain health care services; those having a poverty card all lived in Borey Kaylah
where an NGO operates (and manages) a health equity fund.
2


Figure 4: Income of main income earners (4,000 riel = US$1)


1
US$1 is equivalent to approximately 4,000 riel (Khmer currency)
2
A Health Equity Fund is a pro poor health insurance scheme for hospital care services and for a selection of
primary care medical services (see Annear et al, 2007)
Average income per day of main income earner in household
(N = 160)
5,000–20,000 riel
62%
Greater than
20,000 riel
33%
Not regular
2%
Unsure
1%
Less than 5,000 riel
2%
- 15 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009

Health communication and health knowledge

Health communication: Some 77 per cent of the 160 mothers reported hearing or seeing a
media message on immunization within the previous three months. Of those who heard or
saw the information, 84 per cent picked it up through television. Based on the responses,
obtaining information on the importance of routine immunization or an immunization campaign
seems limited beyond the television. Government health workers (who the mothers said they
do not know very well) are the main source of information outside of television (40 per cent).
Around 82 per cent of the survey respondents reported hearing or seeing a media
message/programme on women’s health within the previous three months. Of those who
heard or saw the information, 89.4 per cent picked it up through television. Outside television,
government health workers (20 per cent) are the next largest source of information for
women’s health, followed by friends and neighbours (at 15 per cent) and then parents or
relatives (at 5 per cent). This data, combined with the service coverage data indicates the
effectiveness of television in its reach. However, the survey results also suggest poor social
networks for health information, especially women’s health.

Health knowledge: The majority of mothers could state three major diseases prevented by
immunization. This finding is reinforced by the fact that 63 per cent of mothers had the
government immunization yellow card in their household possessions. This is a high retention
rate, considering the insecurity and crowded living conditions of the households.

Figure 5: Mothers’ knowledge of diseases preventable by immunization



The respondents were also questioned on their knowledge of child and maternal health
danger signs. As shown in figure 6, 46 per cent of the 160 mothers identified bleeding as a
danger sign in pregnacy, and 27.5 per cent cited swollen hands and feet. These responses
link with the finding that only 40 per cent of mothers reported hearing from government health
11.0
18.1
25.2
31.6
68.4
71.0
76.8
0.0 20.0 40.0 60.0 80.0 100.0
% of mothers who mentioned disease prevented
by immunization
Diphtheria
Whooping cough
Tuberculosis
Hepatitis B
Measles
Polio
Tetanus
Mothers’ knowledge of diseases preventable by
immunization (N = 160)
- 16 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
workers about maternal health issues. It also links with the finding that only 60 per cent of
respondents reported hearing information on danger signs from a health worker during their
last antenatal care visit.

Figure 6: Mothers’ knowledge of maternal danger signs



For child health, only 26 per cent and 25 per cent of mothers identified fast and difficult
breathing, respectively, as reasons for immediately seeking a health facility.

Figure 7: Mothers’ knowledge of child health danger signs


3.1
6.9
11.9
21.9
25.0
26.3
45.0
48.8
95.6
0 10 20 30 40 50 60 70 80 90 100
% of mothers who identified danger signs
Child has blood in the stool
Child becomes sicker
Child not able to drink or breastfeed
Severe vomiting
Child has difficult breathing
Child has fast breathing
Severe diarrhoea
Others
Child develops a fever
Mother’s knowledge of child health symptoms
requiring referral (N= 160)
0.6
10.0
11.9
12.5
27.5
46.3
69.4
0.0 20.0 40.0 60.0 80.0 100.0
% of mothers who Identified danger signs
Trouble with vision
Reduced/faster foetal movement
Severe headache
Fever
Swollen hands or face
Bleeding
Others
Mothers’ Knowledge of Danger Signs in Pregnancy
(N = 160)
- 17 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Health service coverage and use

Immunization: Immunization coverage in the poor communities is satisfactory. As figure 8
shows, the third dose of diphtheria, pertussis and tetanus, and the hepatitis B vaccines was
verified by cards for 88 children of an eligible population of 139 (63 per cent). A further 41
children (29.5 per cent) had been vaccinated, according to the oral history from the mothers.
Only 10 of 139 children (7 per cent) were reported by the mothers as not vaccinated.

Figure 8: DPT-Hepatitis B coverage




Of the 160 children, 148 received vaccinations as scheduled. The main reason given for the
child not being immunized was that the mother was ‘busy’ (9 of the 12 responses). Of the
vaccinations provided, 68 per cent were provided at the health centre, 11 per cent at the
government hospital and 7 per cent at Kantha Bopha hospital. Only 2 per cent were provided
through the private sector. Some 53 per cent of the mothers reported paying for the previous
vaccination. The main reason for not vaccinating at the health centre was that some mothers
did not know the staff at the health centre (33 per cent) or preferred to vaccinate at another
place (23.5 per cent).

The Government stopped funding immunization health outreach services to communities two
years ago. The survey results confirm the health outreach services have stopped. When
asked how often an EPI team visited their area, 35 per cent of the mothers replied they were
unsure, and 15 per cent said not at all. Around 34 per cent indicated there were six monthly
visits from an EPI team. As stated earlier, 53 per cent of mothers reported paying for the last
immunization provided. However, only 10 per cent of those who did not attend the health
centre for a vaccination indicated that the cost was the barrier, suggesting that costs for
immunization services are not a significant barrier or are sufficiently low. However, the fact
that 9 of 12 mothers who did not receive vaccination at all indicated they were busy does
suggest competing economic priorities with immunization programmes that might not exist if
the service was free.

63.3
29.5
7.2
0.0 20.0 40.0 60.0 80.0 100.0
% DTP3
Immunization date DPT-HepB
recorded on the
yellow card
Mother reports
immunization was
given
Immunization not
given
DPT-HepB3 coverage (N = 139)
- 18 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Figure 9: Reasons for not receiving immunization at the health centre




Child health: Respondents were asked to identify the last child illnesses experienced by their
child (younger than 5 years) within the previous six months. A total of 149 children of 160 had
had an illness, with the different conditions shown in figure 10. The most common childhood
illnesses experienced were acute respiratory infection (ARI) (40 per cent), fever (37 per cent)
and diarrhoea (13 per cent).

Figure 10: Previous childhood illness



3
7
13
37
40
0 20 40 60 80 100
% of children
Other
Not sick
Diarrhoea
Fever
ARI
Previous illness experienced by child in the previous six months
(N = 160)
3.9
5.9
5.9
5.9
9.8
11.8
23.5
33.3
0 20 40 60 80 100
% response N = 51
Distance
Poor quality
Do not care
Other
Cost of immunization
Mother busy
Vaccinated at other place
Mother doesn’t know
or trust staff
Main reasons child did not receive vaccination at the health centre
(N = 51)
- 19 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
When mothers were asked if they had used the nearest government health centre for a child
health consultation in the previous six months, 19 per cent (31) of the 160 replied affirmatively.
When mothers were asked how well they know the health centre staff, 75 per cent replied that
they do not know them very well, 16 per cent said they know them a little bit, and 9 per cent
know the staff very well. If their child had been ill in the six months prior to the survey, the
respondents were asked to identify their first provider of choice. Private clinics (27 per cent)
and local pharmacies (23 per cent) were the main providers of choice; some 21 per cent said
they used Kantha Bopha hospital, and 9 per cent used the health centre.

Figure 11: First choice of provider for treating child illness























1
1
3
9
15
21
23
27
0 10 20 30 40 50 60 70 80 90 100
% responses
Not yet treatment
Self-treat
Shop
Health centre
Public hospital
Kantha Bopha hosp.
Local pharmacy
Private clinic/hospital
First choice of provider for childhood illness consultation
(N = 149)
- 20 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Figure 12 outlines main reasons for choice of provider. Perception of quality is the main
reason for the first choice of provider (49 per cent), followed by cost factors (19 per cent) and
distance (12.2 per cent).

Figure 12: Reasons for first choice of provider to treat child illness



Reproductive health: Unlike for child health care, the findings for reproductive health care
indicate a higher level of use of government facilities. Some 61 per cent of respondents had
three or more antenatal care visits for their previous pregnancy. As shown in figure 13, the
majority of the mother respondents stated they received most of the recommended antenatal
care services, although information provided on warning signs and vitamin A had lower
coverage.

Figure 13: Services provided during antenatal care




0
10
20
30
40
50
60
70
80
90
100
% coverage
Vitamin A
supplement
Warning
signs
Diet
advice
Tetanus
vaccination
Iron
supplement
What services were provided during antenatal care
(N=160)
3.4
6.8
9.5
12.2
18.9
49.3
0 10 20 30 40 50 60 70 80 90 100
% responses
Trust
Waiting
Other
Distance
Economic
Quality
Main reason for first choice of provider for previous
childhood illness (N = 148)
- 21 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Table 4 indicates that the vast majority of previous deliveries were facility based, with the
majority taking place in public hospitals (48 per cent) and health centres (31 per cent).

Table 4: Location of previous delivery

Delivery location Frequency %

Public hospital

76

48
Health centre 49 31
Home 20 13
Private clinic 15 9
Total 160 100


Consistent with previous responses regarding choice of health care provider, the majority of
the mothers perceived quality as the main factor (40 per cent) in choosing a reproductive
health provider, with distance (21 per cent), economic reasons (19 per cent) and staff attitude
(10 per cent) as additional factors.

In terms of delivery location, the first choice was driven by economic factors (24 per cent),
distance (20 per cent), trust (19 per cent), quality (19 per cent) and attitude (14 per cent). If
trust, quality and attitude are combined, then clearly quality factors are more important than
economic factors in health care-seeking behaviours.



- 23 -
Health Service Access Among Poor Communities in Phnom Penh 2009





4. INTERVIEW AND
FOCUS GROUP
DISCUSSION FINDINGS
- 24 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Social context for health service access

Social structures and health care-seeking behaviour

To obtain a deeper understanding of health care behaviours and family capacity to access
health services, the study’s researchers looked at social structures in the four communities, in
particular:
x the history of the community
x any differences between the village and the community
x the main source of family employment
x how families manage competing resource demands for health, nutrition and education.

In most cases, the communities were
established directly after the overthrow
of the Khmer Rouge rule, which took
place in 1979. Thus they have a
relatively long history of
multigenerational entrapment in poor
living conditions. The communities
appear to be continuously growing;
there was a particularly strong growth
period around 2000. The exception is
Trabeng Chuuk, from which many
families had been dispersed because of
fire.

It is not apparent that these
communities are homogeneous
economically, although without doubt the majority of the populations are very poor. However,
most of the communities appear to have a visible social hierarchy. This is often evident in the
way the communities are physically structured. For example, at Tuol Sangkhae, the poorest
community members live closest to the railway line, and slightly better off households are
situated further from the track. At Dam Charn, the poorest communities live closest to the river
banks, with more established families in better housing located further up the river banks. At
Borey Kaylah, some families have been relocated into apartment blocks, in contrast to poorer
groups who are still residing in temporary housing. At Trabeng Chuuk, residents are classified
as those who have procured land and those who are renters.









The researchers observed that community members often differentiated between
administrative structures (village) and ideas of ‘community’. Most understood the term ‘village’
in an administrative sense, such as in reference to the village leaders. Village leaders make
the final decision on key issues and are social mobilizers, but they were not identified with the
Finding 1: Social class and health
Poor communities are long sustaining, and the poverty found in them is multigenerational.
However, not all members of each community are very poor. This makes a case for
sustained and targeted social support in order to break the cycle of multigenerational
poverty entrapment.
- 25 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
term ‘community’ (saharkum). This was reserved most often for local agencies, groups or
NGOs that assisted with networks for health service or credit or security of land tenure. In one
community, a private medical doctor was identified as the community leader, and this was
different to the role of the krom leader or village leader. In another location, the community
was identified as within a social protection health network.

In a third location, the community was identified in terms of defending land tenure for the poor.
Up to 12 subcommunities were identified within one of the four communities, with the local
authority in this case expressing some dissatisfaction with the lack of communication and
vested interests among so many subcommunity groups. An ‘ethnic community’ was identified
as parallel to the Khmer local authority system in one community.

In most cases, the collaboration between community substructures and administrative
structures appeared to be positive. In particular, the local authority in Borey Kaylah cited the
collaboration between the NGO Family Health Development (FHD), local authorities and the
population as being the best model of relationship between community subgroupings.

Beneath these administrative and community layers, families and neighbours form the basic
social structure. In times of social stress (such as needing funds to cover high health care
costs), it is to family and neighbours that people turn first for help.












The different dimensions of social insecurity among the very poor

Many of the focus group participants expressed feelings of insecurity, which very much relates
to their social context rather than individual behavioural constraints. Physical insecurity was
expressed in terms of night-time disturbances, assaults and abuse of alcohol and drugs. But it
was social and income insecurity that was the most predominant theme in the discussion of
social context.

Social insecurity was expressed in terms of insecurity of land tenure. “We don’t know what will
happen to us” and “we don’t know when we will have to move” were common statements from
community members in two of the communities.

Income insecurity was often expressed in terms of irregularity of income of the main earners in
households. Motorcycle taxi drivers, construction workers, hairdressers and markets sellers
are all subject to the vagaries of the market place. For most income earners in society,
variation in income can be managed through savings or borrowings. But for income earners of
US$1–$2 per day, their family lives in a chronic state of insecurity – uncertain of the income
that will come, especially for daily nutrition and education needs for children. This is especially
the case when income is irregular.
Finding 2: Social structure and health
Poor communities are complex in structure and do not rely solely on the administrative
leadership for social cohesion or social action. Community members often identify
more closely with community subgroups, NGOs and even resident health practitioners
and are primarily reliant on their own family and neighbours for assistance. This
supports a case for a health promotion strategy to work locally with community
subgroups and families and their networks rather than relying on the administrative
organization and procedures.
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
The researchers found that in many cases, the income insecurity led to restrictions on food
purchases and indications of under-nutrition. Notably, families will borrow or sell household
items when they need to pay for health services, but the daily education costs are often
deemed non-affordable. There were frequent reports of children dropping out from school or
attending irregularly due to lack of family income.

Health insecurity was surprisingly not often expressed in terms of not being able to afford
health care services (although this is sometimes the case). Access to water and sanitation
and the absence of any institutional or social mechanisms for waste management was the
most dominant theme in the discussions. Community members, local authorities and health
workers consistently identified poor waste management, water supply and sanitation as the
main threats to the health of families. Most childhood illnesses and even adult illnesses were
attributed to uncleared rubbish, lack of toilets, standing water and mosquitoes. Sometimes the
problems were attributed to personal and household behaviour, but more often, they were
identified as community characteristics that people – even the local authorities – felt
powerless to resolve. “The words of the poor are cheap,” explained one long-term resident.

Given these conditions, it is hardly surprising that there is a heightened sense of ‘living for the
moment’. It is difficult to undertake or envision long-term community or household planning in
this chronic state of daily insecurity and powerlessness. Frequently, the researchers heard
community members say they are “living for the day”. One local authority member indicated
that many community members do not even live for the day but live from “moment to moment”
in order to cope with each day’s needs.












Exclusion and social isolation

Participants in both the in-depth interviews and focus group discussions talked of exclusion
and social isolation, mostly related to the structural determinants of income capacity,
education access and powerlessness previously noted.

Single mothers in particular are at high risk of exclusion due to absolute income poverty. In
one case, a single mother was completely dependent on her neighbours for income and social
contact. Because they dropped out of school, many young adults are exposed to risks of drug
abuse and prostitution.

The researchers found limited examples of community activities or structured gathering
locations for young people. In one community, an NGO was active in providing therapy for
injecting-drug users, and in other communities, home care visits were conducted by an NGO
supporting people who are HIV-positive. Overall, services or social activities are not in place
for young people in the four communities.
Finding 3: Social insecurity
There are many aspects of social insecurity in communities that impact on health and
well-being. These include physical, income and health insecurity. This social context
for health and well-being indicates that the primary determinants of poor health in these
communities can best be understood in structural rather than behavioural terms. This
supports a case for a more comprehensive social policy approach to address the
structural factors rather than a reliance on health education strategies for individual
behaviour change.
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Health Service Access Among Poor Communities in Phnom Penh 2009

The process of social exclusion starts very early. Repeatedly, community members
highlighted the daily income demands of education as a major strain on family income and on
social participation. In some cases, NGOs provide education programmes for young children
within the community. In other cases, NGOs provide income support for children to attend
schools. Local authorities try to help the children of poor families through the provision of a
letter to the school teacher exempting them from paying school fees (as is the case with
certain health care services). There was one example of children being transported to the
local pagoda for education classes where children in a community could not afford the
government school.





























The dynamics of social exclusion are structural rather than behavioural in nature. Although,
there were reports about negative attitudes among health clinic workers who look to see what
a patient is wearing to decide who will be treated first – “You have to have money. If you do
not have money, they won’t pay much attention to us,” explained one resident. Community
members also reported that they are “looked at” by health staff to determine whether they can
pay or not.

In all four communities, health centre staff indicated that they exempt the very poor from
payment for certain health services. However, those health workers also indicated that in the
absence of a poverty card or a letter of exemption from the local authority, they will look at the
clothing or personal items of a patient to make an on-the-spot poverty assessment.

Finding 4: High-risk groups for social isolation
There are particular subgroups of the poorest families in the four communities that are
particularly at high risk of social exclusion and social isolation – these include single
mothers, young school-age children (but not attending school) and teenagers. Social
programmes should target these most vulnerable groups to provide them with a
minimum level of social opportunity for development and social protection.
Social exclusion

The depth of social exclusion is
perhaps expressed most clearly in
Dam Slaeng where makeshift homes
crowd around burial plots in the
cemetery and children run between the
tombstones. “The children are not
afraid of the ghosts – the ghosts are
afraid of the children,” one resident
commented. In one abandoned
building, six families had set up
blanket partitions to separate sleeping
areas. Some of the current residents in
the community had only recently
moved there due to newly
impoverished circumstances. One
woman said she had lived there since
the early 1980s.
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
The absence of systematic social protection mechanisms increases the risk of a mistrustful
relationship between health professionals and clients. This equally applies to the relationship
between the education sector and community, with some people indicating that children are
“afraid” of the teacher if they do not have enough money to pay for school expenses.

The daily struggle to manage family food, education and health care costs with a low income
was a consistent theme spoken of throughout the research.

According to one local authority official, “Health is a big problem here. When people get sick
here they go to the private health care provider first and buy medicine. This means they
spend a lot of money on this – they spend a lot on medicine. But if they go to the government
service, they would not spend so much money. Then they spend on the children for going to
school. I provide them a letter sometimes to the teacher so the teacher does not take money
from the poor, but the teacher still needs to take money. So if we think about it, health and
education and food, they spend more on education – they have to spend on education every
day…when they do go to school they often stop at level two or three…they just don’t have the
capacity to send them to school.”

And one mother commented, “I have two children going to school, but one has had to
stop...because we have no money for the teacher. Our family is spending more money than
our income….our standard of living is lacking. We have no rice field or garden. For health
care, we pay money every now and then, but for education you have to pay every day and for
food we have to spend most of all.”

Families use various coping mechanisms for their day-to-day survival and basic needs. For
health care, they typically sell household or personal property, borrow from a family member
or neighbours, seek out NGO or pagoda support, or ask for assistance from the local authority
(letter of poverty status to exempt them from certain fees). Health centre staff indicated that
they do not ask the poorest of the poor to pay, but there were many cases in which people did
not seek out health care, opting for exclusion or social restriction.

In summary, people in the four
communities mentioned the following
coping mechanisms:
x not sending children to school
x restricting food intake
x in some instances, not seeking
health care for chronic conditions
x borrowing money or selling
property to pay for health care.





Finding 5: Social vulnerability and health protection
Health workers assess the poverty status of their patients, and patients know they are
being assessed for their capacity to pay. As a result, mistrustful relationships have
developed between government health centre staff and community members. Those
people with exemption cards expressed confidence in attending health facilities. This
makes the case for extending the health equity fund or related health protection schemes
to increase the use of health care services by the very poor.
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Social networks for health

When questions regarding social networks for health care were asked in the research
interviews and discussion groups, most of the participants indicated that they were not aware
of any formal network (with the exception of the health equity fund scheme in one community).
However, following further discussion on patterns of health service use, it became clear there
are many informal social networks for health care.

Informal networks: Informal networks mostly consist of word-to-word relay of information about
where to access health services that are of quality or are affordable. Many mothers reported
taking their children to the Kantha Bopha Hospital for care and treatment; reasons given for
this choice were quality, perceived skill of the health providers, effectiveness of treatment and
the zero cost. Nearly all the mothers interviewed said they had heard about the hospital from a
neighbour or family member.

The same applied to seeking abortion services Women discussed the various methods and
outlets available for an abortion, nearly exclusively through pharmacy shops or through
favoured private practitioners. But what they knew they had learned from other women.

For other situations, the choice of delivery was motivated by perceptions of the quality of the
provider as expressed by a family member or neighbour. The women reported that within their
family, they are the main caregiver and decision-maker on health issues. In fact, they were
quite dismissive of the man’s role in health care decision making. The man’s role was valued
more in terms of arranging transport in an emergency or in organizing the funds to cover the
health care costs. But in terms of importance, women identified themselves as the primary
agent, care giver and decision maker on health matters.

In terms of recommendations for improving health service access and public health in general,
many of the research participants indicated that it is necessary for local authorities and
community members to be active through discussion, meetings and even house-to-house
awareness raising. This suggestion reflects the importance of word-of-mouth networking of
health information and how it appears to be the most influential factor affecting health care-
seeking behaviour.













Formal networks: The researchers identified clear NGO roles for improving health care access
or in alleviating social conditions that impact on people’s health. Examples of practices
already in place include agencies providing home-based care for people with HIV or AIDS
(these were very visible and frequently mentioned), community schooling or subsidizing
Finding 6: Informal health networks
Informal networks are likely to be the most influential factor in determining health care-
seeking behaviour. The quality and cost of health care services are routinely discussed
among families, friends and neighbours. This being the case, the most powerful
advertisement for improving health care and health care access is the quality, attitude and
cost of services provided directly to the communities. Community members then share
this information through their local social networks. Because people have choices, they
will make their own decision about which service is most effective and affordable. If
providers do not change, then the only way to influence health care-seeking behaviour is
through local social networks.
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
payments to teachers, direct health care services provided by NGOs and helping people
access services through health insurance or health referral mechanisms. Both the local
authorities (village leaders and group leaders) and community members were highly trustful
and confident in the role of NGOs at the community level in supporting social protection and
poverty alleviation. The main limitation of the NGOs was perceived to be the lack of adequate
service coverage for the poor.

Local authority networks: Local authorities’ identified there own role in health networking,
mainly in the passive terms of gathering population statistics or conducting social mobilization
activities for immunization campaigns. However, the apparent limited role of local authorities
in public health networking for safe water, sanitation and waste removal was striking. Both
health workers and local authorities and community members seemed to lack clarity on
exactly who were the primary organizers and responsible agents for public health care and
how information and requests for public health interventions are networked. (Note: Care
should be taken with this conclusion. The hesitancy of local authorities to participate in public
health functions in these communities may be related to the perception that some of the
communities are illegally occupying public lands.)

Resident health practitioners and volunteers: The researchers found examples of health
practitioners who had been residents in the communities over a long period of time (doctor,
midwife). These resident practitioners are well known and trusted members of the community
as well as trusted health care providers. They are very influential in affecting the health care-
seeking behaviour of the population. One resident practitioner had previously worked in a
community clinic operated by the Reproductive Health Association of Cambodia (RHAC),
which is a national NGO. When the RHAC support ended, the practitioner continued to refer
community members to the health centre and meet with the health centre staff regularly to
discuss the health status of the community. This study confirms the findings of previous urban
health evaluations in Phnom Penh (such as Vickery, 2003), which advised that positioning
health workers in at-risk communities is an effective way to link the population to the formal
health system.










Finding 7: Local health networks
Resident health practitioners and NGO networks are powerful ways to spread health
information and make health referrals, especially when linked to local health authorities
and local government health services. Local health networks are linked to social
networks through the formal and informal providers who frequently visit the
communities or actually live in them.
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009


























Utilization patterns of health care services and access barriers

The health care market and the health care system

With help from local women’s groups, the researchers mapped the health care market options
available to the urban poor in the four communities. The women’s group members identified
the locations and types of providers on hand-drawn maps and listed out the reasons why each
provider is used and the choice of service. For example, the map of Dam Charn community
(figure 14) illustrates the significant range of available health service choice.

Not marked on the map (outside the map boundary) is the wide range of choices of
government and NGO hospitals and clinics used for delivery care, immunization, family
planning and child sickness care. An additional range of services and choice is available
locally for treating sick children, such as pharmacies and shops selling medicines. What
became apparent from the health mapping exercise is the lack of an overall single system or
consistency in patterns of health care use – there is considerable variation based on local
characteristics. These include the presence or not of resident health practitioners, the distance
to facilities and the local perceptions of quality of care and cost. Thus, the health care system
is a complex market system with a range of choice in terms of provider type, service type and
cost.

A local official’s story

“Before 2000, there were not many people who lived at the lake. The land
belonged to the disabled community. So we bought the land from them, and the
area filled with people. We built the bridge across the lake and people set up
houses on both sides. Before the fire, there were 460 migrant [somewhat recent
arrival] families and 300 renters. Many of the migrant families had purchased
the land. After the fire burned, some people left. But some just could not do it.
They came to me and asked, ‘Can we put a house here?’ What can I say to them
– I used to live with them. I know them and I cannot turn them away.

Since we moved here, standards have dropped. We are insecure at night. We lost
our possessions in the fire. Incomes are down. We cannot lock our possessions
up at night. We have problems of shelter, water and toilets. We can’t live without
water, so we asked the local authority. Now the local authority brings the water
in the truck daily – but it is still not enough. The local authority charges 100 riel
[for the water]. For toilets, people just use a plastic bag and throw it away.
Maybe we could build toilets for the community, but we need $2,000. I do not
want to ask the [next level of] local authority. The rubbish is not taken away.

People get by on the food they have. It’s the same with education. Most children
go to school. A Christian NGO supports some of the children, and others go to
the temple to learn. Bridge builders nearby send two trucks a day to take
children to school. NGOs can help us ask local authorities for what we need. For
the poor, it’s hard to pay – if the local authority, like the group leader, prepares
a letter saying a person is poor, it is not the case that the health staff will follow
this. So the Ministry of Health needs clear support for the local authority so the
poor do not have to pay so much.”
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Figure 14: Market choices for health care in Dam Charn















Perceptions of quality and the exercise of choice

In line with the household survey findings, the interviews and group discussions demonstrated
that choice is affected by perceptions of quality, attitude and cost of services. There are also
‘preferred service providers’ for specific types of services.

Quality was often defined in terms of hygiene or technology, such as “the hospital is very
clean” or “they have all the modern equipment”, or in terms of outcomes, such as “the
medicine is very effective” or “the child gets better quickly”. The community members often
cited the perceived skill of the provider as being critical when they were seeking health care.
On the other hand, a provider with a poor attitude is viewed very dimly by clients. The poor
attitude was interpreted mostly in terms of waiting longer because you are poor, being looked
at to see if you are poor or not, and impolite speech. All of these quality factors seem to
influence people’s selection of provider.

Additionally, specific types of facilities were preferred for having packages of quality services.
Health centres are highly valued for immunization services, antenatal care, AIDS (and HIV,
Finding 8: The health system and the poor
There is no single unified health care system in the urban context. There is instead a
health care market with a wide range of choice of provider and type of service, even for
the urban poor. A better understanding of the dynamics of this health care market for the
poor could guide policy makers towards improving mechanisms for quality health care
and social protection. Given the scale of the market mechanism, there is also a strong
case for increasing the market competitiveness of government health centres through a
reduction of client costs (social protection) and improvements in the quality of service.
Health care and social
service market in
Dam Charn

Referral hospital (RH)
Health centre (HC)
Pharmacies (3)
Traditional birth
attendant
Midwife house (1)
Midwife from Viet
Nam
NGO clinic (2)
market
NGO schools (2)

The top right of the
picture shows the river
and locations of groups
alongside it.
- 33 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
including testing and counselling) services and, increasingly, birth deliveries. Government
hospitals are highly valued for acute child health illness and delivery care. The private sector
is highly valued for the convenience of managing childhood illness. NGOs are valued for
reproductive health care and social protection (where it exists). Choice is therefore mediated
by location, perceptions of quality and type of service provided. However, cost is a major issue
and thus is a major factor in decision making about when and where to seek health care.

For immunization services, the household survey indicated that 53 per cent of the
respondents were paying for the service. Nevertheless, costs were not high. There was no
reported case of refusing any immunization service because of high cost, although, the
household survey indicated that 10 of 51 mothers who did not have their child vaccinated at a
health centre stated that cost was the deciding factor. It also helps that the health centres
have a reputation for providing good-quality immunization services. One health centre worker
commented that “even people in Land Cruisers” come to get their children immunized at the
facility. But when it comes to a baby delivery, health staff reported the richer patients will use
hospitals.

Figure 15: Analysis of health care per capita costs in the four communities
3





The need for health care are intermittent and thus the poor seem to find some way to mobilize
the funds needed to cover the costs. Even the poorest seem able to find $100 for birth
delivery fees in a hospital. This is understandable given that it is a predictable cost. However,
it does not diminish the significant impact on the poor of unpredictable or catastrophic health
care costs. This study indicates that the poor in the four communities pay more than (at $43.7
per capita) for health care than the nationally estimated $33 per capita (National Health Sector
Plan, 2008).

Covering the recurrent costs of education and food leaves the poor the most insecure
financially. However, there were instances in which people in the research areas did not seek
out health care services because of the cost. In one krom, women in one FGD stated that they

3
For national health care per capita costs, 75 per cent of costs are out of pocket. For this study, the costs were all
out of pocket.
Health care costs per capita
$10.9
$33
$43.7
5 10 15 20 25 30 35 40 45 50
3 months (study)
per year (study)
National health care
costs per capita, 2008
(HSP2)
Costs per capita US$
Health care cost
per capita
Health care cost
per capita per
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
did not seek care for female health issues because they feared the expense. Some local
authorities noted that many people delay seeking health care until quite late out of fear of the
expense and subsequent economic loss. There was also one case of a man who sold his
house to cover medical care expenses in the family. Thus, the fact that health care costs are
intermittent does not mitigate the severe impact that these expenses have on very limited
family income.

Participants in the women’s group in Borey Kaylah expressed a high degree of satisfaction
with the system of health insurance operating through the NGO Family Health Development
(FHD), in partnership with local authorities and government health services. However, there
was no evidence of any systematic implementation of financial social protection measures for
the poor in any of the other communities.










Gaps in knowledge

During the focus group discussions with mothers and with health centre workers, the
participants were asked to list the main health problems that arise in their family and rank
them according to seriousness; they were also asked to identify causes and solutions. Both
communicable and non-communicable diseases were ranked, but with childhood
communicable diseases (fever, cough, diarrhoea) being the most consistently mentioned.

It is interesting that the community members and health workers consistently highlighted
structural factors as the most predominant causes of ill health. This includes poor nutrition,
stagnating water and poor sanitation. That is, poor health is equated with living conditions or
individual behaviours rather than patterns of health care-seeking behaviour (such as promptly
taking a child with fast breathing to a clinic).

The participants articulated the causes and solutions for communicable disease conditions,
such as vaccine-preventable diseases, HIV infection and dengue fever, which were identified
as particular problems in the communities. Although the lack of an adequate food supply was
often referred to in the interviews, it was not correlated with illness – invariably, it was the
living environment and personal hygiene and behaviours that were considered the main
causes of the high rate of illness.

Women’s health was often identified as a problem by both men and women but it was not
linked to sexual health. Rather, women’s common health problems were linked to individual
behavioural risk factors of a non-sexual kind, such as poor personal hygiene.

Repeatedly, the cause of illness was linked to social and environmental conditions: dirty
water, poor sanitation and waste removal, nutritional limitations, social isolation, gambling,
drug and alcohol abuse, unemployment among youth, low income and insecurity (night-time
violence).
Finding 9: Health care costs and the limitation of choice
Evidence from this study indicates that the very poor pay levels of cost for both
preventive and curative care services that are disproportionate to their capacity to pay.
This capacity to pay through borrowing, sale of personal goods or support from
neighbours reflects the high priority the poor place on accessing health care. This being
the case, policy and systems interventions are needed to protect the poor from the burden
of these disproportionate costs through social protection, improvements to public health
services and health system strengthening strategies.
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Health Service Access Among Poor Communities in Phnom Penh 2009













Gaps in health care

Health services: The findings from the household survey indicate that access among the very
poor to basic preventive medical services is very good in the four communities. This was
confirmed in the interviews and focus group discussions in most cases, which reflected the
following patterns of use:

Health centre services are trusted and relied upon for specific packages of preventive
services, in particular: immunization, antenatal care, voluntary counselling services for HIV
and, increasingly, birth deliveries. Government hospitals are used for treating reproductive
health problems and severe illness. The private sector is relied upon for managing mild
childhood illnesses and certain adult illnesses. The research participants reported that local
private sector practitioners are close to the community, are well known and that visits to them
do not impose any hardship on the daily income earning. This contrasts with the use of
government facilities; people stated they frequently have to wait for a long time. If children are
seriously ill, they are taken to a hospital (Kantha Bopha or the National Pediatric Hospital).
Health centres were not mentioned in terms of treatment for a sick child. In fact, staff in one
health centre reported that they had not had any formal training in the integrated management
of childhood illness (IMCI).













The introduction of the fixed facility strategy for immunization through the National
Immunization Program in 2006 has clearly provided some benefits to the services and to the
population in terms of increasing demand, efficiency and income generation for health
centres. However, during the health centre mapping exercise, it became apparent that the
service providers were no longer confident on who in the community was immunized and who
was not. Prior to 2007, health centre staff conducted regular outreach programmes to the
Finding 10: Health knowledge and awareness
The findings from this study indicate that where health education programmes of the
government and international organizations have been active (immunization, HIV
prevention, dengue fever) the very poor demonstrate a good knowledge of what causes
common illness and what is required to avoid them. However, the research participants
were less knowledgeable on matters relating to maternal health risks, a sick child and
sexual health. Overall, people identified ill health in the context of the social conditions
in which they live rather than in terms of gaps in health services.
Finding 11: Child care for the very poor
The private sector is the first choice of care for people in poor communities in the case of
mild illness; government hospitals are preferred for severe illness. Health centres are
preferred for prevention services (immunization, antenatal care, HIV testing and
counselling). There is a case for strengthening IMCI service provision in health centres
that is then supported with the same strategy for communication applied for
immunization campaigns and antenatal care. This would prevent the unnecessary and
potentially costly procurement of non-essential drugs by clients through private-sector
outlets.
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
harder-to-reach areas. Thus regular contact was made with village volunteers, local
authorities and the community. Now in Phnom Penh, all immunization services are provided
only in health centres.

When marking hard-to-reach or slum areas on health centre catchment maps, the health
centre workers demonstrated knowledge in locating them but they expressed less confidence
in identifying pockets of non-immunized children. Comments, such as the following, indicated
the health centre staff’s uncertainty of population coverage in high-risk areas:
x “We are not sure what is going on there now.”
x “Funding for outreach has stopped so we cannot be sure.”
x “These places are confusing – people are coming and going all the time.”

It was also not clear whether social mobilization and communication meetings were taking
place regularly enough with local authorities and village volunteers. Even though it is a fixed-
facility site strategy that relies on population demand, funding is still required for health
education and social mobilization in communities for the fixed facility strategy to work. Staff in
one health centre noted this to be a problem, and action had already been taken by the district
director to develop systematic meetings with local authorities on a monthly basis in order to
identify and resolve issues that health staff and local authorities could manage together.
Despite this limitation, the research participants expressed a feeling that the quality and
demand for services at health centres had improved in recent years. Figure 16 highlights other
strategies that are working well in terms of access by the poor to health services; figure 17
summarizes findings of reactions to the fixed facility strategy of the National Immunization
Program.

Figure 16: Summary of what is working well in relation to health service access













It’s a very confusing situation there.
People are coming and going there all the time.










x Community members and health centre staff report that health centres are preferred and are
increasingly relied upon for immunization services and antenatal care.
x There is a high rate of household possession of immunization cards – the population values
immunization and its benefits. This is also apparent for antenatal care and birth delivery by
professional providers.
x Community members and local authorities in Borey Kaylah all expressed a high level of
satisfaction with the health financing scheme. It eases the financial burden of the poor, engages the
local authority in health care and increases the use of the government facility where quality can be
more assured, compared with the private sector.
x In some cases, there are health practitioners residing in communities who work as private
providers through NGOs or as volunteers. These resident practitioners have the trust and
confidence of the community and are the vital referral link to government services.
x Health messaging by the MOH and international partners is clearly having an effect – the poorest
of the poor are making every effort to access immunization, antenatal care and birth delivery
services despite the high costs (relative to their income and living conditions). This also reflects
the high level of commitment by health workers and families to the care of women and children,
despite the situation of extreme poverty.
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Figure 17: Summary of responses to the fixed-facility site strategy










Based on the study’s findings, however, Phnom Penh is still at-risk of vaccine preventable
disease in at-risk populations in Phnom Penh. This is due to the lack of adequate financing for
operational monitoring of unreached areas. This operational surveillance could be
strengthened through i) systematic micro-planning and mapping in high risk areas; ii) meeting
with local authorities and volunteers in high-risk areas on a regular basis; iii) scheduling
community visits by health centre staff to high-risk areas; and iv) developing stronger
partnerships with NGOs and volunteers and local area practitioners in these areas.










Public health: As previously noted, community members, health workers and local authorities
(village and krom leaders) consistently pinpointed social and economic conditions as the
prime determinants of poor health. Although limitations in access to health services due to the
cost were also identified as an issue, it was clear the social and economic conditions of daily
life represented the fundamental health and disease burden, as reflected in the following
comments from the research participants:
x “Water is pooling everywhere, especially in the wet season. The mosquitoes bring
dengue.”
x “The air is bad here, the community is not healthy. There is too much rubbish and water
lying around.”
x “There is one toilet here for 300 to 400 families.”
x “We are afraid to ask for better drainage systems and water. This is a temporary
location.”
x “We used to try and organize the rubbish to be collected in one place, but then [the
government] stopped coming to collect it. So people now don’t collect the rubbish in one
place.”
x “Some of the new people who come who are the renters are causing a lot of trouble at
night. So after dark, we close the doors and don’t go out.”
x “There is nothing here for young people to do and parents cannot afford to keep them at
school, so they just wander around. It’s easy for them to get into trouble.”
x “Education – that’s the problematic one. We have to pay for this every day. Health we
pay for some times. But education we have to pay every day. It’s a big problem.”
Finding 12: Reaching the hard to reach
Although the fixed-facility site strategy has been successful in maintaining coverage,
health centre workers and manager are concerned about pockets of non-immunized
children in selected high-risk locations. Under the outreach scheme, regular contact was
made with village volunteers, local authorities and the community; this community
exchange has been significantly diminished under the fixed-facility site strategy.
x The fixed-facility site strategy has been successful in increasing demand for health centre services
(primary medical care). However, the mapping of health centres revealed there is a lack of clarity
among health centre managers on the numbers and locations of unreached populations. Also, the
community members said they are unfamiliar with their health workers, which makes them less
likely to use public services because of a lack of trust. The lack of resourcing of outreach health
education and communication and an inadequate mapping of catchment populations means that
these communities remain at high risk of a vaccine-preventable disease outbreak.

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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
x “What we eat each day depends on our income. Sometimes we cannot eat what we
want.”
x “There is nothing here for the young people to do or any place for them to go. There are
no programmes for them.”

Although health costs and occasionally the attitude of health workers were sometimes
identified as a problem (costs were mentioned more often), it remains the case that it is the
economic and social conditions of everyday life that are the main factors affecting access to
healthy conditions of life, in contrast to access to health services. Figure 18 contrasts
recommendations from a health centre focus group and a women’s group from a local poor
community. What is interesting in the contrast of perspectives is the service delivery focus of
the health centre staff and the public health care focus of the community perspective.

One of the principal findings of this study is that the main barrier to health care for very poor
communities is not so much health service access but rather limited access to basic public
service functions in the community. Consistently, community members and local authorities
(and health centre staff to a lesser extent) cited structural determinants of poor health as the
main cause of ill health rather than limited access to medical services. Sanitation, waste
removal, stagnating water, poor nutrition, security and income generation were perceived to
be the main drivers of poor community health. But when asked who is responsible for the
environmental and social conditions in the community, the responses were not well
articulated. Health centre workers hesitated to respond. In the end, the consensus seemed to
be that it was a joint function of the Ministry of Health and local authorities.

Figure 18: Contrasting perspectives on recommendations for improving health and
health care access

























Recommendations
from health centre staff

x Disseminate information so people
know and understand what services are
available through the health centre.
x Communicate closely with the local
authority so he can inform the
population about services at the health
centre.
x Inform people who come to the health
centre to tell other people about the
services at the facility.
x Raise awareness among people about
not buying medicines from pharmacies
as a first choice of treatment.
x Ensure an adequate medicine supply at
the health centres.
x Ensure sufficient space for services (an
additional room) in the health centre.
x Provide additional technical training
for health centre staff.
x Increase the salary (make more
appropriate) of health centre staff;
health centres should have higher
salaries for a smaller number of staff.
Recommendations from a women’s group

x Please ensure health centre staff speak politely
to sick patients.
x Please make the cost of health services cheaper.
x Please ensure the health staff pay attention to the
needs of the sick.
x Please don’t let the sick patients wait too long.
x We need to have poverty cards (bun krey kro) so
the health staff do not take money (charge for
service).
x Please help the local authority provide an
adequate water supply and electricity.
x Please help the local authority prepare adequate
drainage systems in the community.

From a mother
x We have to keep our environment around the
house clean and also look after food hygiene.
x NGOs should help our children to go to school
and learn, help us find work and provide loans
so we can earn income to send the children to
school.
x NGOs should help us about domestic violence
so to protect households from men coming home
to their family when they have been drinking
and using violence in the house.
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Health Service Access Among Poor Communities in Phnom Penh 2009



When asked to define their own function in relation to health, local authorities saw their role
more in terms of gathering statistics and social mobilization and less so in actually requesting
or mobilizing resources for public health interventions. This lack of clarity on accountability for
environmental and social conditions relates in part to insecurity of land tenure – local
authorities may not want to put in place environmental infrastructure when there are legal
disputes over the land. Regardless of legal or political questions, these communities are
highly vulnerable to an outbreak of communicable diseases because of dysfunctional public
health functions relating to safe water, sanitation, waste removal, nutrition and youth affairs.
This requires urgent attention.












Finding 13: The public health function
Although there is some degree of clarity of role in relation to medical service provision
through health facilities, the broader functions of public health/primary health care are ill
defined. This leaves the communities vulnerable to a communicable disease outbreak.
Essential functions of public health need to be defined and resourced, with clear lines of
accountability for the Ministry of Health staff, local authorities and communities.
Specifically, it must be clear what needs to be done and who is responsible for it.
A community leader’s story

“This community started in 1979 after the end of the Khmer Rouge time. It started
with 10–20 houses. But in 2000, the numbers increased sharply. Then the people just
bought and sold land from each other. About 70 per cent of the population is lacking a
means for basic livelihood. There are motorcycle taxi drivers and factory workers
here. But the main problem is poverty. People are short of food, especially children.
There is little living space for some people. There is gambling and fighting. Children
stop going to school at year 8 or 9. They start walking around in groups. What people
want is what they can be provided now. It is hard for them to think beyond this time.
In 2003 we started a community association. A community is a way of negotiating on
rights for people. But the words of the poor are cheap.

Local authorities can help with many health issues – environment, nutrition and
hygiene, for example. But what is in it for them? I say we need a sanitation system,
they say – “You got a million dollars?” The direction has to come from the central
Government, otherwise they will not move. Sometimes people’s houses fall down, so
they rebuild and still the police walk by and ask for money to authorize
reconstruction. There has to be something in it for people.

It is not enough for one person to have commitment for things to change. So I am
quiet now.”
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009





5. RECOMMENDATIONS
FOR IMPROVING
ACCESS
TO HEALTH SERVICES


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Health Service Access Among Poor Communities in Phnom Penh 2009
g
As the study progressed, it became clear to the researchers that the social dynamics and
interactions of low income, education and health care costs and food prices place significant
daily pressure on poor families. More frequently than not, it is education costs that are most
commonly set aside. However, it is education that offers the best opportunity for the families to
escape poverty by providing the younger generation with skills and capacity to bring more
income into the family at a later age. The inability to afford and secure education costs for
young children is a sure way to lock families into multigenerational poverty. Families are
already disadvantaged by high health care costs (relative to low incomes). But due to the
dysfunction of urban public health, these families are also exposed to higher rates of illness
due to environmental hazards and nutritional deficiencies. This cycle of illness and poverty is
effectively excluding the very poor populations from wider social participation in the skilled
workforce and in public dialogue regarding their social conditions.

Figure 19: Framework for analysing the social determinants of health















The recommendations from this study derive from suggestions of local authorities, health
centre workers and managers and community members. The suggestions spoke generally to
two issues: making health service more affordable and of higher quality and making daily
living environments more conducive to a healthy way of life. That is, it was structural and
systematic factors of health systems, society and government rather than behavioural
changes of individuals that were identified as the best ways to move forward. These structural
or systematic strategies should target three levels: service delivery strengthening, public
health functions and social protection policy.

The researchers for this study propose five recommendations that cut across those three
levels of intervention. The following outlines the five recommendations and includes a list of
associated priority actions for implementing them.
Education
Health
Food
Employment
Society
Environment
The cycle of poverty and ill health

Low and irregular incomes mean that people
cannot meet all their expenses. This includes
food, health and education. People live in a
poor environment they know is unhealthy, so
people are sick more often; this means
spending more on health care. Because
education costs are cut, it is hard for children
when they grow up to make a decent enough
income to escape this cycle. This is what
distances people from society. It is not so much
people are deliberately excluded – rather, they
are locked into a culture of poverty. This is a
structural problem requiring structural or
‘systematic’ solutions; it cannot be solved
solely by suggesting to people they change
their health or health care-seeking behaviour.
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Health Service Access Among Poor Communities in Phnom Penh 2009

RECOMMENDATION 1: Community-based services for the urban poor

This study has found that health authorities and agencies have been very effective in
informing poor populations of the benefits of maternal and child health care – particularly for
immunization and antenatal care. But there are gaps in the service delivery generally for
maternal and child care, especially for maternal health, women’s health and management of a
sick child. It is also highly likely there are pockets of undetected at-risk populations that are
not accessing services at all.

There is no question that the access of the very poor to health care services for a narrow band
of preventive and curative services is impressive. Information from this study indicates that the
communication strategies of the Ministry of Health and development partners and health
centres have been effective in stimulating demand for immunization, antenatal and delivery
services in particular.

Health facilities have been noted to be centres of high demand for immunization, antenatal
care, birth delivery and HIV testing and counselling services. However, the researchers qualify
this statement based on their observations on the scope of care; the success of the fixed
facility strategy (in stimulating access for the majority) may come at a cost to a minority of the
population. That is, the cessation of outreach services and lack of strong connections with
local informants, NGOs and local authorities means that fixed-facility sites do not have the
surveillance and resource capacity to detect and respond to the needs of small pockets of
unreached populations. For this reason, a service and communication strategy needs to be
developed specifically to meet the needs of the urban very poor.




Recommendation 1: Community-based services for the urban poor

Adequate resourcing of health centres is needed for conducting health education and services
outreach to at-risk communities on a regular basis. The additional resourcing would i)
strengthen links between health services, community practitioners, local authorities, NGOs
and communities, ii) establish contact with and support local social networks for health
(formal and informal) and iii) provide mobile services for the most at-risk populations.
Implementing action:

x Identify the 20 most at-risk communities in Phnom Penh in four operational districts and
define an essential package of health services to be provided to each community on a
monthly basis.
x Facilitate the networking of local health care practitioners, NGOs and community leaders
for health communication, referral and local problem solving of priority public health
issues. This can entail monthly communication meetings with formal and informal social
networks (similar to fixed-site meetings) but with a wider public health agenda.
x Facilitate the formation of local community groups (mothers’ clubs or health providers
groups, etc.) for linking a community to maternal and child health and other social
services.
x Define clearly the adequate human and financial resources required for responsible heath
centres to provide additional services to the urban poor.
x Develop a detailed, costed multi-year action plan; include it in the annual operational
plan for the National Immunization Program and the Municipal Health Department; the
plan should identify human and material and communication resource requirements.
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
RECOMMENDATION 2: Community-based health monitoring of the urban poor

As noted in the findings, most surveillance focuses on disease outbreak. This is particularly
the case in relation to vaccine-preventable disease. Less emphasis is placed on surveillance
of health and public health. This necessitates the transition of surveillance from a current
focus on ‘disease’ to a broader view – structuring a more systematic approach to health
monitoring of the social and economic factors that impact on health and health access for at-
risk populations, namely food security, waste management, water and sanitation and social
protection for health and education.

More recent analysis and findings through the Cambodian Anthropometric Survey (2008) has
highlighted high rates of severe malnutrition among the urban poor and the associated need
to put in place effective community-based monitoring (CBM) of the nutritional status of
children. Based on the findings of this health service access study, it is clear that such a CBM
system should be extended to incorporate immunization status, school attendance and
assessment of health insurance status to ensure that health practitioners, planners and policy
makers have a comprehensive assessment of the situation of the urban poor and thus can
structure a well-informed response plan. This will also assist with targeting the urban poor for
more comprehensive social policy measures (see recommendation 5).


















RECOMMENDATION 3: Health services quality improvement

Despite the high coverage of care, this study has detected limitations in the quality of care,
particularly in relation to the management of a sick child. A range of other studies have
indicated the dubious quality of care provided through private facilities. There is no systematic
strategy for ensuring quality in this sector. Yet it is to this sector that most families turn in the
event of child illness.

Operational Districts and health centres have demonstrated that they can generate a large
demand for immunization, antenatal care, HIV testing and counselling, and birth delivery
services. Despite these successes, the vast majority of the very poor still prefer to access
Recommendation 2: Community-based health monitoring of the urban poor

The Municipal Health Department (MHD) needs to undertake a systematic approach to
surveillance of at-risk populations through the support of district health centres. In
conjunction with local authorities and civil society partners, the MHD should conduct
regular mapping and micro-planning for at-risk populations. Such mapping and micro-
planning should be built into the routine functioning of the surveillance and planning
system so that surveillance focuses both on disease and on detecting health risks and
health inequities, specifically for:

x childhood immunization
x primary school retention
x health insurance status
x anthropometric assessment/food security measures
x environmental health.
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Health Service Access Among Poor Communities in Phnom Penh 2009
private medical services in the first instance when a child becomes sick. This comes at a
relatively high cost. This being the case, the integrated management of childhood illnesses
(IMCI) services (with an associated communication strategy) should be applied at urban
health centres in order to improve the quality and coverage of care for sick children in very
poor families.

Given the successes of the MOH, partners and health centres in generating demand for
certain services, there is definite scope for promoting public health care through the
strengthening of these centres in order to provide good-quality IMCI services at an affordable
cost. As well, the poor should be protected from high health care costs through the provision
of health insurance or user fee-exemption systems.













RECOMMENDATION 4: Review of the public health functions

With the publication of Cambodia’s National Strategic Development Plan and in light of the
findings of the Global Commission on the Social Determinants of Health, along with the 2008
World Health report (WHO, 2008), there is now a strong national and international focus on
widening the scope of health interventions from medical care to public health or primary health
care.

However, the capacity of health centres and districts is already stretched in terms of providing
medical care services. This being the case, the development of public health strategies and
interventions will require strong partnerships and institutional and human resource
development programmes within local authority, health and civil society structures at the
village and district levels. This will mean significantly raising the level of function and
resourcing of local authorities for public health functions. Further, the endeavour will require
shifting roles from social mobilization and data collection to more proactive leadership and
participation in the problem-solving process and in the delivery of essential public services,
such as environmental health and social affairs.

Recommendation 3: Health services quality improvement

A combined health education and quality improvement strategy should be adopted so
that poor families can access better quality and more affordable care for sick children
from health centres (for example, facility and community IMCI).

Implementing action:

x Develop and cost a detailed plan to train and implement an IMCI strategy in
urban health centres.
x Consider developing community-based partnerships for a community-level
IMCI strategy (involving referral and care community practice networks of
local private practitioners, pharmacists, NGOs, local community and
administrative leaders).
x Support the implementation of a child sickness management strategy with a
national communication campaign along the already successful lines of EPI,
dengue fever and HIV prevention.

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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
The trend towards selective primary health care and health sector reform has delivered
important results for population health in terms of scaling up essential service delivery
packages. However, health inequities across different socio-economic groups are persisting.
Although medical services are increasingly available, even for the urban poor, the
accountability for performance of essential public health or primary health care functions
(water, sanitation, waste management, social affairs) remains very unclear. A thorough review
of essential public health functions of local administrative and health authorities should be
undertaken in order to define essential public health functions, the resources required for
implementation and accountabilities for performance.













RECOMMENDATION 5: Review and scale up social protection policies

It is time to recognize the synergies in development between health, education and nutrition.
Then in recognition of these synergies, consideration should be given to the implementation of
a social protection policy or social safety nets with cross-sector links.

The main finding from this study is that the primary determinant of poor health and poor
access to health services are essentially structural in character. ‘Structural’ refers to the social
and economic constraints of daily living and how this impacts on health, income availability,
education access, cost of health services, the exercise of power by local authorities, water
and sanitation and social opportunities for the young in particular. This is of course not a new
finding – internationally, the Commission on the Social Determinants of Health has indicated
that the first of the three principles of action for reducing health inequities is to “improve the
conditions of daily life – the circumstances in which people are born, grow, live, work and age”
(WHO, 2008 p. 2). Health equity should therefore be at the centre of urban planning and not
on the periphery of it.

Recommendation 4: Review of the public health functions

A review of essential public health functions for urban health should identify
resources required; a capacity-building plan is needed to strengthen the delivery of
essential public health functions, either through local authorities, NGOs, health
centres or a combination of all.

Implementing action:

x Conduct a review of essential public health functions for urban health that
identifies resources required, specifies accountabilities and leads to a
capacity-building plan to strengthen the delivery of essential public health
functions, either through local authorities, NGOs, health centres or a
combination of all.
x Design the concept paper and terms of reference for the review, identify
resource requirements and seek consensus from the MOH and other
relevant ministries for implementing the review.

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Health Service Access Among Poor Communities in Phnom Penh 2009
This study has found that a majority of the very poor are willing to listen to health care
messages and pay for health care services to follow these messages, even though it
sometimes comes at a formidable cost. The daily cost of education and food and the
intermittent costs of health care means that sometimes families have to go without or self-
restrict demand for basic human needs. Other studies support these findings. The Cambodian
Anthropometrics Survey conducted in 2008 indicates that acute malnutrition among poor
urban children has increased from 9 per cent in 2005 to 16 per cent in 2008, exceeding the
threshold of 15 per cent wasting rate use, to identify a humanitarian emergency. As for the
demand-side factors, poverty was confirmed as the most critical factor in determining the level
of effective access to primary education in Cambodia (UNICEF, 2007).

Government and development agencies need to focus on the social determinants of health.
Over-emphasis on economic growth and lack of emphasis on social development, particularly
for the very poor, means that a government objective of poverty reduction is not attainable for
many of the very poor. Although a health sector-specific policy can make a difference, it
cannot reduce poverty when not acting in collaboration with food security, income generation
and education initiatives. In this sense, there is an important distinction that needs to be made
between health policy and social policy. Broader social policy initiatives (or social safety nets)
that take into account the social determinants of health status and that address the needs of
the very poor should be designed and implemented in high-risk communities as a first step.

Key components of such a strategy should include:
x social protection measures for health and education in collaboration with civil
society and local authorities;
x implementation of health strategies focusing not only on essential medical service
packages but also on essential public health functions that address the social
determinants of health status;
x health surveillance focused on the needs of the poor and not just on their disease
(see recommendation 2 on community-based monitoring).

These social policy developments will be critical in the coming years, given the global and
national trends in urbanization. A UN Habitat report on urban slums stated that in 2001, 924
million people, or 31.6 per cent of the world’s urban population, lived in slums. In Cambodia,
recently released census data indicates that the growth rate for urban areas has been 2.55
per cent and 1.3 per cent for rural areas. The population in Phnom Penh has grown 32 per
cent in ten years, between 1998 and 2008 (NIS Census, 2008). These demographic facts
point to the need for a long-term comprehensive strategy for urban health care for the very
poor in order that public policy can anticipate and respond to the well-established social and
demographic trends.

Focusing the discussion about social exclusion on structural determinants also opens up the
possibility to have a more fruitful public dialogue regarding causes and solutions to urban
poverty and ill health. It enables the discussion to move away from a ‘blame game’ (health
workers have a bad attitude, the poor don’t look after themselves and governments don’t care)
to a problem-solving exercise focusing on structural and process change.

This study has documented how activities of daily living, including income generation, food
security, education and access to health care are interlinked issues in a family setting. For this
reason, there is a strong case for linking policy initiatives of health, education, labour and
environment into a broader and more cohesive healthy public policy (combined with social
policy) that takes into account the social determinants of health status and their impact on
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
quality of life for families. Clearly one area where this linking could take place is social
protection.

The information from Borey Kaylah community indicates the high value that community
members, health centre staff and local authorities place on the operation of the health equity
fund scheme. People in the other three communities, where no or very limited social
protection measures are in place, also recommended the introduction of these schemes as a
high priority to reduce health care costs for the very poor. Studies across Cambodia published
in the international literature support the claims of residents, local authorities and health centre
workers that social protection schemes, such as the health equity fund, can increase poor
people’s access to public facilities (Annear, 2008; Jacobs, 2007; Noirhomme, 2007). Targeting
the health sector for quality improvement is necessary but insufficient – the approach needs to
comprehensively address social sector barriers to good health and not only to medical care
services. This is also currently being addressed by higher level Government of Cambodia
policy discussions regarding efforts to research and development comprehensive social safety
net strategies for the very poor (Council for Agriculture and Rural Development, 2009).







Recommendation 5: Review and scale up social protection policies

Social safety-net equity funds, based on a model of the health equity fund, need to be
established in the poorest communities in Phnom Penh on a comprehensive basis to
ensure access to health care and education services for the very poor.

Implementing action:

x OPTION 1: Scale up existing health equity funds to all the urban poor
areas of Phnom Penh (comprehensive health equity fund scheme for the
urban poor).

x OPTION 2: Conduct a feasibility study on the development of a social
safety-net equity fund model for health, education, food security,
building on the already successful model of health equity funds in
Phnom Penh.
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009













6. CONCLUSIONS




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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
This study has confirmed that, even for the very poor, health access to basic preventive and
curative services for women and children is relatively good, in proportion to one’s capacity to
pay, in some of the poorest communities in Phnom Penh.

Immunization rates are high and antenatal care services are well utilized. Mothers have good
knowledge of the risk factors for vaccine-preventable disease, pregnancy, HIV infection,
dengue fever and communicable disease. There is also a wide range of market choice of
health care servicers from traditional, private and public sector care services, although quality
assurance of private and traditional care services cannot be confirmed (Rose, 2002; Ramage,
2001).

However, despite the wide access and high coverage, there is consensus across families,
local authorities and health centre workers that the principle source of poor health outcomes
are the unhealthy social and environmental conditions in which people live on a daily basis.
The combination of barriers in access to education services, low incomes and poor
environmental conditions means that families are at chronic risk of communicable disease. It
is the social and environmental conditions rather than access to medical services that are the
main barriers to sustaining and improving family and community health.

This being the case, this study concludes that improving the health status of at-risk
populations means improving their access to healthy life conditions and not simply removing
the barriers to health care services. Certainly there are immediate steps that can be
undertaken to improve links to the community to identify the most vulnerable. In the short
term, practical improvements to primary medical services, health management practices and
in health education strategy would make a difference to health care access for the poor. In
the medium term, improvements to essential public service functions and in the long term,
development of healthy public policy, expressed through the extension of social protection for
health care, education services and food security, presents the best prospects for breaking
the multigenerational cycle of poverty in the poorest communities of Phnom Penh.




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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
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assignment: UNICEF Maastricht Graduate School of Governance. Evidence-based policy
analysis and advocacy.

Vickery, C. 2001. Review of health services for urban poor component options.

Vickery, C. 2003. Health Systems for the urban poor final report options.

World Health Organization. 2008. Commission on social determinants for health. Geneva.

World Health Organization. 2008. World health report 2008: Primary health care.
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
ANNEX 1: RESEARCH INSTRUMENTS


Details of quantitative research instruments

Household surveys

The purpose of the household survey was to develop background information on knowledge,
utilization and health service client satisfaction prior to conducting more in depth analysis
through in-depth interviews. Topic areas centred on the following:

BACKGROUND INFORMATION. This part of the questionnaire collected information
regarding population mobility, socio-economic status and cultural backgrounds of
respondents.

KAP EPI – MCH. This part of the questionnaire collected information on health communication
and knowledge of mothers with respect to maternal and child health care and immunization.

UTILIZATION OF SERVICES. This part of the questionnaire assessed immunization
coverage and patterns of use for maternal and child care health services (delivery,
management of a sick child and reasons for selecting a provider).


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Health Service Access Among Poor Communities in Phnom Penh 2009
Household questionnaire

Section 1: Background
11
What is your current marital status?
Married 2
Divorced 3
Separated 4
No. Questions Coding
1 What age are you? Years old_________
2 How long have you been living in this
community?

Months_________
3 Are you a migrant to this community? Migrant 1
Mobile 2
4 Before you came to this community, where did
you live?

5

How many children do you have? #_______
6





What was the main reason you /your family
moved to this community?

CAN ANSWER UP TO THREE RESPONSE
(RANKING ACCORDING TO PRIORITY)
________________1
________________2
________________3
7 What education level have you completed?

Code 0 Never learned or entered primary
school
Code 1 Completed primary school
Code 2 Completed secondary
Code 3 Completed university
Code 4 Post-graduate study
Code 5 No answer
# Code __________

8 How many persons reside in this household? # Residents____________
9
What religion are you?


Buddhism 1
Catholic 2
Muslim 3
No religion 4
Other religion (please specify)__________
5
No response 9
10
To which ethnic group do you belong?


Khmer 1
Vietnamese 2
Cham 3
Chinese 4
Other (please specify)________________
5
No response 9
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Widow 5
12



What is the job of the main income earner in
the family household?

___________________________________
___________________________________
___________________________________
____________
13 What is your estimated family income per day? Less than 5,000 riel per day 1
5,000–20,000 riel per day 2
More than 20,000 riel per day 3
Not regular 4
Unsure 9
14 In the past three months, what is the estimated
family income spent on health?
#
15 Can you understand the staff in the health
centre?

Yes 1
No 2
16 Are you able to read and write Khmer? Very well 1
Not so well 2
Cannot read or write 3
Section 2: KAP immunization and MCH
ion 2: Knowledge Attitude and Practice Immunization and MCH
No. Questions Coding


CHILD HEALTH
17 In the past three months, did you see or hear
anything on the radio, television,
newspaper/magazine or loudspeaker about
childhood immunization or child health?

Yes 1
No 2
Don’t remember 3
18 From what source do you hear the most
about the childhood immunization or child
health?

PLEASE SELECT ONE
Television 1
Radio 2
Newspaper/magazine 3
Loudspeaker 4
Poster 5
Public meetings 6
Others (please specify) ____________ 7
Don’t know 9
19 Apart from the sources mentioned above,
from whom do you hear the most about
childhood immunization or child health?

PLEASE SELECT ONE
Government health workers 1
Drug seller or private clinic 2
Traditional healers 3
Heads of village/commune 4
Parents or relatives 5
Friends or neighbours 6
NGO 7
Others (please specify) ____________ 8
Don’t know 9
20 In the previous three months, did you see or
hear anything on the radio, television,
newspaper/magazine or loudspeaker about
women’s health (or maternal health)?
Yes 1
No 2
Don’t remember 3
21 From what source do you hear the most
about women’s health? (maternal or
reproductive health)

PLEASE SELECT ONE
Television 1
Radio 2
Newspaper/magazine 3
Poster 4
Public meetings 5
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Others (please specify) ____________ 6
Don’t know 9
22 From whom do you hear the most about
maternal health?

PLEASE SELECT ONE


Government health workers 1
Drug seller or private clinic 2
Traditional healers 2
Heads of village/commune 3
Parents or relatives 4
Friends or neighbours 5
NGO 6
Others (please specify) ____________ 7
Don’t know 9

ANTENATAL CARE
23
How many times did you see any health
worker for antenatal care for the previous
pregnancy?

CIRCLE CORRECT ANSWER



Did not see anyone 1
One to three times 2
Four to six times 3
Six times or more 4

No. Questions Coding
24 At an ANC visit, did you receive any of the
following:

CHECK RECORDS (CHECK PINK
MOTHER CARD) IF CANNOT REMEMBER

PROMPT WITH OPTIONS

Tetanus injection Y/N/DK
Iron tablets Y/N/DK
Advice on your diet in pregnancy Y/N/DK
Information about warning signs during
pregnancy Y/N/DK
Mebendazole capsule Y/N/DK
3
25 What diseases can be prevented by
immunization?

DO NOT PROMPT
_________________________1
_________________________2
_________________________3
__________________________4
__________________________5
__________________________6
_________________________7
__________________________8
DANGER SIGNS IN PREGNANCY
26
What are the danger signs in pregnancy that
require a woman to seek medical care?

FOLLOW WITH OPEN QUESTION: ASK,
“ANY MORE?”

DO NOT PROMPT
Bleeding 1
Severe headache 2
Trouble with vision 3
Fever 4
Swollen hands or face 5
Reduced or faster foetal movement 6
Other please record________________8
Do not know 9
27 Sometimes children have severe diseases
and should be taken immediately to a health
facility. What types of symptoms (danger
signs) would cause you to take your child to
a health facility right away?

OPEN QUESTION, DO NOT PROMPT –
Child not able to drink or breastfeed 1
Child develops a fever 2
Child has fast breathing 3
Child has difficult breathing 4
Child has blood in the stool 5
Child is drinking poorly 6
Other please record________________8
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
ASK “ANY OTHERS?”
IF YOU ARE NOT SURE IF A CERTAIN
SIGN FITS IN ONE OF THE CATEGORIES,
WRITE IT DOWN IN FULL AND CHECK
WITH YOUR SUPERVISOR LATER.

Do not know 9

Section 3: Utilization patterns of health services for immunization and MCH

No. Questions Coding

28

Did your child receive a DPT Hep B
vaccination?

CHECK THE IMMUNIZATION
YELLOW CARD AND RECORD
DATES


Mother reports immunization was given 1
Immunization date DPT3 recorded on the yellow
card 2
Immunization not given 3
Record date of birth of child………
Record date DPT1 provided……….
Record date DPT 2 provided……….
Record date DPT 3 provided……….
IF RECEIVE ONE DOSE OR COMPLETE DOES
GO TO QUESTION 30
29 If your child did not get required
vaccination as scheduled, what were
the reasons?

______________________________________1
_______________________________________2
_______________________________________3
30 Who came to tell you information
about receiving immunization
services?
Government health workers 1
Head of Group/Heads of village/commune 2
Village volunteer 3
Neighbours 4
Went by themselves 5

Others (please specify) ____________ 8
Don’t know 9
31 Where did your child usually have
vaccination?
Health centre 1
(if 1, please go to question 30)
Hospital 2
Community 3
Private clinic 4
Others (please specify)______________ 5
Don’t know 9
32 What are the main reasons your child
did not receive vaccinations at the
health centre?

RECORD ACCORDING TO
PRIORITY 1
1________________________________________
____2____________________________________
________3________________________________
____________
33 How often does an immunization
team reach your area?

SELECT ONE ONLY

Monthly 1
3 monthly 2
6 monthly 3
Not at all 4
Unsure 9
34 For the previous vaccine your child
received, did you have to pay for it?
Pay 1
Not pay 2
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
MATERNAL HEALTH

35 Where was the location of delivery of
your most recent birth?

Phnom Penh 1
Province 2
In this community 3
Other 4
36 Where was the place of delivery of
your last child?

DO NOT PROMPT
Health Centre 1
Public hospital 2
Private clinic 3
If answer 2, 3 or 4, skip to questions 38 and 39
Home 4
Other please describe_____________5
37 What was the main reason for choice
of location for delivery?

PROVIDE RANKING (1 – 3)
1………………………………………………….
2………………………………………………….
3………………………………………………….
38 Who assisted with the delivery?

IF DELIVER AT HOUSE OR OTHER
LOCATION
Midwife 1
TBA 2
Doctor 3
Other please describe_____________4
39 What was the main reason for choice
of provider for your last delivery?

PROVIDE RANKING (1–3)
1………………………………………………….
2………………………………………………….
3………………………………………………….
40 Do have an insurance card for
receiving health care services?


Yes 1
No 2
IF NO SKIP TO QUESTION 42
41 Who provided the insurance card to
you?
Local authority 1
NGO 2
Church 3
Government 4
Other 5

42 Do have a poverty status card (health
card) for receiving health care
services?


Yes 1
No 2
43 Who provided the poverty card
(health card) to you?
Local authority 1
NGO 2
Church 3
Government. 4
Other 5
44 How far is the nearest government
health centre from your house?
#________
Do not know 6
Not sure 9
45 Do you know the health staff who
works there very well?
Know very well 1
Know a little bit 2
Do not know well 3
46 Do you know whether the staff has a
daily immunization service that is
provided at the health centre?
Yes 1
No 2
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
47 What was the type of illness last
experienced by your child in the
previous six months ?


_________________________________________
_
48 For this illness, who was the first
choice for seeking treatment?
Local pharmacy 1
Private clinic/hospital 2
Health centre 3
Public hospital 4
Other please describe_____________5
49 What was the main reason for the
first choice of health provider?


PROVIDE RANKING (1–5)
_________________________________________
______
50 Have you used the nearest
government health centre for child
health consultation in the last three
months?
Yes 1
No 2
IF NO, GO TO QUESTION 53
51 What do you like best about the
government health centre?

PROVIDE RANKING (1–3)

1………………………………………………….
2………………………………………………….
3………………………………………………….
4………………………………………………….
52 What is the thing you dislike most
about this health facility?

PROVIDE RANKING (1–3)
1………………………………………………….
2………………………………………………….
3………………………………………………….
4………………………………………………….
5………………………………………………….

53 For the last consultation for
reproductive health (delivery,
women’s health, birth spacing,
antenatal care), who was the first
choice for seeking treatment?
Local pharmacy 1
Private clinic 2
Health centre 3
Hospital 4
Other please describe_____________9
54 What was the main reason for the
first choice of health provider?


PROVIDE RANKING (1–5)
1………………………………………………….
2………………………………………………….
3………………………………………………….
4………………………………………………….
5…………………………………………










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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
Qualitative research instruments

Qualitative survey

For the in-depth interviews and focus group discussions, an open-ended questionnaire
guideline was designed for mothers, local authorities and health centre staff. All three
contained specifics for each category and the questions followed the main topic areas:

SOCIAL CONTEXT FOR HEALTH. This topic area involved discussions about standards of
living, daily living priorities of health, food and education and the history and background of
the community. The purpose of this line of discussion was to gain a deeper understanding of
the social context and determinants of good health and health service access.

LEARNING ABOUT SOCIAL NETWORKS FOR HEALTH. This area of discussion focused on
patterns of health care-seeking behaviour and communication in the community about health
and health service use. The purpose of this discussion was to gain a deeper understanding of
how people learn about health services from their own community.

DETERMINANTS FOR SERVICE UTLILIZATION. This area of discussion focused on why
community members choose to use specific health services. This also enabled deeper
understanding of the quality, provider behaviour and the impact of cost on access.

RECOMMENDATIONS FOR IMPROVING ACCESS. Following on from the previous
discussions, participants were encouraged to provide their own recommendations on
improving health care service access.

The principal approach in the focus group discussions was based on the participatory learning
action (PLA) approach, which contains three main components:
1. Facilitators’ behaviours and attitudes (being sensitive to who controls the collection and
use of information).
2. Methods that combine visuals materials (such as mapping, modelling, diagrams) and
working with small groups.
3. Sharing (encouraging practices and behaviours that empower through local creativity
and ownership of study process and findings).

In the context of this study, participants were encouraged to lead the discussion through a
range of PLA techniques, such as:
1. Mapping of health service access by community members and health centre workers –
participants were encouraged to physically map the community, its main features as
well as health access points (whether traditional, private or public).
2. Listing and ranking of main health problems (either through writing or pictorial
representation).
3. Making recommendations for improvements to health care access.

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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009

1. Focus group discussion with community members

1. Facilitator describes objectives
2. Listing main health problems and locate on map. Use poster with the following throughout
the focus group discussion (FGD):

List with symbols and detail the following:
x frequency
x seriousness
x causes
x solutions

3. Discussion of seriousness – put a star against the most serious health problems
4. Discussion of reasons for main health problems
5. Mapping
x physically map the community with local community members
x map important locations
x map where people go for health services, especially MCH-related services

6. Suggested solutions
Select four topic areas for problem solving health improvement or improvement to health
service access, especially for MCH.

2. Focus group discussion with health centre staff

1. Mapping
x physically map community
x map important locations
x map where people go for health services, especially if MCH related

2. Listing and rank main health problems and locate on map
x discussion of main health problems in the slum areas
x discussion of reasons for main health problems
x ranking of health problems in slum areas specifically

3. Suggested solutions
Select four topic areas for problem solving health improvement or improvement to health
service access, especially for MCH in slum areas.


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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
ANNEX 2: LITERATURE REVIEW
History of urban health service delivery in Phnom Penh

Year Detail Source
1979–
1990s
At the end of the Khmer Rouge rule, returnees to Phnom Penh were
able to occupy buildings on a first-come first-serve basis. They were
mainly public officials and the few remaining professionals after the
mass killing of all educated people in Phnom Penh. The scarce
professionals were allowed to occupy any vacant dwellings close to
their new place of employment. The new owners appropriated many
centrally located buildings in the city, which they then subdivided and
started to sell, with no formal titles.

In 1990, the first year of the Human Development Report,
Cambodia’s Human Development Index (HDI) was calculated at only
0.501, placing the country at the “low human development” status.

After the Paris Peace Accord in 1991 and the establishment of the
new government in 1993, the national reconciliation policy allowed
about 200,000 displaced people who had lived in the refugee camps
along the Thailand and Cambodia border and also in Thailand
territory to repatriate.

1993 The Urban Sector Group (USG) is a Cambodian NGO established in
1993 that works in 48 poor communities in Phnom Penh. USG was
originally established by a group of local and international NGOs
working in Cambodia with the aim of helping squatter communities to
address issues of poverty, including land ownership, housing, basic
infrastructure services, water, sanitation and solid waste disposal.

1994–
2005
Development of the Health Coverage Plan by the Ministry of Health,
designates restructuring of the health system based on primary care
centres and referral hospitals with defined catchments and packages
of essential services for each level of care.

Ministry of Health,
Health Coverage
Plan 1996/
Guidelines for
Operational Health
Districts 1996
Health Coverage
Plan Updated
2005,
1996 Introduction of the Health Financing Charter by the Ministry of
Health, legitimizes and attempts to regulate user fees for health
services, additionally through the introduction of exemption schemes
for the poor.
Ministry of Health
1996
1997 As far back as 1997, a supplementary study of the Socio-Economic
Survey concluded that “health care costs are simply unaffordable for
the poor. Even a single outpatient visit….takes up one third of all non
food expenditure for a year for a typical person in the poorest
quintile”.
Socio Economic
Survey 1997,
quoted in D.
Thomas, Social
Development
Priorities in Health
Sector Reform
Options, August
1999 439/99/DFID
1998 Back in 1998, bilateral agencies started to become interested in
urban health. One of the outcomes of the health sector reform project
in the 1990s was the establishment of the Urban Health Project. A

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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
baseline demand survey was conducted in 2000 in five urban slums.
It was mostly a qualitative study, with data on access, quality and
affordability. After the study, the Urban Health Project set up ‘urban
health rooms’. These were small facilities based in the slums. They
provided basic treatment free of charge for slum dwellers. Staff at
these facilities (who received incentives) also assisted in referring
patients to the municipal hospital. The staff also assisted to
administer the health equity fund. The first (or one of the first) health
equity funds was established in the period 2001–2002). The health
equity fund became independently managed by the Urban Sector
Group. Due to management issues internal to the organization, the
health equity fund function of the USG was then taken up by Apiwat
Krusaa (Family Development – a local NGO). At the time of the
health equity fund and health rooms, the Municipal Health
Department lobbied hard for financing and official status of the health
rooms. But this strategy was not ever integrated within the health
sector strategy.
2000 “In Phnom Penh, the term ‘squatters’ describes people living on land
and in buildings over which the government claims ownership.
However, because squatters translates as ‘anarchists’ in Khmer, the
word is usually avoided in official documents. The term ‘urban poor’
is used to describe families who claim some form of occupancy rights
but who are economically poor, who live in inadequate housing
conditions, poor environment and lack of access to basic services.”








M. Slingsby,
Phnom Penh
Urban Poverty
Reduction Project
(CMB/00/003): a
UNCHS/UNDP/UK,
2000
DFID-supported
project - Draft
Project Proposal.
Phnom Penh:
United Nations
Centre for Human
Settlements.
2001 The Urban Health Project was officially started in 2001with funding
through the UK Department for International Development (DFID)
and Options consultant services. The aim was to explore alternative
models of service delivery for health care for the urban poor. A
demand-based baseline survey was conducted in two communities
in 2001 (Tonle Bassac and Boeung Kak). The main findings were:
x Poor people felt that government staff ignored their needs.
x The cost of health care is the most common cause of poverty
and homelessness.
x The richest of those living in the two communities estimate they
can spare a maximum of 5,000 riel per day for health care.
x The poorest of the poor have no money for healthy care.
x Fee exemption schemes did not work in the communities, with
high levels of unofficial charges.
x The private medical sector is the first choice of treatment source
for the population of Phnom Penh but is largely unregulated and
of dubious quality.
Urban Health
Project Briefing
papers –7
Options,
MHD/DFID/WHO
2002
2001 An Urban Health Project Management Unit was based in the
Municipal Health Department, with services provided through
government health staff supervised by the MHD.

2001 Some of the strategies applied in the program implementation were
as follows:
x Establishment of ‘health rooms’ in communities as primary care
C. Vickery, Review
of Health Services
for Urban Poor
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
and referral points, staffed by municipal health employees with
performance payments.
x Development of ‘user group’, mostly in the form of mothers’ club
to advocate for and promote community health.
x Establishment of local financing schemes (health equity funds)
with poverty identification schemes.


Component
Options, 2001
2001 An economic evaluation of the Urban Health Project (health services
component) established the following:
x Health rooms are heavily used by a predominantly poor
population. Population served by the two health rooms was
making about 1.8 visits per person annually, compared with the
city wide average of 0.16 to all public health facilities in 1999.
x A target population of 200,000 was identified for health equity
funds, with scale-up costs over a three-year period estimated at
$320,228.
x Benefits of the equity fund were noted: increased access to
treatment, prevention of poverty and prevention of cost of
$1,000 per capita of government expenditure on poverty
alleviation schemes.

A final evaluation indicated that health rooms became the first choice
of health provider for 66 per cent of residents (who previously used
private practitioners).
J. Knowles, An
Economic
Evaluation of the
Health Services for
Urban Poor
Component,
420/99/DFID, 2001

Extension of
Health Services to
the Urban Poor,
420/99/DFID, 2002
2001 An assessment of the status and numbers of the poor in 2001
established the following: “About 35,000 families (180,000 people)
live in 502 low-income settlements within Phnom Penh’s seven
municipal districts. Five per cent of these families live along railway
tracks, 5 per cent along roadsides, 9 per cent on rooftops of
downtown buildings, 26 per cent on river banks and along canals,
and 40 per cent on open land. In addition, there are growing
numbers of poor tenants who rent makeshift shacks around the
factories or who live in crowded sub-divided rooms in the city centre
or in isolated but insecure circumstances. Adding these would raise
the total to about 450,000 people or about 40 per cent of the city’s
1.1 million population.” (p. 63)
Environment and
Urbanization, Vol.
13 No 2, October
2001, The Asian
Coalition for
Housing Rights
2002 DFID approved a 12-month extension to Health Services for the
Urban Poor Project (HSUP) in 2002. A final evaluation raised ethical
implications of creating highly subsidized services and then
withdrawing all support at the end of project. In 2002, the Urban
Sector Group took responsibility for implementing the equity fund of
the Urban Health Program (UHP), in partnership with the Municipal
Health Department of Phnom Penh. In October 2003, University
Research Co Ltd. provided USG’s equity fund with a grant, funding it
for one year until September 2004.
Extension of
Health Services to
the Urban Poor
420/99/DFID, 2002
2003 In 2003, the UN released a report on urban slums. In 2001, 924
million people, or 31.6 per cent of the world’s urban population, lived
in slums. The majority of them were in the developing regions,
accounting for 43 per cent of the urban population, in contrast to 6
per cent in more developed regions. Eastern Asia (36.4 per cent),
Western Asia (33.1 per cent), Estimates for Phnom Penh range from
20–30 per cent. It is further projected that in the next 30 years, the
global number of slum dwellers will increase to about 2 billion if no
concrete action is taken. The urban population in less developed
Global Report on
Human
Settlements 2003
UN Habitat
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Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
regions increased by 36 per cent in the past decade.
Slums are not homogeneous – “Slums and poverty are closely
related and mutually reinforcing, but the relationship is not always
direct or simple. On the one hand, slum dwellers are not a
homogeneous population, and some people of reasonable incomes
live within or on the edges of slum communities. Even though most
slum dwellers work in the informal
economy, it is not unusual for them to have incomes that exceed the
earnings of formal sector employees. On the other hand, in many
cities, there are more poor people outside slum areas than within
them.”
2003 An final evaluation of the Urban Health Project identified the following
service features/strategies that worked:
x providing services at hours that allow the poorest to attend
x involving users in the management of services
x establishing affordable charges and eliminating unofficial
payments
x providing exemptions for those who cannot afford the fees
x improving access to second-level care by removing finance,
transport and institutional barriers to care.

C. Vickery, Health
Systems for the
Urban Poor Final
Report Options,
2003
2002–
2003
UNCHS provided supplementary funds to the Municipal Health
Department to extend project activities to relocation sites (Extension
of Health Services to the Urban Poor 420/99/DFID 2002for
populations from Tonle Bassac and Chbar Ampeu, following fires
that destroyed the settlements. Project activities continued at Boeung
Kak Health Room and despite funding shortages. The MHD opened
a new health room at Anglong Kngan with the support of UNCHS
and also to the Samaki relocation site.
Extension of
Health Services to
the Urban Poor
420/99/DFID, 2002
2003 The health equity fund has been operated by a local group who
formerly worked under an NGO called Urban Health Sector Group;
now they go by the name of Family Health Development and from
October 2003 until June 2008 they operated with funding from the
USAID-HSSC project. Through the proposed project, poor
households, identified either through the pre-identification process or
through a post-identification process followed by a field verification
visit, will be provided with a Priority Access Card (PAC). The card
can be used by any member of the family listed during the
identification process to access services at the Municipal Referral
Hospital, CPA1 referral hospital or health centres that have a
contract to provide services with the health equity fund.
Proposal, Apiwat
Krusaa, 2008
2004 An Urban Health Task Force was also established under the chair of
MHD. Evaluations of the Urban Sector Project was conducted in
2004.There have always been difficulties accessing financing for the
health equity fund, health rooms and municipal health staff. User
groups and mothers’ clubs were also established. The US Agency for
International Development, through the University Research Council,
still supports the health equity fund through local NGOs, such as
Apiwat Krusaa (Family Development). Although health posts have
been set up, the health rooms could not be financially sustained
despite the documented successes in use and coverage. The main
barriers to sustaining the programme include lack of financing and
inability to convince decision makers of the need to integrate the
health room into the health system. Financing therefore remains
project dependent.
Consultation Notes
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Health Service Access Among Poor Communities in Phnom Penh 2009
2005 The Municipality of Phnom Penh Conducts a statistical survey of the
population.
Municipality of
Phnom Penh
2006–
2007
Development by Ministry of Health of National Guidelines Health
Equity Funds.

Ministry of Health
2007 In 2007, the National Immunization Program, in partnership with the
World Health Organization and other partners developed an at-risk
strategy for slum areas of Phnom Penh and other parts of the
country. This followed the detection of a vaccine derived polio case
(and documented lower EPI coverage) in the slum area of Tonle
Bassac, which required a nationwide campaign to reduce the risk of
further transmission. In the process of this campaign effort and
implementation of at-risk strategy, 347,000 in 109 villages of Phnom
Penh were identified as high risk. Criteria for high risk was not clearly
identified, although the following criteria for classification were
identified in interview – i) low coverage; ii) unstructured housing
developments; iii) the very poor; iv) minority groups (Vietnamese,
Cham).
Consultation Notes
2007 “Officially, poverty stands at 12 per cent of the city population. The
poorest areas include a total of 22 different recognized squatter
settlements, including six in which HEF is provided (Anlong Kngan,
Anlong Kong, Beoung Kak, Bori Kila, Samake, Tonle Bassac).”

The Phnom Penh Municipal Hospital is the referral hospital for the
four Operational Districts of Kandal (with four health centres),
Cheung (with five health centres), Tboung (with six health centres)
and Lech (with six health centres) and a total of 21 health centres.

Sky Health Insurance (initiated by GRET with support from GTZ)
established a pilot project at one site in 2005. The SKY Health
Centre is located within the Municipal Hospital. Funding provided by
AFD (Agence France Development) from 2007. “Monthly premiums
are charged pro-rata according to family size: single person at
16,000 riel, 2–4 persons at 20,000 riel, 5–7 persons at 24,000 riel,
and 8 and more persons at 28,000 riel.”
Study of
financial access
to health services
for the poor
in Cambodia
Phase 2:
In-depth analysis
of selected case
studies,
Dr Peter Leslie
Annear (RMIT
University) et al.
2007
2008 As part of the programmes for child survival and immunization,
UNICEF and the NIP (National Immunization Program) partner with
the MHD will undertake a study of health service access in selected
communities as well as identifying strategies for improving
communication and access between at-risk communities and
government health services.

2008 Family Health Development designs are a new proposal for
extension of health equity fun system (USAID HSSC). Main
characteristics: Poor households are identified, either through the
pre-identification process or through a post-identification process
followed by a field verification visit, are provided with a Priority
Access Card (PAC). The card can be used by any member of the
family listed during the identification process to access services at
the Municipal Referral Hospital, CPA1 referral hospital or Health
Centres which have a contract to provide services with the health
equity fund. The initiative also involves the establishment of village
user groups.
Proposal, Apiwat
Krusaa, 2008
2008 Cambodia had experienced three years of double digit economic
growth, but still an estimated 30 per cent of the population lives
below the poverty line. The international economic crisis, leading to
sharp rises in fuel and food prices, has pushed many families below
Consultation notes
and literature
sources.
- 67 -
Health Service Access Among Poor Communities in Phnom Penh 2009
Health Service Access Among Poor Communities in Phnom Penh 2009
the poverty line status. The Asian Development Bank recently
announced a $30 million food security fund for the slum areas of
Phnom Penh. In some cases, slum areas are still being relocated. In
other cases, some populations are moving out of slums. But new
rural migrants sell land and are replacing populations that leave the
slums.
2008 The 2008 census in Cambodia indicated that the proportion of urban
population in Cambodia was 19.5 per cent. Growth rate for urban
areas is 2.55 per cent and rural areas 1.3 per cent (Phnom Penh,
specifically 2.82 per cent). The population has grown 32 per cent in
Phnom Penh in ten years, between 1998 and 2008. Urbanization has
increased over the past decade. The proportion of urban population
according to the new definition of urban areas has increased from
17.4 per cent in 1998 to 19.5 per cent in 2008. Average household
size in Phnom Penh is 5.1 people. The provinces of Phnom Penh
and Kandal, particularly their urban areas, have been attracting a
large number of young women who take up jobs in garment factories.
This is contributing to very low sex ratios in the urban parts of Phnom
Penh (88.2) and Kandal (88.0). Urban Phnom Penh and urban
Kandal with their large female populations, depress the sex ratio of
urban Cambodia as a whole. Subject to confirmation by age and
migration data, the possible reasons for the large numbers of
females in these two areas in the de facto count could be: i). Large-
scale migration of younger women to work in garment factories in
Phnom Penh, Ta Khmau etc.; ii) sizeable out migration of men to
provinces like Battambang, Oddar Meanchey, Stung Treng, Ratana
Kiri, Mondul Kiri, Preah Vihear, etc.
General Population
Census
of Cambodia 2008

Provisional
Population Totals

National Institute of
Statistics, Ministry
of Planning
Phnom Penh,
Cambodia, August
2008
2008 About 20 per cent of the poor now live in Phnom Penh and other
urban areas. By 2035, the proportion is projected to reach 50 per
cent. Most of the urban poor live in slums and squatter settlements,
without adequate access to clean water, sanitation, and health care
(Urban Health Project 2002).

National Immunization Program = 16 per cent (NIP, 2008)
Municipality of Phnom Penh= 20 per cent (Municipality, 2005)
Urban poor =12 per cent (Annear et al, 2007)
Urban poor = 19.7 per cent (241,000) (UN Habitat, 2002)



Health Service Access Among Poor Communities in Phnom Penh 2009

PREFACE
The Health Sector Strategic Plan 2008-2015 clearly stipulates that the long term vision of the Ministry of Health is “to enhance sustainable development of the health sector for better health and well-being of all Cambodian, especially of the poor, women and children, thereby contributing to poverty alleviation and socio-economic development.”; and furthermore that “A value-based commitment of the Ministry of Health is Equity and the Right to Health for all Cambodians”; and the first of its five Working Principles is “ Social health protection, especially for the poor and vulnerable groups: To promote pro-poor approaches, focusing on targeting resources to the poor and groups with special needs and to areas in greatest need, especially rural and remote areas, and the urban poor. Through the efforts of the Ministry of Health and health development partners, we have made important steps forward in recent years in expanding health services coverage across the country, and in trying to meet the health needs of the poor in particular through implementation of health financing reforms and extension of health outreach services to the most remote villages of the country. The results of those efforts have translated into overall increase in coverage of main maternal and child health care programs as well as communicable diseases interventions and a significant reduction in the child mortality rate. However, as Demographic and Health Surveys have demonstrated, there are persisting problems of inequity of health care access and health outcomes that are related to the economic status and education backgrounds of the population. Lower levels of income and education in families means that women and children in these families are more likely to have lower access to health care and have a higher mortality risk. Along with the fast growing urbanization in the recent years, we have seen the expansion of settlement communities in Phnom Penh which consist largely of those families with lower incomes and levels of educational attainment and poorer living conditions. These settlement communities have been the source of public health threats such as a circulating vaccine derived poliovirus in 2006. In 2010 these areas still present a high risk for further communicable disease outbreaks. Thus, better health services will not only improve the health status of these poorer communities, but also will help protect the health of the whole Cambodian population. This study enables us to understand more clearly the challenges these communities have in keeping their families healthy and gaining access to health care services. Ministry of Health wish is that the Ministry of Health, Provincial and District health staff, relevant local authorities, international agencies and NGOs and community leaders themselves will use these findings to develop strategies to work together to reach out to these populations for both better health services and improved health for the more disadvantaged sections of our society. Phnom Penh, July 9th, 2010

Professor Eng Huot
Secretary of State Ministry of Health

Health Service Access Among Poor Communities in Phnom Penh 2009

Acknowledgments
The study was designed and conducted by the principal consultant John Grundy in collaboration with researchers from the Centre for Advanced Studies: Dr. Hean Sokhom, Ms. Bun Malen, Ms. Khun Chandavy, Mr.Ou Sirren, Mr. Hun Thirith, Ms. Lim Sidedine and Ms. Som Dany. The National Immunization Programme’s director, Prof. Sann Chan Soeung and other staff, Dr. Svay Sarath, Mr. Ork Vichit and Mrs. Choun Vuthoeun, as well as the staff from Phnom Penh Municipal Health Department , Dr. Paou Linar and Dr. Vong Vannak, have provided valuable inputs to the design and implementation process. UNICEF staff, Dr Thor Rasoka, Mr. Chum Aun, Ms Julie Forder and the WHO advisor, Dr. Kohei Toda, have provided technical assistance. A special thanks to Ms. Diana Chang Blanc, UNICEF-EAPRO, for valuable financial contribution and technical advice to the study. The study was funded by UNICEF. And a particular note of appreciation to staff and local authorities for their time and to the children and their families, especially the mothers who provided valuable descriptions of their lives and the challenges they face when trying to ensure a better life for their children.

Contact Information Ministry of Health National Immunisation Programme Telephone: (023) 426 257 Website: www.moh.gov.kh

UNICEF Cambodia Telephone: (023) 426 214 Website: www.unicef.org

.................................................................... 53 Details of quantitative research instruments 53 Household questionnaire 54 Qualitative research instruments 60 ANNEX 2: LITERATURE REVIEW .............. 7 Community profile 1: Trabeng Chuuk 8 Community profile 2: Dam Charn and Dam Slaeng 9 Community profile 3: Borey Kaylah 9 Community profile 4: Tuol Sangkhae 10 3................. COMMUNITY CONSULTATION FINDINGS .................................................... 23 The social context for health and health service access 24 Social networks for health 29 Utilization patterns of health care services and access barriers 31 5............................................................................................................................ V 1....... 1 Ethics 2 Objectives 2 Research methods 3 Data analysis 6 Study limitations 6 2................................................................................ 62 History of urban health service delivery in Phnom Penh 62 i ................. INTRODUCTION TO THE STUDY .................... INTERVIEWS AND FOCUS GROUP DISCUSSION FINDINGS ....... 41 Recommendation 1: Community-based services for the urban poor 43 Recommendation 2: Community-based health monitoring of the urban poor 44 Recommendation 3: Health services quality improvement 44 Recommendation 4: Review of the public health functions 45 Recommendation 5: Review and scale up social protection policies 46 6.........Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 CONTENTS EXECUTIVE SUMMARY ................... 49 REFERENCES ................................................................................... CONCLUSIONS ..................... RECOMMENDATIONS FOR IMPROVING ACCESS TO HEALTH SERVICES.......................................... HOUSEHOLD SURVEY FINDINGS AND OBSERVATIONS ............................. 51 ANNEX 1: RESEARCH INSTRUMENTS .................................................................................................................................................................. 11 Community background and family socio-economics 12 Health communication and health knowledge 15 Health service coverage and use 17 4......................

Health Service Access Among Poor Communities in Phnom Penh 2009 TABLES Table 1: Study communities for household survey Table 2: Communities included in the household survey Table 3: Study sample for interviews and focus group discussions Table 4: Location of previous delivery FIGURES Figure 1: Hand-drawn map of Dam Charn community Figure 2: Summary of household survey findings Figure 3: Main reason survey respondents moved to the community Figure 4: Income of main income earners Figure 5: Mothers’ knowledge of diseases preventable by immunization Figure 6: Mother’s knowledge of maternal danger signs Figure 7: Mother’s knowledge of child health danger signs Figure 8: DPT-Hepatitis B coverage Figure 9: Reasons for not receiving immunization at the health centre Figure 10: Previous childhood illness Figure 11: First choice of provider for treating child illness Figure 12: Reasons for first choice of provider to treat child illness Figure 13: Services provided during antenatal care Figure 14: Market choices for health care in Dam Charn Figure 15: Analysis of health care costs in the four communities Figure 16: Summary of what is working well in relation to health service access Figure 17: Summary of responses to the fixed-facility site strategy Figure 18: Contrasting perspectives on recommendations for improving health and health access Figure 19: Frameworks for analysing the social determinants of health 4 12 13 14 15 16 16 17 18 18 19 20 20 32 33 36 37 38 42 4 5 6 21 ii .

Health Service Access Among Poor Communities in Phnom Penh 2009 ACRONYMS ADB AFD ANC ARI CAS CBM CPA DFID DPT EPI FDG FHD GRET GTZ HC HDI HEF HSP2 HSSC HSUP IMCI KAP MCH MHD MoH NGO NIP NIS OD PAC RH RHAC RMIT TBA UHP UN UNCHS UNDP UNICEF USAID USG WHO Asian Development Bank Agence Francaice de Development Antenatal Care Acute Respiratory Infection Centre for Advanced Studies Community-Based Monitoring Complementary Package of Activities Department for International Development Diphtheria. Attitudes and Practices Maternal and Child Health The Municipal Health Department Ministry of Health Non-Governmental Organization National Immunization Programme National Institute of Statistics Operational Districts Priority Access Card Referral Hospital Reproductive Health Association of Cambodia Royal Melbourne Institute of Technology Traditional Birth Attendant Urban Health Program United Nations United Nations Centre on Human Settlements United Nations Development Programme United Nations Children’s Fund US Agency for International Development Urban Sector Group World Health Organization iii . Pertussis and Tetanus Expanded Programme on Immunization Focus Discussion Group Family Health Development Groupe de Recherche et d'Echanges Technologiques Deutsche Gesellschaft für Technische Zusammenarbeit (=German Development Cooperation) Health Centre Human Development Index Health Equity Fund Second Health Sector Strategic Plan Health System Strengthening in Cambodia Health Services for the Urban Poor Project Integrated Management of Childhood Illnesses Knowledge.

Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 = study areas iv .

concerns remain that coverage has not been complete and that the health care system is inadequate to reach the at-risk populations. Although the research was not population based with a sampling methodology that allows the results to be generalized. health centre staff and local health authorities in four very poor communities (62 per cent of the households live on US$1–$5 a day). Findings This study of selected poor populations in Phnom Penh confirmed that health care access to basic preventive and curative services for women and children has relatively high coverage. Despite the available access and high coverage of health services. However. one-on-one interviews and focus groups discussions with mothers (of children younger than 5 years). the National Immunization Program identified up to 16 per cent of villages as at risk of outbreaks of vaccine-preventable disease. the National Immunization Program and UNICEF first initiated a health access study. The communities were generally described as having poor solid and waste management as well as inadequate shelter and water supply in some locations. the Centre for Advanced Studies (CAS) along with the Municipal Health Department (MDOH) conducted the study from January through March 2009. it has provided in-depth analysis of what the local residents in a few communities think of the health service and how access can be improved for populations at risk. private and public sector services. Mothers have a good knowledge of the risk factors for vaccine-preventable disease. Some 57 per cent of the mothers who participated in the research had completed primary school. HIV infection. In 2005 in Phnom Penh alone. dengue fever and communicable disease. Around 53 per cent of the mothers said that they had to pay for their v . The purpose was to identify how communication and health system strategies could be strengthened in terms maternal and child health care. Immunization rates are high and antenatal services are well used. In collaboration. despite those efforts. The study's purpose was to identify the main barriers to service access and ways to overcome them. considering people's capacity to pay. and services come at a high cost relative to income. although the quality could not be confirmed.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 EXECUTIVE SUMMARY There is a long-running problem of poor health service access among populations in the lowest socio-economic quintiles throughout Cambodia. a household survey. One of these at-risk communities had been the source of a vaccine-derived polio case earlier in the year. covering traditional. the respondents in the study reported poor health outcomes. The research entailed a literature review. The four communities selected for the study were chosen through consultations with local authorities. To improve the quality and coverage of immunization and maternal and child health preventive programmes for the at-risk populations in Phnom Penh. There is also a wide range of market choice of health care service providers. However. But they attributed their poor health primarily to the unhealthy social and environmental conditions in which they live. which led to a nationwide immunization campaign and targeted strategies to reach the most vulnerable populations. particularly preventive care. They reported their family had spent an average of $66 on health care during the three months prior to the research study.

All the respondents in the different research methods seemed to lack clarity on exactly who is responsible for public health functions and how to request needed public health interventions. dengue fever) the very poor demonstrate good knowledge of the causes of illness and what is required to avoid illness. young school-aged children and teenagers. resident health care practitioners and non-government organization (NGO) networks are powerful channels for networking health information and health referrals. Additionally. HIV prevention and care. The private sector is a mother's first choice for child curative care (50. but especially health centres and government hospitals. In some instances. vi . Because of the fixed-facility strategy. Overall. and only 19 per cent of mothers had used the health centre in the previous six months when their child was sick. Social programmes should target these most vulnerable groups to provide them with a minimum level of social protection for interlinked issues of health. even in the poorest communities.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 child's immunizations. security and income generation were perceived to be the main cause of poor health. Despite high health care costs relative to their income. Quality is defined in terms of effectiveness of medicines. This highlights the need to refocus public health strategies in order to alleviate the daily health and social conditions of the very poor. sanitation. education. sanitation and waste removal was striking. people identified poor health in the context of the social conditions in which they live rather than gaps in health service access. Electronic forms of media and word of mouth are the main channels for spreading health information in communities. 75 per cent of the interviewed mothers said they do not know staff in their local health centre very well. waste removal. Local authorities identified their role in health networking mainly in passive terms relating to the gathering of population statistics or conducting social mobilization activities for immunization campaigns. Coverage for immunizations. outreach services have stopped.3 per cent). in recognition of the strong interaction among access to health. education and food security. there is a need for wider health public policy implementation for the very poor that takes into account the social determinants of health. nutrition. There are particular subgroups of the poorest families in the studied communities that are particularly at high risk of social exclusion and social isolation. only 14 per cent of the mothers interviewed (160) held a poverty or health insurance card exempting them from certain health care fees. these include single mothers. The study's findings indicate that where health education programmes of the government and international organizations have been active (immunization. antenatal care and birth delivery at a facility is surprisingly high. Perceptions of quality and cost heavily influence the choice of provider. child illness and reproductive health. perceived skills and attitudes of the health centre staff and the cleanliness and presentation of the facility. However. environmental conditions and income generation. The apparent limited role of local authorities in public health networking for safe water. The interviewed mothers were less informed on matters relating to maternal health risks. Health centres and government hospitals are the first choice for preventive care (79 per cent of immunization services were provided at health centres and 66 per cent of reproductive health services at government facilities). Reproductive health services (antenatal and birth delivery) are well used at a range of providers. food security. Water. especially when linked to local health authorities and local government health services.

even for the urban poor. and making living environments more conducive to a healthy way of life. This leaves communities at high risk of communicable disease outbreak. x implementing health care strategies that focus not only on essential medical service packages but also on essential public health functions that address the social determinants of health. Although the fixed facility strategy has been successful in maintaining coverage. The report notes the following primary areas of action: x scaling up social protection measures for health care and education in collaboration with civil society and local authorities. conduct health education outreach and build stronger partnerships with local practitioners. there is also a strong case for increasing the market competitiveness of government health centres through the reduction of client costs (social protection) and improvements in the quality of service. Essential functions of public health need to be defined and resourced.Health Service Access Among Poor Communities in Phnom Penh 2009 In Cambodia. x conducting health surveillance focused on the needs of the poor and not just on their diseases. there is no single unified health system in the urban context. ii) public health function and iii) social protection policy – and largely derive from suggestions by local authorities. The recommendations speak to two prime needs: making health service more affordable and of higher quality. Given the scale of the market mechanism for health care. health centre staff and mothers. Their willingness to pay by borrowing or selling personal property reflects the high priority the poor place on accessing health care. More investment is required for health centres to micro plan. A better understanding of the dynamics of this health market for the poor would guide policy makers towards improving quality health care and social protection for them. Policies and systems interventions are needed to protect the poor from the burden of the disproportionate costs through social protection. Recommendation 1: Community-based services for the urban poor Adequate resourcing of health centres should be introduced for conducting health education and service outreach to at-risk communities on a regular basis. The purpose is three-fold: i) vii . Although there is some degree of clarity of role in relation to the medical service provision through health facilities. with clear lines of accountability for the Ministry of Health staff. there is still concern regarding pockets of non-immunized children in selected highrisk locations. authorities and NGOs in high-risk communities. local authorities and communities. There is in fact a health market with a wide range of choice of providers and types of service. improvements in public health functions and the health care system. Recommendations The five recommendations that are presented in the report cut across three levels of intervention – i) service delivery strengthening. The study's findings indicate that the very poor pay levels of cost for both preventive and curative care services that are disproportionate to their capacity to pay. the broader functions of public health and primary health care are ill defined. Conclusions Improving access to health care among at-risk populations means improving access to healthy social conditions as well as improving access to health care services.

Recommendation 4: Review of the public health functions A review of essential public health functions for improving urban people's health should identify the resources required and a capacity-building plan to strengthen the delivery of services.Health Service Access Among Poor Communities in Phnom Penh 2009 strengthen links among health services. Recommendation 2: Community-based health monitoring of the urban poor The Municipal Health Department (MHD) needs to undertake a systematic approach to the surveillance of at-risk populations through support to districts and health centres. community practitioners. Recommendation 5: Review and scaling up the social protection policy Social equity funds or 'social-safety net' funds. local authorities. viii . the MHD also needs to conduct regular mapping and micro planning for at-risk populations. such as facility and community-integrated management of childhood illness. based on a model of the health-equity fund. and iii) provide mobile services for the most at-risk populations. ii) make contact with and support local social networks for health (formal and informal). health centres or a combination of all. should be established in the poorest communities in Phnom Penh on a comprehensive basis to ensure very poor people's access to both health care and education services. either through local authorities. The mapping exercise should be built into the routine functioning of the surveillance and planning system so that surveillance focuses both on disease and on detecting health risks and health inequities. In conjunction with local authorities and civil society partners. NGOs. NGOs and communities. Recommendation 3: Health services quality improvement A combined health education and quality improvement strategy should be adopted so poor people can access good-quality and more affordable child-illness care at health centres.

Health Service Access Among Poor Communities in Phnom Penh 2009 1. INTRODUCTION TO THE STUDY -1- .

Ethical considerations including obtaining consent and community participation were discussed during the training of the data collectors from the Centre for Advanced Studies in January 2009. the National Immunization Programme and UNICEF first initiated a health access study. The study entailed three stages: 1) community consultations. Specifically. people in the lowest socio-economic quintiles have substantially less access to health services. the Centre for Advanced Studies (CAS) along with the The Municipal Health Department (MDOH) conducted the study from January through March 2009 and included observations and interviews with residents of communities in four operational districts (OD) of Phnom Penh municipality: Cheung. A Steering Committee consisting of representatives from the four research partners (the National Immunization Program. which is the lowest administrative unit in the Cambodian system. The National Immunization Programme (NIP) in 2005 identified up to 16 per cent of villages in Phnom Penh (109 of 695) as at risk of insufficient coverage (NIP documentation. This report highlights the findings and responses. Despite the campaigns and coverage improvements. In collaboration. the insight and recommendations would help improve coverage of the Expanded Programme on Immunization (EPI) as well as maternal and child health (MCH) preventative care. Lech. Ultimately. incorporating both quantitative and qualitative components. UNICEF. Each village within an operational district consists of one or more krom. national and municipal health managers continue to be concerned that Cambodia’s communication and health system strategies remain ineffective in reaching the at-risk populations. Thus remains the possibility of repeat outbreaks of the vaccine-preventable disease as well as inequities in maternal and child health outcomes. the respondents lived in a selected krom. One of the identified communities in the National Immunization Programme research was the source of a vaccine-derived polio case earlier in the year. which had prompted national immunization campaigns and other targeted strategies for populations at risk of infection from vaccine-preventable diseases. 2) household survey and 3) interviews and focus group discussions. Tboung and Kandal. 2008). The krom consists of approximately 50 families and has an identified krom leader. -2- . Objectives The study was designed to analyse the situation in selected at-risk communities within Phnom Penh in terms of health service access. Ethics A study proposal was submitted to and approved by the National Ethics Committee of the Ministry of Health in December 2008. To improve the quality and coverage of immunization and maternal and child health preventive programmes for the at-risk populations in Phnom Penh.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 According to the Cambodian 2005 Demographic Health Survey (Ministry of Planning). The purpose was to generate sufficient insight for recommendations on improving the communication and health access strategy for at-risk populations. CAS and MDOH) managed the study’s proceedings.

Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 In particular. Stage 3: Interviews and focus group discussions (March 2009): To gather more qualitative feedback. Stage 2: Household survey (February 2009): A standardized household questionnaire was used to randomly survey 160 mothers of children younger than 5 years in the four selected communities. and local NGO staff. From these consultations. -3- . The four communities were selected by the following criteria: x area identified by health managers and municipal authorities as the poorest or ‘most difficult’ in terms of accessibility and coverage x willingness of community leaders (head of village and/or krom) to participate in the study. The questionnaire enabled the gathering of background information of respondents and their overall knowledge. through conversations and interviews with community members. the riverbank. The targeted secondary populations were the authorities and agency staff tasked to provide or facilitate health services to the at-risk population. sidewalks. four study communities were selected for stages 1 and 2 research. detailed interviews were conducted with 20 health centre staff and key informants. The researchers then travelled to the suggested villages to consult with the village leaders and explain the objectives of the study. the study aimed to: x identify and describe the main barriers to access of health services. A questionnaire guideline was designed for use with the mothers and with local authorities and health centre staff (annex 1 provides the framework for these interviews). along railways and rubbish sites or in clusters of densely occupied temporary or unstructured housing. health centre staff and local authorities x identify and describe health system delivery approaches and communication strategies to improve and sustain health service access for maternal and child health care among at-risk populations. rooftops. health clinic managers and workers. The targeted at-risk population – typically categorized as ‘slum dweller’ – was characterized as living in the lowest socio-economic conditions: on open land. primarily local authorities. The FGDs ranged in size from 8 to 20 participants and relied on open-ended questions. Research methods The study adopted a case study approach to gain the needed in-depth understanding of the barriers and potential solutions. The study was conducted in three stages: Stage 1: Community consultations (January 2009): Researchers visited the health centres in the four operational districts to identify ‘the most difficult’ or poorest populations. dikes. Four small focus group discussions (FGD) were conducted with health centre teams and mothers. attitude and practices regarding maternal and child health care services (see annex 1 for the questionnaire).

with supervision by municipal and national health authorities. a UNICEF consultant and senior CAS researchers. A two-day training with the eight researchers and a testing of the questionnaire in Boeung Kak community was conducted prior to the beginning the household survey. Lech OD Mean Chey HC. the chief had an outdated list (according to the krom leader). The village chief identified the krom with people considered the poorest economically. In one village. Cheng OD *These areas are highlighted on the map on p. Figure 1: Hand-drawn map of Dam Charn community (poorest krom labelled in black. Stage 2: Household survey Eight researchers from the Centre for Advanced Studies conducted the household survey. with 10–15 mothers with children younger than 5 years selected from each block. ii of this report. Tboung OD 7 Makara HC. A two-day orientation with the researchers and one-day testing of the questionnaire took place to ensure good-quality data collection. In three of the four communities. Community Trabeng Chuuk Dam Charn and Dam Slaeng Borey Kaylah Tuol Sangkhae Stage 1: Community consultations The researchers and the national and municipal health authorities visited each operational district office to identify the health centres with the most difficult to access or poorest populations. The researchers then travelled to those identified health centres to target the areas in their catchment that were the poorest or the most difficult to reach. The researchers then moved to the krom to meet with the krom leader to explain the objectives of the research and the survey’s timeframe and make observations of the area based on their guidelines. Then the researchers headed to those villages to meet with the village chief and explain the purpose of the research. The researchers made their own maps when necessary to ensure that they were sampling the poorest areas.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Table 1: Study communities* Health centre (HC) catchment and operational district (OD) Tec Tlar HC. at the top along the Bassac River) 4 -4- . the krom leaders did not have a tabulated list of all households or family names. the researchers moved from house to house in each block until 40 mothers had been interviewed. The researchers decided to divide the targeted poorest village areas into three or four blocks. There were also inconsistent estimates provided on the numbers of families residing in each krom. Kandal OD Samdach Ov HC.

methods and content). the researchers followed the same process as the household survey. Participation was limited to the workers with employee status of the health centre. one group was selected from each community. Representatives from the National Immunization Programme and UNICEF observed the process. depending on the size of the facility and the staff’s willingness. There are 30 groups in the village. However. -5- .341* 89 *The sample was selected from all the groups in Borey Kaylah. Permission was requested from the participants for recording each conversation. Thus a majority of the interviewees were purposefully selected for the in-depth interviews. In every case.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Table 2: Communities included in the household survey Health centre catchment and operational district Tec Tlar HC. resident practitioner or community leader) assisted in the selection of eight mothers. Kandal OD Samdach Ov HC. the researchers were asked to identify mothers and/or key informants during the community consultations and household survey who could articulate the social context and barriers to health service that they and their neighbours experience. all with a child younger than 5 years and from a very poor household. Stage 3: Interviews and focus group discussions For the qualitative survey. Given the limited scope of the survey. Lech OD Mean Chey HC. For the FGDs with mothers. of families Sample household survey 40 30 10 40 40 160 mothers Trabeng Chuuk Dam Charn & Dam Slaeng Borey Kaylah Tuol Sangkhae 300–400 250 50 2. the focus groups ultimately ranged in size from 8 to 20 mothers because they were conducted in an open area and other residents joined the discussion. The FGDs ranged in size from 6 to 12 participants. The FGDs with health centre staff were conducted in the health centre closest to each of the four communities. although discussion took place with women on the role of men in seeking health care (see annex 1 for more details on the research instruments. Tboung OD 7 Makara HC. men (aside from the local authorities) were not purposefully targeted for interviews. For the remainder of the sample. Cheng OD Total Community No. with a specific request for the health centre manager. The interviews and focus group discussions were conducted by the Khmer researchers in Khmer. and one group consists of 75–80 households. randomly selecting mothers according to the criteria of having a child younger than 5 years and living in the community. Dam Charn and Dam Slaeng are treated as one community in this report. an immunization specialist and an MCH provider. a key informant (local authority.

the research is not a quality assessment of health service provision. based on the three stages of research. local authorities. local authorities. Rather.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Table 3: Study sample for interviews and focus group discussions Health centre catchment and operational district Tec Tlar HC. The findings from the three research method were cross-referenced for consistency in themes. Lech OD Community In-depth interviews Focus group discussion Mothers Health centre staff Mothers Health centre staff Mothers Health centre staff Mothers Health centre staff 8 focus groups Trabeng Chuuk Dam Charn & Dam Slaeng Borey Kaylah Mothers. Study limitations The research is not a population-based survey with a sampling methodology that produces generalised results regarding health status. The outcomes of the analysis were organized into three sections. Further. the overall findings were compared and contrasted with analysis in national and international literature to arrive at a representation of the situation and the recommendations on strategy for improving health service access. Interpretation of the findings was further debated and validated with the team of researchers at a follow-up meeting. health centre staff Mothers. health centre staff Mothers. knowledge or behaviours which is representative of at-risk populations in Phnom Penh. health staff and local authorities perceive their access to health services and their opinions on how to improve that access among marginalized populations. Kandal OD Samdach Ov HC. the researchers recorded the summaries into thematic areas. although it seeks to understand community members’ perceptions of the quality of the service available to them. Finally. it provides an in-depth analysis of four communities in terms of how community members. The data was analysed again in the SPSS program and entered into the Excel format for graphic presentation. Interviews and focus group discussion analysis Following the interviews and focus group discussions in stage 3. -6- . local authorities. health centre staff Mean Chey HC. Tboung OD 7 Makara HC. the researchers met to discuss the main findings and the implications for recommendations. The summaries were recorded in Khmer and were typically five pages in length. Following those interviews and FGDs. Cheng OD Total Tuol Sangkhae Data analysis Following the collection of data through the household survey in stage 2. debriefing meetings were conducted in the CAS office. health centre staff Mothers. Responses to the few open-ended questions were recoded before the data was entered into the SPSS program (statistical analysis software). local authorities.

COMMUNITY CONSULTATIONS FINDINGS -7- .Health Service Access Among Poor Communities in Phnom Penh 2009 2.

However. Because of the recent relocation due to fire. But this did not happen. My mother was from a remote province. Families do not have health insurance or ‘poverty exemption cards’. and now he is in prison for two years.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Community profile 1: Trabeng Chuuk Trabeng Chuuk is located in the catchment area of Tec Tlar Health Centre. According to interviews and observations. ranging from 300 to 500 families. The staff of the Tec Tlar Health Centre comes to the area if called. I am alone now and I have nothing. The [police] caught him. CARITAS brings water supplies. Various NGOs are helping the community. She was very beautiful. ten months prior to the study research. I loved the baby and now I am keeping him. Different estimates were given for the number of families residing here. World Vision provides for home-based care for people who are HIV-positive. Many children are not attending school. Hope Hospital provides a once-weekly service for medical curative care. The environmental conditions are very poor. But the community members are unclear on the timing of the return or if there will be any compensation if they are unable to return. I do not want to see him again. which was being redeveloped. It cost me $100 to deliver the baby at the hospital. others are living under coconut palm. And he was a drug [addict]. Some of the community members work as builders and market sellers. I cannot return to my mother. I have no education. I receive no help from the outside – but the people who live nearby me.5 h in size. and large water containers are available. with uncollected rubbish heaped in one corner of the site. But after I delivered the baby. Liquid and solid waste are visible in most pathways and roadways. he was a much older man. I work for $2 a day washing the clothes of the people who live by me. But incomes are very low. which is an empty building site about 1. most of the families are still living in plastic shelters. I tried to drink a lot of alcohol so the baby would abort.or tin-roof structures. there is one toilet for the entire community – at least 300 families. which exempt them from certain health care fees. My father drove the boats up and down the river and was away a lot…. in the Lech Operational District. Then I met my husband. I came to Phnom Penh to work in the garment factory. but there is no consistent mobile health service. I am too ashamed. They said that they would take my baby for $100. But then I started also working in the beer halls and karaoke clubs.” – the young mother was living with her newborn under a tarpaulin in a space 2 x 2 m -8- . Drinking water is piped to the site. a large fire destroyed their housing and the residents relocated to Trabeng Chuuk. A mother’s story in Trabeng Chuuk “My father had many wives and children. they help. The community members originally resided near a lake a short distance away. Many of the families reported that they were waiting for the local authorities to permit them to return to the original housing site. I [was pregnant]. I have nothing.

Dam Charn’s population is unclear. The community is of mixed Vietnamese and Khmer ethnic origin. some of the poorest residents in Dam Slaeng (in krom 8. but the people recently returned to live along the bank of the Bassac River. located in the cemetery) had recently migrated from other provinces (such as Prey Veng and Takeo). and a total of 30 krom were recorded. Due to the proximity of these two communities to each other and their historical connections. Dam Slaeng village was originally part of Dam Charn village until they were separated in 2007. These include the referral hospital. A large fire several years ago destroyed most of the community. in Tboung Operational District. One NGO provides on-site bilingual education programme for the children. The residents began moving here in the early 1980s. Six families are living in an unused building. According to the local authorities. The staff at the health centre report that they are unclear on current service use by Borey Kaylah community members because they are so mobile and there is no structured outreach health service programme. Hope Hospital (an NGO) and other government hospitals. As well.779 families and a population of 9. the communities were studied jointly using one sampling frame. for the purpose of this study. No one had any accurate figure or household listing. There are no toilets or safe water supplies in the area. with crowding and lack of solid waste disposal. and the district (sangkhat) authority appointed a village chief. The standard of living is very low. The researchers reported there is no waste removal system or system for managing liquid waste for people living closer to the river. Between 2003 and 2007. Community profile 3: Borey Kaylah The Borey Kaylah community is located in the catchment area of 7 Makara Health Centre. The researchers verified that many of the community members have health insurance cards. Many children were observed at home with elders while the parents were away working. while others reside in more temporary single-level dwellings. Some of the families live in high-rise tenement blocks. the 7 Makara Health Centre. The community was established here in the early 1980s. -9- .The krom consists of approximately 50 families. in Kandal Operational District. setting up temporary homes. According to the village chief. The residents typically earn money as construction workers. many children seemed to be not attending school. formal building structures were established in some spots. The krom leader was unclear on the number of residents or families but said that the village chief’s list was probably outdated. There is a Khmer village chief and a Vietnamese community leader. Here also the environmental conditions are very poor. The groups in total entail some 1. Three health volunteers cover the population. Each krom in this location contains 79–80 families. In 1993. the community received official status. There are many health service outlets near the community.979 people. people do not live day to day but moment to moment. rubbish collectors and market sellers.Health Service Access Among Poor Communities in Phnom Penh 2009 Community profile 2: Dam Charn and Dam Slaeng Dam Charn is a village in the catchment area of Mean Chey Health Centre.

A migrant’s story in Tuol Sangkhae “I have been here for two years. some have been selling land at the railway site to others and moving on. There the soil is dry and sandy. Most of the population are factory workers.” – the woman and her family live in a space 2 x 3 m. Some community members reported experiencing economic hardship associated with the recent closure of factories. I had my baby one month ago. But now the factories are closing. I moved from another temporary location after [the authorities] wanted to relocate the homes. This area has formed its own community association. [Someone] contacted the private doctor and he came quickly and cut the cord. maybe we can get some money … and we can go back to the province and make a well. Community members said they are using the health centre for vaccination services.Health Service Access Among Poor Communities in Phnom Penh 2009 g Community profile 4: Tuol Sangkhae Tuol Sangkhae is a village in the Samdach Ov Health Centre catchment area. having moved here since 1988. This is also a mixed community. A few better-off families live further away from the railway track. My family’s land is in the higher country. A private doctor operates a clinic along the track and assisted the researchers in contacting households for the study.10 - . with people of Khmer and Vietnamese ethnicity. The houses appear to be temporary and are crowded close to the railway track. and it’s harder to find money. The birth was quick – it took only ten minutes so I delivered the baby myself. in Cheng Operational District. There are obvious problems with solid and liquid waste and mosquito control. So we moved here. So we came here to earn income. Tuol Sangkhae consists of 19 krom. Without a well you cannot make a garden – you cannot make a living there. If I stay here long enough. with a total of 367 families. The community members live alongside a narrow gauge railway track with a train running through twice daily to transport fuel to a nearby depot. I left my province ten years ago. There was no room. roughly 8 m from the railway track . builders and motorcycle taxi drivers. they go to private providers and government hospitals. Where I was staying was too crowded. For other health services. 153 women have children younger than 5 years. Of them.

Health Service Access Among Poor Communities in Phnom Penh 2009 3.11 - . HOUSEHOLD SURVEY FINDINGS AND OBSERVATIONS .

so the random selection was done by dividing a community into ‘blocks’. health knowledge and communication and service coverage and use. with ten mothers selected randomly from each block. 6RFLRHFRQRPLFV DQG HQYLURQPHQW VXUYH\ DQG REVHUYDWLRQ. x In most cases. x The questionnaire of mostly closed but also open-ended questions covered family socio-economics. there was no household list. Figure 2: Summary of household survey findings 6DPSOH VL]H x A total of 160 mothers with children younger than 5 years were randomly selected from the four communities.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Figure 2 provides a snapshot of the household survey findings and observations the researchers made during their visit to the four targeted communities and the 160 households. x The communities were identified by operational district officers and health centre staff as the ‘most poor’.

antenatal care and birth delivery at facility is good. x Some 19 per cent of the 160 mothers had used the health centre in the six months prior to the survey for a child health consultation. 6HUYLFH FRYHUDJH DQG XVH x Coverage for EPI. especially at night. x All respondents reported a low income (62 per cent had an income of $1–$5 per day from the main income earner) and a low education level (57 per cent had not completed primary school). .3 per cent) and Kantha Bopha hospital (20. x There are high health costs. even in the poorest communities. x Local health educators/communicators are not very visible. x Health centres/government hospitals are the first choice for preventive care (EPI: 79 per cent and reproductive health: 66 per cent at government facilities). x The respondents noted a lack of social mobility.12 - . x The private sector is the first choice for child curative care (50. only 14 per cent of the respondents have health insurance of any kind. cost and trust.6 years. x The communities suffer from poor solid and liquid waste management. there is inadequate shelter. x In some cases. with families spending on average of $66 in the previous three months on health care costs. despite being the four poorest communities identified by health district officers. x Health centres are used for prevention programmes. such as EPI and reproductive health awareness. and 75 per cent of the survey respondents said they do not know staff at the health centres very well. x The use of provider is driven by perceptions of quality.8 per cent). x Outreach services have stopped. x Knowledge on danger signs in pregnancy and warning signs for child illness is limited. x The mothers retain their children’s yellow immunization card (63 per cent) despite their difficult housing conditions. +HDOWK FRPPXQLFDWLRQ DQG NQRZOHGJH x Mothers have good knowledge of EPI. x Electronic media (TV) seems to be effective in reaching mothers. they had been in the four communities on an average of 7. x The population prioritizes health care. x The respondents reported a sense of physical insecurity. x The respondents also cited lack of social protection. Community background and family socio-economics x Some 53 per cent of the mothers said they have to pay for immunizations.

21 (13%) Others.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Of the 160 survey respondents (women with a child younger than 5 years). Figure 3 highlights the primary reasons the respondents moved to the community. gambling and alcohol consumption. Mosquitoes and dengue fever were mentioned as common problems. 93 per cent are Buddhist. There is one pit toilet for at least 300 families. nonschool attendance and increasing unemployment due to the economic crisis (specifically. secretarial (8 per cent) and government jobs (7 per cent). in slum conditions this represents overcrowding. Most shelter here is plastic sheeting or makeshift materials. The Vietnamese respondents resided predominantly in the Dam Charn community. The mean size of household is 5. The researchers observed that many families live in 2 x 3 m living spaces. loss of work at garment factories). Trabeng Chuuk. Other work includes carpentry and electrical repair (11 per cent). Some 38 per cent of them moved to their current location from another area in Phnom Penh. Although the average household size of 5.6 years. . the respondents have lived in the community for 7. in particular. Figure 3: Main reason survey respondents moved to the community What was the main reason you moved to this community? (N = 160) Land or home lost. home or market selling (19 per cent) and motorcycle taxi driving (17 per cent).8 persons is similar to the national average. 3 (2%) Family reason. and 29 per cent identify themselves as ‘mobile’ (respondents were requested to self identify as mobile – this commonly means that they are frequently coming and going and also residing in other locations). Social problems: Other problems noted during interviews in the community include physical insecurity at night. 62 (39%) Economic reason. resembles a humanitarian emergency community. Some 84 per cent of the respondents are Khmer and 13 per cent are Vietnamese. 74 (46%) Environmental conditions: Observations made during the community consultation and household survey detected immensely poor environmental standards.13 - . social isolation of single mothers. Socio-economics: Most professions of the main income earners in each respondent’s family are construction (22 per cent). There are open drains and waterways and no collection of rubbish. the mean age is 29 years. 55 per cent came from other provinces.8 persons. Around 71 per cent of the respondents identify themselves as migrants. On average.

Some 53 per cent (148) of the mothers surveyed reported that they paid for their child’s previous immunization. Given the low education levels. City costs tend to be higher than in rural areas. Although this is in line with the gross national income for Cambodia (at $591).000–20. particularly for health care.000 riel 62% 1 2 US$1 is equivalent to approximately 4. the health care costs are clearly very high. Only 14 per cent had a ‘poverty card’ or ‘insurance card’.14 - . those having a poverty card all lived in Borey Kaylah where an NGO operates (and manages) a health equity fund. although no specific information was collected on how much each paid. these respondents need to support an urban cost of living. Some 25 per cent of the respondents’ households spent $100 or more.2 Figure 4: Income of main income earners (4. the mean expenditure by households on health care was $66.000 riel 33% Less than 5. which exempted them from fees for certain health care services. In the three months prior to the survey.000 riel = US$1) Average income per day of main income earner in household (N = 160) Not regular Unsure 1% 2% Greater than 20.25 and $5 per day1 (figure 4). At least 300 families share this one toilet in Trabeng Chuuk community When balanced against the income and other family necessities of education and food. Some 62 per cent of the respondents stated that the household income is between $1.000 riel (Khmer currency) A Health Equity Fund is a pro poor health insurance scheme for hospital care services and for a selection of primary care medical services (see Annear et al.Health Service Access Among Poor Communities in Phnom Penh 2009 Only 57.5 per cent of the respondents had completed primary education. 2007) . it is not surprising that the income levels in the families surveyed are also low.000 riel 2% 5.

15 - . These responses link with the finding that only 40 per cent of mothers reported hearing from government health .0 60. obtaining information on the importance of routine immunization or an immunization campaign seems limited beyond the television.8 71. This finding is reinforced by the fact that 63 per cent of mothers had the government immunization yellow card in their household possessions.5 per cent cited swollen hands and feet. 46 per cent of the 160 mothers identified bleeding as a danger sign in pregnacy. Government health workers (who the mothers said they do not know very well) are the main source of information outside of television (40 per cent).2 18. considering the insecurity and crowded living conditions of the households.0 40.0 11. government health workers (20 per cent) are the next largest source of information for women’s health. 89. especially women’s health. Around 82 per cent of the survey respondents reported hearing or seeing a media message/programme on women’s health within the previous three months. Based on the responses. Of those who heard or saw the information. Of those who heard or saw the information.0 % of mothers who mentioned disease prevented by immunization The respondents were also questioned on their knowledge of child and maternal health danger signs.4 80. Figure 5: Mothers’ knowledge of diseases preventable by immunization Mothers’ knowledge of diseases preventable by immunization (N = 160) Tetanus Polio Measles Hepatitis B Tuberculosis Whooping cough Diphtheria 0.0 100. followed by friends and neighbours (at 15 per cent) and then parents or relatives (at 5 per cent). the survey results also suggest poor social networks for health information.6 25.0 20. This data. However. This is a high retention rate.0 68.4 per cent picked it up through television. Outside television.1 76. and 27. combined with the service coverage data indicates the effectiveness of television in its reach. As shown in figure 6. 84 per cent picked it up through television.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Health communication and health knowledge Health communication: Some 77 per cent of the 160 mothers reported hearing or seeing a media message on immunization within the previous three months. Health knowledge: The majority of mothers could state three major diseases prevented by immunization.0 31.

3 % of mothers who Identified danger signs For child health.4 Others Bleeding Swollen hands or face Fever Severe headache Reduced/faster foetal movement Trouble with vision 0.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 workers about maternal health issues.9 10.6 100 % of mothers who identified danger signs .0 95.0 27.5 46. Figure 6: Mothers’ knowledge of maternal danger signs Mothers’ Knowledge of Danger Signs in Pregnancy (N = 160) 69.9 11.8 45.0 12.0 21.0 100.0 0. respectively. only 26 per cent and 25 per cent of mothers identified fast and difficult breathing.0 60.1 10 20 30 40 50 60 70 80 90 6.9 26.0 40.16 - .6 20.0 80. Figure 7: Mothers’ knowledge of child health danger signs Mother’s knowledge of child health symptoms requiring referral (N= 160) Child develops a fever Others Severe diarrhoea Child has fast breathing Child has difficult breathing Severe vomiting Child not able to drink or breastfeed Child becomes sicker Child has blood in the stool 0 3.3 25.5 11. as reasons for immediately seeking a health facility. It also links with the finding that only 60 per cent of respondents reported hearing information on danger signs from a health worker during their last antenatal care visit.9 48.

The Government stopped funding immunization health outreach services to communities two years ago. only 10 per cent of those who did not attend the health centre for a vaccination indicated that the cost was the barrier. When asked how often an EPI team visited their area.0 % DTP3 80. 11 per cent at the government hospital and 7 per cent at Kantha Bopha hospital. Of the vaccinations provided. the third dose of diphtheria.3 20.0 Of the 160 children. 148 received vaccinations as scheduled. 68 per cent were provided at the health centre. Some 53 per cent of the mothers reported paying for the previous vaccination. Figure 8: DPT-Hepatitis B coverage DPT-HepB3 coverage (N = 139) Immunization not given Mother reports immunization was given Immunization date DPT-HepB recorded on the yellow card 0. the fact that 9 of 12 mothers who did not receive vaccination at all indicated they were busy does suggest competing economic priorities with immunization programmes that might not exist if the service was free.0 40. and the hepatitis B vaccines was verified by cards for 88 children of an eligible population of 139 (63 per cent). As stated earlier.17 - .5 per cent) had been vaccinated.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Health service coverage and use Immunization: Immunization coverage in the poor communities is satisfactory. The main reason given for the child not being immunized was that the mother was ‘busy’ (9 of the 12 responses). A further 41 children (29.0 60. As figure 8 shows.5 per cent). However. Around 34 per cent indicated there were six monthly visits from an EPI team. . and 15 per cent said not at all. The survey results confirm the health outreach services have stopped.0 100. Only 2 per cent were provided through the private sector.5 63. suggesting that costs for immunization services are not a significant barrier or are sufficiently low. Only 10 of 139 children (7 per cent) were reported by the mothers as not vaccinated. 53 per cent of mothers reported paying for the last immunization provided.2 29. pertussis and tetanus. However. 35 per cent of the mothers replied they were unsure. The main reason for not vaccinating at the health centre was that some mothers did not know the staff at the health centre (33 per cent) or preferred to vaccinate at another place (23. according to the oral history from the mothers.0 7.

9 5. The most common childhood illnesses experienced were acute respiratory infection (ARI) (40 per cent).9 5.8 5.3 23.18 - .8 9. A total of 149 children of 160 had had an illness.5 11. with the different conditions shown in figure 10.9 20 40 60 80 100 % response N = 51 Child health: Respondents were asked to identify the last child illnesses experienced by their child (younger than 5 years) within the previous six months.9 3. Figure 10: Previous childhood illness Previous illness experienced by child in the previous six months (N = 160) ARI Fever Diarrhoea Not sick Other 0 3 20 40 7 13 37 40 60 80 100 % of children . fever (37 per cent) and diarrhoea (13 per cent).Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Figure 9: Reasons for not receiving immunization at the health centre Main reasons child did not receive vaccination at the health centre (N = 51) Mother doesn’t know or trust staff Vaccinated at other place Mother busy Cost of immunization Other Do not care Poor quality Distance 0 33.

Private clinics (27 per cent) and local pharmacies (23 per cent) were the main providers of choice. 75 per cent replied that they do not know them very well.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 When mothers were asked if they had used the nearest government health centre for a child health consultation in the previous six months. If their child had been ill in the six months prior to the survey.19 - . and 9 per cent used the health centre. Figure 11: First choice of provider for treating child illness First choice of provider for childhood illness consultation (N = 149) Private clinic/hospital Local pharmacy Kantha Bopha hosp. Public hospital Health centre Shop Self-treat Not yet treatment 0 3 1 1 10 20 9 15 21 27 23 30 40 50 60 70 80 90 100 % responses . 16 per cent said they know them a little bit. When mothers were asked how well they know the health centre staff. and 9 per cent know the staff very well. some 21 per cent said they used Kantha Bopha hospital. the respondents were asked to identify their first provider of choice. 19 per cent (31) of the 160 replied affirmatively.

Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Figure 12 outlines main reasons for choice of provider. Figure 12: Reasons for first choice of provider to treat child illness Main reason for first choice of provider for previous childhood illness (N = 148) Quality Economic Distance Other Waiting Trust 0 9.2 per cent). Perception of quality is the main reason for the first choice of provider (49 per cent).4 10 20 30 40 50 18. Some 61 per cent of respondents had three or more antenatal care visits for their previous pregnancy. the majority of the mother respondents stated they received most of the recommended antenatal care services.3 60 70 80 90 100 % responses Reproductive health: Unlike for child health care.20 - .2 49.9 12. As shown in figure 13. Figure 13: Services provided during antenatal care What services were provided during antenatal care (N=160) % coverage 100 90 80 70 60 50 40 30 20 10 0 Vitamin A Warning supplement signs Diet advice Tetanus Iron vaccination supplement .8 3. although information provided on warning signs and vitamin A had lower coverage. the findings for reproductive health care indicate a higher level of use of government facilities. followed by cost factors (19 per cent) and distance (12.5 6.

Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Table 4 indicates that the vast majority of previous deliveries were facility based. distance (20 per cent). trust (19 per cent). with distance (21 per cent). economic reasons (19 per cent) and staff attitude (10 per cent) as additional factors. quality (19 per cent) and attitude (14 per cent). the first choice was driven by economic factors (24 per cent). . If trust. then clearly quality factors are more important than economic factors in health care-seeking behaviours. with the majority taking place in public hospitals (48 per cent) and health centres (31 per cent). In terms of delivery location. quality and attitude are combined.21 - . the majority of the mothers perceived quality as the main factor (40 per cent) in choosing a reproductive health provider. Table 4: Location of previous delivery Delivery location Public hospital Health centre Home Private clinic Total Frequency 76 49 20 15 160 % 48 31 13 9 100 Consistent with previous responses regarding choice of health care provider.

23 - .Health Service Access Among Poor Communities in Phnom Penh 2009 4. INTERVIEW AND FOCUS GROUP DISCUSSION FINDINGS .

the communities were established directly after the overthrow of the Khmer Rouge rule. Thus they have a relatively long history of multigenerational entrapment in poor living conditions. most of the communities appear to have a visible social hierarchy. some families have been relocated into apartment blocks. residents are classified as those who have procured land and those who are renters. in particular: x the history of the community x any differences between the village and the community x the main source of family employment x how families manage competing resource demands for health. Finding 1: Social class and health Poor communities are long sustaining. At Dam Charn. However. the poorest communities live closest to the river banks. not all members of each community are very poor. and slightly better off households are situated further from the track. although without doubt the majority of the populations are very poor. At Borey Kaylah. At Trabeng Chuuk. with more established families in better housing located further up the river banks.Health Service Access Among Poor Communities in Phnom Penh 2009 Social context for health service access Social structures and health care-seeking behaviour To obtain a deeper understanding of health care behaviours and family capacity to access health services. which took place in 1979. at Tuol Sangkhae. In most cases.24 - . The researchers observed that community members often differentiated between administrative structures (village) and ideas of ‘community’. This makes a case for sustained and targeted social support in order to break the cycle of multigenerational poverty entrapment. there was a particularly strong growth period around 2000. Most understood the term ‘village’ in an administrative sense. such as in reference to the village leaders. in contrast to poorer groups who are still residing in temporary housing. The communities appear to be continuously growing. However. the poorest community members live closest to the railway line. Village leaders make the final decision on key issues and are social mobilizers. This is often evident in the way the communities are physically structured. For example. from which many families had been dispersed because of fire. It is not apparent that these communities are homogeneous economically. nutrition and education. the study’s researchers looked at social structures in the four communities. The exception is Trabeng Chuuk. and the poverty found in them is multigenerational. but they were not identified with the .

NGOs and even resident health practitioners and are primarily reliant on their own family and neighbours for assistance. their family lives in a chronic state of insecurity – uncertain of the income that will come. Up to 12 subcommunities were identified within one of the four communities. This supports a case for a health promotion strategy to work locally with community subgroups and families and their networks rather than relying on the administrative organization and procedures. construction workers. groups or NGOs that assisted with networks for health service or credit or security of land tenure. with the local authority in this case expressing some dissatisfaction with the lack of communication and vested interests among so many subcommunity groups. Income insecurity was often expressed in terms of irregularity of income of the main earners in households. Beneath these administrative and community layers. which very much relates to their social context rather than individual behavioural constraints. hairdressers and markets sellers are all subject to the vagaries of the market place. But it was social and income insecurity that was the most predominant theme in the discussion of social context. Community members often identify more closely with community subgroups. Motorcycle taxi drivers. In one community. and this was different to the role of the krom leader or village leader. Physical insecurity was expressed in terms of night-time disturbances. the community was identified as within a social protection health network. families and neighbours form the basic social structure. In particular. An ‘ethnic community’ was identified as parallel to the Khmer local authority system in one community. the collaboration between community substructures and administrative structures appeared to be positive. it is to family and neighbours that people turn first for help. In times of social stress (such as needing funds to cover high health care costs). Finding 2: Social structure and health Poor communities are complex in structure and do not rely solely on the administrative leadership for social cohesion or social action. the local authority in Borey Kaylah cited the collaboration between the NGO Family Health Development (FHD). In another location. a private medical doctor was identified as the community leader. In most cases. This was reserved most often for local agencies. local authorities and the population as being the best model of relationship between community subgroupings.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 term ‘community’ (saharkum). The different dimensions of social insecurity among the very poor Many of the focus group participants expressed feelings of insecurity. Social insecurity was expressed in terms of insecurity of land tenure. But for income earners of US$1–$2 per day. This is especially the case when income is irregular. . “We don’t know what will happen to us” and “we don’t know when we will have to move” were common statements from community members in two of the communities. the community was identified in terms of defending land tenure for the poor. variation in income can be managed through savings or borrowings. In a third location. especially for daily nutrition and education needs for children. assaults and abuse of alcohol and drugs. For most income earners in society.25 - .

Health Service Access Among Poor Communities in Phnom Penh 2009

Health Service Access Among Poor Communities in Phnom Penh 2009 The researchers found that in many cases, the income insecurity led to restrictions on food purchases and indications of under-nutrition. Notably, families will borrow or sell household items when they need to pay for health services, but the daily education costs are often deemed non-affordable. There were frequent reports of children dropping out from school or attending irregularly due to lack of family income. Health insecurity was surprisingly not often expressed in terms of not being able to afford health care services (although this is sometimes the case). Access to water and sanitation and the absence of any institutional or social mechanisms for waste management was the most dominant theme in the discussions. Community members, local authorities and health workers consistently identified poor waste management, water supply and sanitation as the main threats to the health of families. Most childhood illnesses and even adult illnesses were attributed to uncleared rubbish, lack of toilets, standing water and mosquitoes. Sometimes the problems were attributed to personal and household behaviour, but more often, they were identified as community characteristics that people – even the local authorities – felt powerless to resolve. “The words of the poor are cheap,” explained one long-term resident. Given these conditions, it is hardly surprising that there is a heightened sense of ‘living for the moment’. It is difficult to undertake or envision long-term community or household planning in this chronic state of daily insecurity and powerlessness. Frequently, the researchers heard community members say they are “living for the day”. One local authority member indicated that many community members do not even live for the day but live from “moment to moment” in order to cope with each day’s needs. Finding 3: Social insecurity There are many aspects of social insecurity in communities that impact on health and well-being. These include physical, income and health insecurity. This social context for health and well-being indicates that the primary determinants of poor health in these communities can best be understood in structural rather than behavioural terms. This supports a case for a more comprehensive social policy approach to address the structural factors rather than a reliance on health education strategies for individual behaviour change.

Exclusion and social isolation Participants in both the in-depth interviews and focus group discussions talked of exclusion and social isolation, mostly related to the structural determinants of income capacity, education access and powerlessness previously noted. Single mothers in particular are at high risk of exclusion due to absolute income poverty. In one case, a single mother was completely dependent on her neighbours for income and social contact. Because they dropped out of school, many young adults are exposed to risks of drug abuse and prostitution. The researchers found limited examples of community activities or structured gathering locations for young people. In one community, an NGO was active in providing therapy for injecting-drug users, and in other communities, home care visits were conducted by an NGO supporting people who are HIV-positive. Overall, services or social activities are not in place for young people in the four communities.

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Health Service Access Among Poor Communities in Phnom Penh 2009

The process of social exclusion starts very early. Repeatedly, community members highlighted the daily income demands of education as a major strain on family income and on social participation. In some cases, NGOs provide education programmes for young children within the community. In other cases, NGOs provide income support for children to attend schools. Local authorities try to help the children of poor families through the provision of a letter to the school teacher exempting them from paying school fees (as is the case with certain health care services). There was one example of children being transported to the local pagoda for education classes where children in a community could not afford the government school.

Social exclusion The depth of social exclusion is perhaps expressed most clearly in Dam Slaeng where makeshift homes crowd around burial plots in the cemetery and children run between the tombstones. “The children are not afraid of the ghosts – the ghosts are afraid of the children,” one resident commented. In one abandoned building, six families had set up blanket partitions to separate sleeping areas. Some of the current residents in the community had only recently moved there due to newly impoverished circumstances. One woman said she had lived there since the early 1980s.

Finding 4: High-risk groups for social isolation There are particular subgroups of the poorest families in the four communities that are particularly at high risk of social exclusion and social isolation – these include single mothers, young school-age children (but not attending school) and teenagers. Social programmes should target these most vulnerable groups to provide them with a minimum level of social opportunity for development and social protection. The dynamics of social exclusion are structural rather than behavioural in nature. Although, there were reports about negative attitudes among health clinic workers who look to see what a patient is wearing to decide who will be treated first – “You have to have money. If you do not have money, they won’t pay much attention to us,” explained one resident. Community members also reported that they are “looked at” by health staff to determine whether they can pay or not. In all four communities, health centre staff indicated that they exempt the very poor from payment for certain health services. However, those health workers also indicated that in the absence of a poverty card or a letter of exemption from the local authority, they will look at the clothing or personal items of a patient to make an on-the-spot poverty assessment.

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Health Service Access Among Poor Communities in Phnom Penh 2009

Health Service Access Among Poor Communities in Phnom Penh 2009 The absence of systematic social protection mechanisms increases the risk of a mistrustful relationship between health professionals and clients. This equally applies to the relationship between the education sector and community, with some people indicating that children are “afraid” of the teacher if they do not have enough money to pay for school expenses. The daily struggle to manage family food, education and health care costs with a low income was a consistent theme spoken of throughout the research. According to one local authority official, “Health is a big problem here. When people get sick here they go to the private health care provider first and buy medicine. This means they spend a lot of money on this – they spend a lot on medicine. But if they go to the government service, they would not spend so much money. Then they spend on the children for going to school. I provide them a letter sometimes to the teacher so the teacher does not take money from the poor, but the teacher still needs to take money. So if we think about it, health and education and food, they spend more on education – they have to spend on education every day…when they do go to school they often stop at level two or three…they just don’t have the capacity to send them to school.” And one mother commented, “I have two children going to school, but one has had to stop...because we have no money for the teacher. Our family is spending more money than our income….our standard of living is lacking. We have no rice field or garden. For health care, we pay money every now and then, but for education you have to pay every day and for food we have to spend most of all.” Families use various coping mechanisms for their day-to-day survival and basic needs. For health care, they typically sell household or personal property, borrow from a family member or neighbours, seek out NGO or pagoda support, or ask for assistance from the local authority (letter of poverty status to exempt them from certain fees). Health centre staff indicated that they do not ask the poorest of the poor to pay, but there were many cases in which people did not seek out health care, opting for exclusion or social restriction. In summary, people in the four communities mentioned the following coping mechanisms: x not sending children to school x restricting food intake x in some instances, not seeking health care for chronic conditions x borrowing money or selling property to pay for health care.

Finding 5: Social vulnerability and health protection Health workers assess the poverty status of their patients, and patients know they are being assessed for their capacity to pay. As a result, mistrustful relationships have developed between government health centre staff and community members. Those people with exemption cards expressed confidence in attending health facilities. This makes the case for extending the health equity fund or related health protection schemes to increase the use of health care services by the very poor.

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most of the participants indicated that they were not aware of any formal network (with the exception of the health equity fund scheme in one community). then the only way to influence health care-seeking behaviour is through local social networks. This suggestion reflects the importance of word-of-mouth networking of health information and how it appears to be the most influential factor affecting health careseeking behaviour. Community members then share this information through their local social networks. women identified themselves as the primary agent. they were quite dismissive of the man’s role in health care decision making. The same applied to seeking abortion services Women discussed the various methods and outlets available for an abortion. The women reported that within their family. following further discussion on patterns of health service use. Nearly all the mothers interviewed said they had heard about the hospital from a neighbour or family member. Examples of practices already in place include agencies providing home-based care for people with HIV or AIDS (these were very visible and frequently mentioned). they are the main caregiver and decision-maker on health issues. effectiveness of treatment and the zero cost. care giver and decision maker on health matters. Because people have choices.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Social networks for health When questions regarding social networks for health care were asked in the research interviews and discussion groups. reasons given for this choice were quality. many of the research participants indicated that it is necessary for local authorities and community members to be active through discussion. the choice of delivery was motivated by perceptions of the quality of the provider as expressed by a family member or neighbour. Informal networks: Informal networks mostly consist of word-to-word relay of information about where to access health services that are of quality or are affordable. nearly exclusively through pharmacy shops or through favoured private practitioners. it became clear there are many informal social networks for health care. If providers do not change. meetings and even house-to-house awareness raising. Many mothers reported taking their children to the Kantha Bopha Hospital for care and treatment. In terms of recommendations for improving health service access and public health in general. attitude and cost of services provided directly to the communities. The quality and cost of health care services are routinely discussed among families. This being the case. community schooling or subsidizing . the most powerful advertisement for improving health care and health care access is the quality. But in terms of importance. Formal networks: The researchers identified clear NGO roles for improving health care access or in alleviating social conditions that impact on people’s health.29 - . perceived skill of the health providers. The man’s role was valued more in terms of arranging transport in an emergency or in organizing the funds to cover the health care costs. For other situations. In fact. However. they will make their own decision about which service is most effective and affordable. friends and neighbours. But what they knew they had learned from other women. Finding 6: Informal health networks Informal networks are likely to be the most influential factor in determining health careseeking behaviour.

When the RHAC support ended. Both health workers and local authorities and community members seemed to lack clarity on exactly who were the primary organizers and responsible agents for public health care and how information and requests for public health interventions are networked. midwife).Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 payments to teachers. mainly in the passive terms of gathering population statistics or conducting social mobilization activities for immunization campaigns. the practitioner continued to refer community members to the health centre and meet with the health centre staff regularly to discuss the health status of the community.30 - . The hesitancy of local authorities to participate in public health functions in these communities may be related to the perception that some of the communities are illegally occupying public lands. which advised that positioning health workers in at-risk communities is an effective way to link the population to the formal health system. sanitation and waste removal was striking. The main limitation of the NGOs was perceived to be the lack of adequate service coverage for the poor. Local authority networks: Local authorities’ identified there own role in health networking. These resident practitioners are well known and trusted members of the community as well as trusted health care providers. Local health networks are linked to social networks through the formal and informal providers who frequently visit the communities or actually live in them. (Note: Care should be taken with this conclusion. Both the local authorities (village leaders and group leaders) and community members were highly trustful and confident in the role of NGOs at the community level in supporting social protection and poverty alleviation. However. 2003). which is a national NGO. Finding 7: Local health networks Resident health practitioners and NGO networks are powerful ways to spread health information and make health referrals. They are very influential in affecting the health careseeking behaviour of the population. especially when linked to local health authorities and local government health services. direct health care services provided by NGOs and helping people access services through health insurance or health referral mechanisms.) Resident health practitioners and volunteers: The researchers found examples of health practitioners who had been residents in the communities over a long period of time (doctor. . This study confirms the findings of previous urban health evaluations in Phnom Penh (such as Vickery. the apparent limited role of local authorities in public health networking for safe water. One resident practitioner had previously worked in a community clinic operated by the Reproductive Health Association of Cambodia (RHAC).

These include the presence or not of resident health practitioners. there were 460 migrant [somewhat recent arrival] families and 300 renters. We are insecure at night. Since we moved here. We have problems of shelter. some people left. I know them and I cannot turn them away. so we asked the local authority. the distance to facilities and the local perceptions of quality of care and cost. So we bought the land from them. After the fire burned. For toilets. people just use a plastic bag and throw it away. The women’s group members identified the locations and types of providers on hand-drawn maps and listed out the reasons why each provider is used and the choice of service.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 A local official’s story “Before 2000. Now the local authority brings the water in the truck daily – but it is still not enough. the researchers mapped the health care market options available to the urban poor in the four communities. Thus. Incomes are down. The land belonged to the disabled community.” Utilization patterns of health care services and access barriers The health care market and the health care system With help from local women’s groups. there were not many people who lived at the lake. We cannot lock our possessions up at night.31 - . Maybe we could build toilets for the community. For example. it’s hard to pay – if the local authority. the map of Dam Charn community (figure 14) illustrates the significant range of available health service choice. Before the fire. We built the bridge across the lake and people set up houses on both sides. the health care system is a complex market system with a range of choice in terms of provider type.000. An additional range of services and choice is available locally for treating sick children. For the poor. Bridge builders nearby send two trucks a day to take children to school. I do not want to ask the [next level of] local authority. Not marked on the map (outside the map boundary) is the wide range of choices of government and NGO hospitals and clinics used for delivery care. prepares a letter saying a person is poor. Many of the migrant families had purchased the land. such as pharmacies and shops selling medicines. They came to me and asked. A Christian NGO supports some of the children. But some just could not do it. It’s the same with education. The local authority charges 100 riel [for the water]. . We lost our possessions in the fire. The rubbish is not taken away. and others go to the temple to learn. ‘Can we put a house here?’ What can I say to them – I used to live with them. NGOs can help us ask local authorities for what we need. it is not the case that the health staff will follow this. but we need $2. People get by on the food they have. standards have dropped. family planning and child sickness care. Most children go to school. So the Ministry of Health needs clear support for the local authority so the poor do not have to pay so much. What became apparent from the health mapping exercise is the lack of an overall single system or consistency in patterns of health care use – there is considerable variation based on local characteristics. water and toilets. and the area filled with people. like the group leader. We can’t live without water. service type and cost. immunization.

antenatal care. Given the scale of the market mechanism. Finding 8: The health system and the poor There is no single unified health care system in the urban context. there is also a strong case for increasing the market competitiveness of government health centres through a reduction of client costs (social protection) and improvements in the quality of service. being looked at to see if you are poor or not. even for the urban poor.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Figure 14: Market choices for health care in Dam Charn Health care and social service market in Dam Charn Referral hospital (RH) Health centre (HC) Pharmacies (3) Traditional birth attendant Midwife house (1) Midwife from Viet Nam NGO clinic (2) market NGO schools (2) The top right of the picture shows the river and locations of groups alongside it. The community members often cited the perceived skill of the provider as being critical when they were seeking health care. There is instead a health care market with a wide range of choice of provider and type of service. The poor attitude was interpreted mostly in terms of waiting longer because you are poor. specific types of facilities were preferred for having packages of quality services. Quality was often defined in terms of hygiene or technology. On the other hand. . There are also ‘preferred service providers’ for specific types of services. such as “the medicine is very effective” or “the child gets better quickly”. and impolite speech. such as “the hospital is very clean” or “they have all the modern equipment”.32 - . AIDS (and HIV. attitude and cost of services. A better understanding of the dynamics of this health care market for the poor could guide policy makers towards improving mechanisms for quality health care and social protection. a provider with a poor attitude is viewed very dimly by clients. Perceptions of quality and the exercise of choice In line with the household survey findings. Health centres are highly valued for immunization services. or in terms of outcomes. the interviews and group discussions demonstrated that choice is affected by perceptions of quality. Additionally. All of these quality factors seem to influence people’s selection of provider.

There was no reported case of refusing any immunization service because of high cost. increasingly. However. In one krom. . cost is a major issue and thus is a major factor in decision making about when and where to seek health care.9 15 20 25 30 35 40 45 50 Costs per capita US$ The need for health care are intermittent and thus the poor seem to find some way to mobilize the funds needed to cover the costs. birth deliveries. But when it comes to a baby delivery. However. 75 per cent of costs are out of pocket. Nevertheless. 2008 (HSP2) Health care cost per capita per year (study) Health care cost per capita per 3 months (study) 5 10 3 $33 $43.33 - . One health centre worker commented that “even people in Land Cruisers” come to get their children immunized at the facility.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 including testing and counselling) services and. It also helps that the health centres have a reputation for providing good-quality immunization services. although. costs were not high. Even the poorest seem able to find $100 for birth delivery fees in a hospital. the costs were all out of pocket.7 per capita) for health care than the nationally estimated $33 per capita (National Health Sector Plan. it does not diminish the significant impact on the poor of unpredictable or catastrophic health care costs. the household survey indicated that 53 per cent of the respondents were paying for the service. Government hospitals are highly valued for acute child health illness and delivery care. Choice is therefore mediated by location. This study indicates that the poor in the four communities pay more than (at $43. The private sector is highly valued for the convenience of managing childhood illness. Figure 15: Analysis of health care per capita costs in the four communities Health care costs per capita National health care costs per capita. perceptions of quality and type of service provided. there were instances in which people in the research areas did not seek out health care services because of the cost. For this study. health staff reported the richer patients will use hospitals. 2008). This is understandable given that it is a predictable cost. women in one FGD stated that they 3 For national health care per capita costs.7 $10. However. Covering the recurrent costs of education and food leaves the poor the most insecure financially. NGOs are valued for reproductive health care and social protection (where it exists). For immunization services. the household survey indicated that 10 of 51 mothers who did not have their child vaccinated at a health centre stated that cost was the deciding factor.

Gaps in knowledge During the focus group discussions with mothers and with health centre workers. social isolation. poor sanitation and waste removal. policy and systems interventions are needed to protect the poor from the burden of these disproportionate costs through social protection. However. It is interesting that the community members and health workers consistently highlighted structural factors as the most predominant causes of ill health. such as poor personal hygiene. Repeatedly. Women’s health was often identified as a problem by both men and women but it was not linked to sexual health. Some local authorities noted that many people delay seeking health care until quite late out of fear of the expense and subsequent economic loss. the participants were asked to list the main health problems that arise in their family and rank them according to seriousness. gambling. there was no evidence of any systematic implementation of financial social protection measures for the poor in any of the other communities. women’s common health problems were linked to individual behavioural risk factors of a non-sexual kind. Thus. Both communicable and non-communicable diseases were ranked. Rather. but with childhood communicable diseases (fever.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 did not seek care for female health issues because they feared the expense. This capacity to pay through borrowing. it was not correlated with illness – invariably. Finding 9: Health care costs and the limitation of choice Evidence from this study indicates that the very poor pay levels of cost for both preventive and curative care services that are disproportionate to their capacity to pay. nutritional limitations. in partnership with local authorities and government health services. which were identified as particular problems in the communities. This being the case. they were also asked to identify causes and solutions. The participants articulated the causes and solutions for communicable disease conditions. Participants in the women’s group in Borey Kaylah expressed a high degree of satisfaction with the system of health insurance operating through the NGO Family Health Development (FHD). cough. There was also one case of a man who sold his house to cover medical care expenses in the family. poor health is equated with living conditions or individual behaviours rather than patterns of health care-seeking behaviour (such as promptly taking a child with fast breathing to a clinic). the cause of illness was linked to social and environmental conditions: dirty water. improvements to public health services and health system strengthening strategies.34 - . stagnating water and poor sanitation. drug and alcohol abuse. sale of personal goods or support from neighbours reflects the high priority the poor place on accessing health care. low income and insecurity (night-time violence). This includes poor nutrition. unemployment among youth. the fact that health care costs are intermittent does not mitigate the severe impact that these expenses have on very limited family income. . Although the lack of an adequate food supply was often referred to in the interviews. That is. it was the living environment and personal hygiene and behaviours that were considered the main causes of the high rate of illness. such as vaccine-preventable diseases. diarrhoea) being the most consistently mentioned. HIV infection and dengue fever.

Overall. they are taken to a hospital (Kantha Bopha or the National Pediatric Hospital). are well known and that visits to them do not impose any hardship on the daily income earning. voluntary counselling services for HIV and. a sick child and sexual health. in particular: immunization. The private sector is relied upon for managing mild childhood illnesses and certain adult illnesses. Gaps in health care Health services: The findings from the household survey indicate that access among the very poor to basic preventive medical services is very good in the four communities. HIV prevention. This was confirmed in the interviews and focus group discussions in most cases. efficiency and income generation for health centres. The introduction of the fixed facility strategy for immunization through the National Immunization Program in 2006 has clearly provided some benefits to the services and to the population in terms of increasing demand. which reflected the following patterns of use: Health centre services are trusted and relied upon for specific packages of preventive services. Finding 11: Child care for the very poor The private sector is the first choice of care for people in poor communities in the case of mild illness.Health Service Access Among Poor Communities in Phnom Penh 2009 Finding 10: Health knowledge and awareness The findings from this study indicate that where health education programmes of the government and international organizations have been active (immunization. The research participants reported that local private sector practitioners are close to the community. birth deliveries. people stated they frequently have to wait for a long time. Health centres were not mentioned in terms of treatment for a sick child. government hospitals are preferred for severe illness. dengue fever) the very poor demonstrate a good knowledge of what causes common illness and what is required to avoid them. staff in one health centre reported that they had not had any formal training in the integrated management of childhood illness (IMCI). antenatal care. health centre staff conducted regular outreach programmes to the . Government hospitals are used for treating reproductive health problems and severe illness. people identified ill health in the context of the social conditions in which they live rather than in terms of gaps in health services. There is a case for strengthening IMCI service provision in health centres that is then supported with the same strategy for communication applied for immunization campaigns and antenatal care. Health centres are preferred for prevention services (immunization. If children are seriously ill. However. This would prevent the unnecessary and potentially costly procurement of non-essential drugs by clients through private-sector outlets. HIV testing and counselling). the research participants were less knowledgeable on matters relating to maternal health risks. it became apparent that the service providers were no longer confident on who in the community was immunized and who was not. during the health centre mapping exercise. Prior to 2007. However. This contrasts with the use of government facilities. increasingly. antenatal care.35 - . In fact.

It eases the financial burden of the poor. compared with the private sector. figure 17 summarizes findings of reactions to the fixed facility strategy of the National Immunization Program. Thus regular contact was made with village volunteers. Comments. Staff in one health centre noted this to be a problem. there are health practitioners residing in communities who work as private providers through NGOs or as volunteers. Even though it is a fixedfacility site strategy that relies on population demand. indicated the health centre staff’s uncertainty of population coverage in high-risk areas: x “We are not sure what is going on there now.” x “Funding for outreach has stopped so we cannot be sure. These resident practitioners have the trust and confidence of the community and are the vital referral link to government services. local authorities and the community. engages the local authority in health care and increases the use of the government facility where quality can be more assured. despite the situation of extreme poverty. funding is still required for health education and social mobilization in communities for the fixed facility strategy to work. the high level of commitment by health workers and families to the care of women and children. and action had already been taken by the district director to develop systematic meetings with local authorities on a monthly basis in order to identify and resolve issues that health staff and local authorities could manage together. all immunization services are provided only in health centres. x Health messaging by the MOH and international partners is clearly having an effect – the poorest It’s a veryof the poor are making every effort to access immunization. x Community members and local authorities in Borey Kaylah all expressed a high level of satisfaction with the health financing scheme. This is also apparent for antenatal care and birth delivery by professional providers. the health centre workers demonstrated knowledge in locating them but they expressed less confidence in identifying pockets of non-immunized children. Now in Phnom Penh. People are coming andthe high there(relative to their income and living conditions). x In some cases.36 - . x .” x “These places are confusing – people are coming and going all the time. the research participants expressed a feeling that the quality and demand for services at health centres had improved in recent years. Despite this limitation.” It was also not clear whether social mobilization and communication meetings were taking place regularly enough with local authorities and village volunteers. such as the following.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 harder-to-reach areas. Figure 16 highlights other strategies that are working well in terms of access by the poor to health services. When marking hard-to-reach or slum areas on health centre catchment maps. x There is a high rate of household possession of immunization cards – the population values immunization and its benefits. This also reflects services despite going costs all the time. antenatal care and birth delivery confusing situation there. Figure 16: Summary of what is working well in relation to health service access Community members and health centre staff report that health centres are preferred and are increasingly relied upon for immunization services and antenatal care.

It’s easy for them to get into trouble. So after dark. Under the outreach scheme.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Figure 17: Summary of responses to the fixed-facility site strategy x The fixed-facility site strategy has been successful in increasing demand for health centre services (primary medical care).” x “Some of the new people who come who are the renters are causing a lot of trouble at night. We have to pay for this every day.” x “The air is bad here. but then [the government] stopped coming to collect it. The lack of resourcing of outreach health education and communication and an inadequate mapping of catchment populations means that these communities remain at high risk of a vaccine-preventable disease outbreak. Finding 12: Reaching the hard to reach Although the fixed-facility site strategy has been successful in maintaining coverage.” x “We are afraid to ask for better drainage systems and water.” x “There is one toilet here for 300 to 400 families. however. especially in the wet season. so they just wander around. community members. as reflected in the following comments from the research participants: x “Water is pooling everywhere. health workers and local authorities (village and krom leaders) consistently pinpointed social and economic conditions as the prime determinants of poor health. local authorities and the community. This is due to the lack of adequate financing for operational monitoring of unreached areas. which makes them less likely to use public services because of a lack of trust. Also. So people now don’t collect the rubbish in one place. health centre workers and manager are concerned about pockets of non-immunized children in selected high-risk locations.” x “We used to try and organize the rubbish to be collected in one place. this community exchange has been significantly diminished under the fixed-facility site strategy. ii) meeting with local authorities and volunteers in high-risk areas on a regular basis.” x “Education – that’s the problematic one. iii) scheduling community visits by health centre staff to high-risk areas. regular contact was made with village volunteers. There is too much rubbish and water lying around. we close the doors and don’t go out. Phnom Penh is still at-risk of vaccine preventable disease in at-risk populations in Phnom Penh. the mapping of health centres revealed there is a lack of clarity among health centre managers on the numbers and locations of unreached populations. and iv) developing stronger partnerships with NGOs and volunteers and local area practitioners in these areas. This operational surveillance could be strengthened through i) systematic micro-planning and mapping in high risk areas.” x “There is nothing here for young people to do and parents cannot afford to keep them at school. It’s a big problem. Based on the study’s findings. the community is not healthy. Health we pay for some times. But education we have to pay every day. Although limitations in access to health services due to the cost were also identified as an issue.37 - . However. This is a temporary location. The mosquitoes bring dengue. Public health: As previously noted. it was clear the social and economic conditions of daily life represented the fundamental health and disease burden.” . the community members said they are unfamiliar with their health workers.

health centres should have higher salaries for a smaller number of staff. x Please help the local authority provide an adequate water supply and electricity. poor nutrition.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 x “What we eat each day depends on our income. Sometimes we cannot eat what we want. in contrast to access to health services. community members and local authorities (and health centre staff to a lesser extent) cited structural determinants of poor health as the main cause of ill health rather than limited access to medical services. security and income generation were perceived to be the main drivers of poor community health. Sanitation. There are no programmes for them. x Communicate closely with the local authority so he can inform the population about services at the health centre. Recommendations from a women’s group x Please ensure health centre staff speak politely to sick patients. the responses were not well articulated. x Please make the cost of health services cheaper. x Ensure sufficient space for services (an additional room) in the health centre. From a mother x We have to keep our environment around the house clean and also look after food hygiene. Health centre workers hesitated to respond.38 - . Figure 18: Contrasting perspectives on recommendations for improving health and health care access Recommendations from health centre staff x Disseminate information so people know and understand what services are available through the health centre. help us find work and provide loans so we can earn income to send the children to school. x NGOs should help our children to go to school and learn. x Please ensure the health staff pay attention to the needs of the sick. Figure 18 contrasts recommendations from a health centre focus group and a women’s group from a local poor community. x Inform people who come to the health centre to tell other people about the services at the facility. it remains the case that it is the economic and social conditions of everyday life that are the main factors affecting access to healthy conditions of life. One of the principal findings of this study is that the main barrier to health care for very poor communities is not so much health service access but rather limited access to basic public service functions in the community. the consensus seemed to be that it was a joint function of the Ministry of Health and local authorities. In the end. x Increase the salary (make more appropriate) of health centre staff. x Please help the local authority prepare adequate drainage systems in the community. waste removal. .” Although health costs and occasionally the attitude of health workers were sometimes identified as a problem (costs were mentioned more often). x We need to have poverty cards (bun krey kro) so the health staff do not take money (charge for service). But when asked who is responsible for the environmental and social conditions in the community.” x “There is nothing here for the young people to do or any place for them to go. x Ensure an adequate medicine supply at the health centres. x NGOs should help us about domestic violence so to protect households from men coming home to their family when they have been drinking and using violence in the house. stagnating water. What is interesting in the contrast of perspectives is the service delivery focus of the health centre staff and the public health care focus of the community perspective. Consistently. x Raise awareness among people about not buying medicines from pharmacies as a first choice of treatment. x Provide additional technical training for health centre staff. x Please don’t let the sick patients wait too long.

This leaves the communities vulnerable to a communicable disease outbreak. waste removal. There are motorcycle taxi drivers and factory workers here. This requires urgent attention. for example. Specifically. with clear lines of accountability for the Ministry of Health staff. local authorities saw their role more in terms of gathering statistics and social mobilization and less so in actually requesting or mobilizing resources for public health interventions. Sometimes people’s houses fall down. There has to be something in it for people. What people want is what they can be provided now. But what is in it for them? I say we need a sanitation system. so they rebuild and still the police walk by and ask for money to authorize reconstruction. This lack of clarity on accountability for environmental and social conditions relates in part to insecurity of land tenure – local authorities may not want to put in place environmental infrastructure when there are legal disputes over the land.” . it must be clear what needs to be done and who is responsible for it. But the main problem is poverty. It is hard for them to think beyond this time. But in 2000.39 - . There is gambling and fighting. There is little living space for some people. Children stop going to school at year 8 or 9. especially children. otherwise they will not move. Then the people just bought and sold land from each other. Finding 13: The public health function Although there is some degree of clarity of role in relation to medical service provision through health facilities. the numbers increased sharply. But the words of the poor are cheap. nutrition and youth affairs. It is not enough for one person to have commitment for things to change. People are short of food. About 70 per cent of the population is lacking a means for basic livelihood. They start walking around in groups. sanitation. they say – “You got a million dollars?” The direction has to come from the central Government. A community is a way of negotiating on rights for people. local authorities and communities. these communities are highly vulnerable to an outbreak of communicable diseases because of dysfunctional public health functions relating to safe water. Regardless of legal or political questions. A community leader’s story “This community started in 1979 after the end of the Khmer Rouge time.Health Service Access Among Poor Communities in Phnom Penh 2009 When asked to define their own function in relation to health. nutrition and hygiene. It started with 10–20 houses. the broader functions of public health/primary health care are ill defined. In 2003 we started a community association. So I am quiet now. Local authorities can help with many health issues – environment. Essential functions of public health need to be defined and resourced.

41 - . RECOMMENDATIONS FOR IMPROVING ACCESS TO HEALTH SERVICES .Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 5.

these families are also exposed to higher rates of illness due to environmental hazards and nutritional deficiencies. The researchers for this study propose five recommendations that cut across those three levels of intervention. That is. This is a structural problem requiring structural or ‘systematic’ solutions. The inability to afford and secure education costs for young children is a sure way to lock families into multigenerational poverty. Figure 19: Framework for analysing the social determinants of health Society Environment The cycle of poverty and ill health Low and irregular incomes mean that people cannot meet all their expenses. Families are already disadvantaged by high health care costs (relative to low incomes).42 - . The suggestions spoke generally to two issues: making health service more affordable and of higher quality and making daily living environments more conducive to a healthy way of life. it is education that offers the best opportunity for the families to escape poverty by providing the younger generation with skills and capacity to bring more income into the family at a later age. it became clear to the researchers that the social dynamics and interactions of low income. so people are sick more often. But due to the dysfunction of urban public health. . These structural or systematic strategies should target three levels: service delivery strengthening. society and government rather than behavioural changes of individuals that were identified as the best ways to move forward. However. This includes food. It is not so much people are deliberately excluded – rather. The following outlines the five recommendations and includes a list of associated priority actions for implementing them. This cycle of illness and poverty is effectively excluding the very poor populations from wider social participation in the skilled workforce and in public dialogue regarding their social conditions. People live in a poor environment they know is unhealthy. it is hard for children when they grow up to make a decent enough income to escape this cycle. Education Employment Health Food The recommendations from this study derive from suggestions of local authorities. More frequently than not. health centre workers and managers and community members. this means spending more on health care. it is education costs that are most commonly set aside.Health Service Access Among Poor Communities in Phnom Penh 2009 g As the study progressed. they are locked into a culture of poverty. Because education costs are cut. education and health care costs and food prices place significant daily pressure on poor families. public health functions and social protection policy. it cannot be solved solely by suggesting to people they change their health or health care-seeking behaviour. This is what distances people from society. it was structural and systematic factors of health systems. health and education.

especially for maternal health.Health Service Access Among Poor Communities in Phnom Penh 2009 RECOMMENDATION 1: Community-based services for the urban poor This study has found that health authorities and agencies have been very effective in informing poor populations of the benefits of maternal and child health care – particularly for immunization and antenatal care. birth delivery and HIV testing and counselling services. women’s health and management of a sick child. the cessation of outreach services and lack of strong connections with local informants. For this reason.43 - . There is no question that the access of the very poor to health care services for a narrow band of preventive and curative services is impressive. Develop a detailed. Recommendation 1: Community-based services for the urban poor Adequate resourcing of health centres is needed for conducting health education and services outreach to at-risk communities on a regular basis. Implementing action: x Identify the 20 most at-risk communities in Phnom Penh in four operational districts and x x x x define an essential package of health services to be provided to each community on a monthly basis. Health facilities have been noted to be centres of high demand for immunization. the success of the fixed facility strategy (in stimulating access for the majority) may come at a cost to a minority of the population. Information from this study indicates that the communication strategies of the Ministry of Health and development partners and health centres have been effective in stimulating demand for immunization. This can entail monthly communication meetings with formal and informal social networks (similar to fixed-site meetings) but with a wider public health agenda. antenatal and delivery services in particular. Facilitate the formation of local community groups (mothers’ clubs or health providers groups. referral and local problem solving of priority public health issues. the researchers qualify this statement based on their observations on the scope of care. a service and communication strategy needs to be developed specifically to meet the needs of the urban very poor. antenatal care. NGOs and community leaders for health communication. etc. But there are gaps in the service delivery generally for maternal and child care. The additional resourcing would i) strengthen links between health services. However. ii) establish contact with and support local social networks for health (formal and informal) and iii) provide mobile services for the most at-risk populations. Facilitate the networking of local health care practitioners. That is. local authorities. community practitioners.) for linking a community to maternal and child health and other social services. Define clearly the adequate human and financial resources required for responsible heath centres to provide additional services to the urban poor. costed multi-year action plan. include it in the annual operational plan for the National Immunization Program and the Municipal Health Department. . It is also highly likely there are pockets of undetected at-risk populations that are not accessing services at all. the plan should identify human and material and communication resource requirements. NGOs and communities. NGOs and local authorities means that fixed-facility sites do not have the surveillance and resource capacity to detect and respond to the needs of small pockets of unreached populations.

planners and policy makers have a comprehensive assessment of the situation of the urban poor and thus can structure a well-informed response plan. Despite these successes. Less emphasis is placed on surveillance of health and public health. school attendance and assessment of health insurance status to ensure that health practitioners. Recommendation 2: Community-based health monitoring of the urban poor The Municipal Health Department (MHD) needs to undertake a systematic approach to surveillance of at-risk populations through the support of district health centres.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 RECOMMENDATION 2: Community-based health monitoring of the urban poor As noted in the findings. Yet it is to this sector that most families turn in the event of child illness. the vast majority of the very poor still prefer to access . specifically for: x x x x x childhood immunization primary school retention health insurance status anthropometric assessment/food security measures environmental health. and birth delivery services. waste management. the MHD should conduct regular mapping and micro-planning for at-risk populations. This will also assist with targeting the urban poor for more comprehensive social policy measures (see recommendation 5). More recent analysis and findings through the Cambodian Anthropometric Survey (2008) has highlighted high rates of severe malnutrition among the urban poor and the associated need to put in place effective community-based monitoring (CBM) of the nutritional status of children. this study has detected limitations in the quality of care. RECOMMENDATION 3: Health services quality improvement Despite the high coverage of care. namely food security. it is clear that such a CBM system should be extended to incorporate immunization status. most surveillance focuses on disease outbreak.44 - . water and sanitation and social protection for health and education. Based on the findings of this health service access study. Such mapping and microplanning should be built into the routine functioning of the surveillance and planning system so that surveillance focuses both on disease and on detecting health risks and health inequities. Operational Districts and health centres have demonstrated that they can generate a large demand for immunization. This necessitates the transition of surveillance from a current focus on ‘disease’ to a broader view – structuring a more systematic approach to health monitoring of the social and economic factors that impact on health and health access for atrisk populations. A range of other studies have indicated the dubious quality of care provided through private facilities. antenatal care. particularly in relation to the management of a sick child. HIV testing and counselling. In conjunction with local authorities and civil society partners. This is particularly the case in relation to vaccine-preventable disease. There is no systematic strategy for ensuring quality in this sector.

the development of public health strategies and interventions will require strong partnerships and institutional and human resource development programmes within local authority. However. local community and administrative leaders). . Given the successes of the MOH. This will mean significantly raising the level of function and resourcing of local authorities for public health functions. there is definite scope for promoting public health care through the strengthening of these centres in order to provide good-quality IMCI services at an affordable cost. Further. RECOMMENDATION 4: Review of the public health functions With the publication of Cambodia’s National Strategic Development Plan and in light of the findings of the Global Commission on the Social Determinants of Health. 2008). Recommendation 3: Health services quality improvement A combined health education and quality improvement strategy should be adopted so that poor families can access better quality and more affordable care for sick children from health centres (for example. such as environmental health and social affairs. NGOs. the capacity of health centres and districts is already stretched in terms of providing medical care services. along with the 2008 World Health report (WHO. pharmacists. x Consider developing community-based partnerships for a community-level IMCI strategy (involving referral and care community practice networks of local private practitioners.45 - . dengue fever and HIV prevention.Health Service Access Among Poor Communities in Phnom Penh 2009 private medical services in the first instance when a child becomes sick. there is now a strong national and international focus on widening the scope of health interventions from medical care to public health or primary health care. This being the case. partners and health centres in generating demand for certain services. This being the case. As well. x Support the implementation of a child sickness management strategy with a national communication campaign along the already successful lines of EPI. This comes at a relatively high cost. facility and community IMCI). the endeavour will require shifting roles from social mobilization and data collection to more proactive leadership and participation in the problem-solving process and in the delivery of essential public services. the integrated management of childhood illnesses (IMCI) services (with an associated communication strategy) should be applied at urban health centres in order to improve the quality and coverage of care for sick children in very poor families. health and civil society structures at the village and district levels. Implementing action: x Develop and cost a detailed plan to train and implement an IMCI strategy in urban health centres. the poor should be protected from high health care costs through the provision of health insurance or user fee-exemption systems.

Then in recognition of these synergies. education and nutrition. 2). Health equity should therefore be at the centre of urban planning and not on the periphery of it. health centres or a combination of all. social affairs) remains very unclear. x Design the concept paper and terms of reference for the review. either through local authorities. . 2008 p. education access. income availability. consideration should be given to the implementation of a social protection policy or social safety nets with cross-sector links. live. cost of health services. This is of course not a new finding – internationally. even for the urban poor. water and sanitation and social opportunities for the young in particular. identify resource requirements and seek consensus from the MOH and other relevant ministries for implementing the review.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 The trend towards selective primary health care and health sector reform has delivered important results for population health in terms of scaling up essential service delivery packages. NGOs. the exercise of power by local authorities. A thorough review of essential public health functions of local administrative and health authorities should be undertaken in order to define essential public health functions. Implementing action: x Conduct a review of essential public health functions for urban health that identifies resources required. the resources required for implementation and accountabilities for performance. RECOMMENDATION 5: Review and scale up social protection policies It is time to recognize the synergies in development between health. health inequities across different socio-economic groups are persisting. a capacity-building plan is needed to strengthen the delivery of essential public health functions. sanitation. waste management. Recommendation 4: Review of the public health functions A review of essential public health functions for urban health should identify resources required. work and age” (WHO.46 - . ‘Structural’ refers to the social and economic constraints of daily living and how this impacts on health. The main finding from this study is that the primary determinant of poor health and poor access to health services are essentially structural in character. However. health centres or a combination of all. the Commission on the Social Determinants of Health has indicated that the first of the three principles of action for reducing health inequities is to “improve the conditions of daily life – the circumstances in which people are born. Although medical services are increasingly available. NGOs. grow. specifies accountabilities and leads to a capacity-building plan to strengthen the delivery of essential public health functions. either through local authorities. the accountability for performance of essential public health or primary health care functions (water.

labour and environment into a broader and more cohesive healthy public policy (combined with social policy) that takes into account the social determinants of health status and their impact on . Government and development agencies need to focus on the social determinants of health. Key components of such a strategy should include: x social protection measures for health and education in collaboration with civil society and local authorities. poverty was confirmed as the most critical factor in determining the level of effective access to primary education in Cambodia (UNICEF. These demographic facts point to the need for a long-term comprehensive strategy for urban health care for the very poor in order that public policy can anticipate and respond to the well-established social and demographic trends. 924 million people. there is a strong case for linking policy initiatives of health. This study has documented how activities of daily living. A UN Habitat report on urban slums stated that in 2001. As for the demand-side factors. Other studies support these findings. the poor don’t look after themselves and governments don’t care) to a problem-solving exercise focusing on structural and process change. or 31. even though it sometimes comes at a formidable cost. Over-emphasis on economic growth and lack of emphasis on social development. These social policy developments will be critical in the coming years. For this reason. Focusing the discussion about social exclusion on structural determinants also opens up the possibility to have a more fruitful public dialogue regarding causes and solutions to urban poverty and ill health.Health Service Access Among Poor Communities in Phnom Penh 2009 This study has found that a majority of the very poor are willing to listen to health care messages and pay for health care services to follow these messages. x implementation of health strategies focusing not only on essential medical service packages but also on essential public health functions that address the social determinants of health status. between 1998 and 2008 (NIS Census. means that a government objective of poverty reduction is not attainable for many of the very poor. recently released census data indicates that the growth rate for urban areas has been 2.55 per cent and 1. particularly for the very poor. The daily cost of education and food and the intermittent costs of health care means that sometimes families have to go without or selfrestrict demand for basic human needs. including income generation. given the global and national trends in urbanization. The population in Phnom Penh has grown 32 per cent in ten years. 2007). It enables the discussion to move away from a ‘blame game’ (health workers have a bad attitude. exceeding the threshold of 15 per cent wasting rate use. 2008). In this sense. The Cambodian Anthropometrics Survey conducted in 2008 indicates that acute malnutrition among poor urban children has increased from 9 per cent in 2005 to 16 per cent in 2008. to identify a humanitarian emergency. Broader social policy initiatives (or social safety nets) that take into account the social determinants of health status and that address the needs of the very poor should be designed and implemented in high-risk communities as a first step. food security. In Cambodia. it cannot reduce poverty when not acting in collaboration with food security. lived in slums.47 - .6 per cent of the world’s urban population. Although a health sector-specific policy can make a difference.3 per cent for rural areas. there is an important distinction that needs to be made between health policy and social policy. x health surveillance focused on the needs of the poor and not just on their disease (see recommendation 2 on community-based monitoring). education. education and access to health care are interlinked issues in a family setting. income generation and education initiatives.

building on the already successful model of health equity funds in Phnom Penh. local authorities and health centre workers that social protection schemes. Jacobs.48 - . food security. Targeting the health sector for quality improvement is necessary but insufficient – the approach needs to comprehensively address social sector barriers to good health and not only to medical care services. Clearly one area where this linking could take place is social protection. People in the other three communities. Recommendation 5: Review and scale up social protection policies Social safety-net equity funds. health centre staff and local authorities place on the operation of the health equity fund scheme. 2008.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 quality of life for families. based on a model of the health equity fund. Implementing action: x OPTION 1: Scale up existing health equity funds to all the urban poor areas of Phnom Penh (comprehensive health equity fund scheme for the urban poor). . 2009). Studies across Cambodia published in the international literature support the claims of residents. The information from Borey Kaylah community indicates the high value that community members. x OPTION 2: Conduct a feasibility study on the development of a social safety-net equity fund model for health. 2007. where no or very limited social protection measures are in place. such as the health equity fund. need to be established in the poorest communities in Phnom Penh on a comprehensive basis to ensure access to health care and education services for the very poor. 2007). This is also currently being addressed by higher level Government of Cambodia policy discussions regarding efforts to research and development comprehensive social safety net strategies for the very poor (Council for Agriculture and Rural Development. Noirhomme. can increase poor people’s access to public facilities (Annear. education. also recommended the introduction of these schemes as a high priority to reduce health care costs for the very poor.

Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 6.49 - . CONCLUSIONS .

Immunization rates are high and antenatal care services are well utilized. in proportion to one’s capacity to pay. there is consensus across families. even for the very poor. However. this study concludes that improving the health status of at-risk populations means improving their access to healthy life conditions and not simply removing the barriers to health care services. This being the case. education services and food security. In the medium term. improvements to essential public service functions and in the long term. There is also a wide range of market choice of health care servicers from traditional. Ramage. in some of the poorest communities in Phnom Penh. presents the best prospects for breaking the multigenerational cycle of poverty in the poorest communities of Phnom Penh. private and public sector care services. dengue fever and communicable disease. It is the social and environmental conditions rather than access to medical services that are the main barriers to sustaining and improving family and community health. The combination of barriers in access to education services. practical improvements to primary medical services. health management practices and in health education strategy would make a difference to health care access for the poor. pregnancy. Certainly there are immediate steps that can be undertaken to improve links to the community to identify the most vulnerable. 2002. . In the short term. 2001). Mothers have good knowledge of the risk factors for vaccine-preventable disease. despite the wide access and high coverage. expressed through the extension of social protection for health care. although quality assurance of private and traditional care services cannot be confirmed (Rose.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 This study has confirmed that. development of healthy public policy. HIV infection.50 - . low incomes and poor environmental conditions means that families are at chronic risk of communicable disease. health access to basic preventive and curative services for women and children is relatively good. local authorities and health centre workers that the principle source of poor health outcomes are the unhealthy social and environmental conditions in which people live on a daily basis.

and data analysis.. World Bank East Asia Human Development Unit. Ministry of Health. 2009.who. Apiwat Krusaa Phnom Penh Jacobs. I. Phnom Penh: World Health Organization. August. W. 2002. Jacobs. 2001. 22: 183–203. James. Ministry of Health. C.html Cambodia Anthropometric Survey. Health Policy and Planning. Meessen. Wilkinson. Men. Cambodia. 1996. RMIT University (Melbourne)..C. P..O.. M.. Ministry of Planning.. Price. Knowles. RMIT University (Melbourne). Study of financial access to health services for the poor in Cambodia–Phase 2: In-depth analysis of selected case studies. P. 2001. (preliminary findings) Council for Agriculture and Rural Development. 420/99/DFID.) Extension of health services to the urban poor. B...E. J. Improving access to hospital care for the poor: comparative analysis of four health equity funds in Cambodia. 2007. Phnom Penh.who. Sam. Ir. WHO.. M. P. . 2007. 13 No 2. Phnom Penh. 22:246–262. 2005. Int J Health Plann Mgmt. F. Assessment of official private providers and delivery of health care services to children under five. R. Safety nets in Cambodia: Concept note and inventory This version: 15 June 2009 Department for International Development. WHO.int/health_financing/countries/experiences/en/index1... General population census of Cambodia 2008: Provisional population totals Phnom Penh. Vol. Study of financial access to health services for the poor in Cambodia–Phase 1: Scope.. N. R. Ros.int/health_financing/countries/experiences/en/index1. An economic evaluation of the health care for the poor component of the Phnom Penh Urban Health Project. Griffiths. October. Ramage. S. 2006. Demographic Health Survey National Institute of Statistics.. Family Health Development. B. Bigdeli. Proposal. Ministry of Health. 2001. 420/99/DFID. 2007. P. www. van Pelt. 2008. UK. A sustainability assessment of a health equity fund initiative in Cambodia. World Food Programme. Ministry of Planning. AusAID. 2009. B.. AusAID.. 2008. M. Annear. Health coverage plan 1996: Guidelines for operational health districts. B. D. Criel. Thor. (www. Noirhomme. Environment and urbanization. Van Damme.html Annear.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 REFERENCES Asian Coalition for Housing Rights.51 - . design.

United Nations Centre for Human Settlements.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Rose. Kiry. S. Evidence-based policy analysis and advocacy. UN Habitat. Phnom Penh Urban Poverty Reduction Project (CMB/00/003): a UNCHS/UNDP/UK DFID-supported project . World Health Organization. Katrin and So. Wilkinson. Chander. Vickery. Urban Health Project Briefing papers 1 – 7 Options Badloe.V. 2008. C. 2003.. UN Habitat global report on human settlements 2003. 2008. L. 2000. Phnom Penh. . John. G.52 - . M. Municipality of Phnom Penh.. Perseveranda. Vickery. Dixon. Health Systems for the urban poor final report options. Phnom Penh: World Health Organization.. The Municipality of Phnom Penh Statistical survey of the population. Tomoo. S. 2001. Geneva. World health report 2008: Primary health care.Draft Project Proposal. Final assignment: UNICEF Maastricht Graduate School of Governance. Slingsby. Vickery. Commission on social determinants for health. Radhika. Flanagan. Review of health services for urban poor component options. Private practitioners in Phnom Penh: A mystery client study. Hozumi. 2003. C. Imhof. 2002. C. World Health Organization. Universal primary education: Reaching the unreached in Cambodia.. Gore.

This part of the questionnaire collected information on health communication and knowledge of mothers with respect to maternal and child health care and immunization. This part of the questionnaire collected information regarding population mobility. UTILIZATION OF SERVICES.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 ANNEX 1: RESEARCH INSTRUMENTS Details of quantitative research instruments Household surveys The purpose of the household survey was to develop background information on knowledge.53 - . utilization and health service client satisfaction prior to conducting more in depth analysis through in-depth interviews. socio-economic status and cultural backgrounds of respondents. This part of the questionnaire assessed immunization coverage and patterns of use for maternal and child care health services (delivery. Topic areas centred on the following: BACKGROUND INFORMATION. management of a sick child and reasons for selecting a provider). KAP EPI – MCH. .

where did you live? 5 6 How many children do you have? What was the main reason you /your family moved to this community? CAN ANSWER UP TO THREE RESPONSE (RANKING ACCORDING TO PRIORITY) #_______ ________________1 ________________2 ________________3 7 What education level have you completed? # Code __________ Code 0 Never learned or entered primary school Code 1 Completed primary school Code 2 Completed secondary Code 3 Completed university Code 4 Post-graduate study Code 5 No answer How many persons reside in this household? 8 9 # Residents____________ Buddhism 1 Catholic 2 Muslim 3 No religion 4 Other religion (please specify)__________ 5 No response 9 Khmer 1 Vietnamese 2 Cham 3 Chinese 4 Other (please specify)________________ 5 No response 9 Married Divorced Separated 2 3 4 What religion are you? 10 To which ethnic group do you belong? 11 What is your current marital status? .Health Service Access Among Poor Communities in Phnom Penh 2009 Household questionnaire Section 1: Background No.54 - . 1 2 Questions What age are you? How long have you been living in this community? Are you a migrant to this community? Coding Years old_________ Months_________ 3 Migrant 1 Mobile 2 4 Before you came to this community.

did you see or hear anything on the radio. did you see or hear anything on the radio. from whom do you hear the most about childhood immunization or child health? PLEASE SELECT ONE 20 21 In the previous three months.000 riel per day 2 More than 20. television. newspaper/magazine or loudspeaker about childhood immunization or child health? From what source do you hear the most about the childhood immunization or child health? PLEASE SELECT ONE Yes No Don’t remember 1 2 3 Questions Coding 18 19 Apart from the sources mentioned above. television.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Widow 5 ___________________________________ ___________________________________ ___________________________________ ____________ Less than 5. what is the estimated family income spent on health? Can you understand the staff in the health centre? Are you able to read and write Khmer? 16 Section 2: KAP immunization and MCH ion 2: Knowledge Attitude and Practice Immunization and MCH No. CHILD HEALTH 17 In the past three months. newspaper/magazine or loudspeaker about women’s health (or maternal health)? From what source do you hear the most about women’s health? (maternal or reproductive health) PLEASE SELECT ONE Television Radio Newspaper/magazine Loudspeaker Poster Public meetings Others (please specify) ____________ Don’t know Government health workers Drug seller or private clinic Traditional healers Heads of village/commune Parents or relatives Friends or neighbours NGO Others (please specify) ____________ Don’t know Yes No Don’t remember Television Radio Newspaper/magazine Poster Public meetings 1 2 3 4 5 6 7 9 1 2 3 4 5 6 7 8 9 1 2 3 1 2 3 4 5 .000 riel per day 3 Not regular 4 Unsure 9 # Yes No Very well Not so well Cannot read or write 1 2 1 2 3 12 What is the job of the main income earner in the family household? 13 What is your estimated family income per day? 14 15 In the past three months.55 - .000–20.000 riel per day 1 5.

Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Others (please specify) ____________ Don’t know Government health workers Drug seller or private clinic Traditional healers Heads of village/commune Parents or relatives Friends or neighbours NGO Others (please specify) ____________ Don’t know 6 9 1 2 2 3 4 5 6 7 9 22 From whom do you hear the most about maternal health? PLEASE SELECT ONE ANTENATAL CARE 23 How many times did you see any health worker for antenatal care for the previous pregnancy? CIRCLE CORRECT ANSWER Did not see anyone 1 One to three times 2 Four to six times 3 Six times or more 4 No. What types of symptoms (danger signs) would cause you to take your child to a health facility right away? OPEN QUESTION. did you receive any of the following: CHECK RECORDS (CHECK PINK MOTHER CARD) IF CANNOT REMEMBER PROMPT WITH OPTIONS Coding Tetanus injection Y/N/DK Iron tablets Y/N/DK Advice on your diet in pregnancy Y/N/DK Information about warning signs during pregnancy Y/N/DK Mebendazole capsule Y/N/DK 3 _________________________1 _________________________2 _________________________3 __________________________4 __________________________5 __________________________6 _________________________7 __________________________8 Bleeding 1 Severe headache 2 Trouble with vision 3 Fever 4 Swollen hands or face 5 Reduced or faster foetal movement 6 Other please record________________8 Do not know 9 Child not able to drink or breastfeed 1 Child develops a fever 2 Child has fast breathing 3 Child has difficult breathing 4 Child has blood in the stool 5 Child is drinking poorly 6 Other please record________________8 25 What diseases can be prevented by immunization? DO NOT PROMPT DANGER SIGNS IN PREGNANCY 26 What are the danger signs in pregnancy that require a woman to seek medical care? FOLLOW WITH OPEN QUESTION: ASK.56 - . DO NOT PROMPT – . “ANY MORE?” DO NOT PROMPT 27 Sometimes children have severe diseases and should be taken immediately to a health facility. 24 Questions At an ANC visit.

did you have to pay for it? Monthly 1 3 monthly 2 6 monthly 3 Not at all 4 Unsure 9 Pay 1 Not pay 2 .57 - . please go to question 30) Hospital 2 Community 3 Private clinic 4 Others (please specify)______________ 5 Don’t know 9 1________________________________________ ____2____________________________________ ________3________________________________ ____________ 32 What are the main reasons your child did not receive vaccinations at the health centre? RECORD ACCORDING TO PRIORITY 1 How often does an immunization team reach your area? SELECT ONE ONLY 33 34 For the previous vaccine your child received. Record date DPT 3 provided………. Record date DPT 2 provided………. IF RECEIVE ONE DOSE OR COMPLETE DOES GO TO QUESTION 30 ______________________________________1 _______________________________________2 _______________________________________3 Government health workers Head of Group/Heads of village/commune Village volunteer Neighbours Went by themselves 1 2 3 4 5 29 If your child did not get required vaccination as scheduled. WRITE IT DOWN IN FULL AND CHECK WITH YOUR SUPERVISOR LATER.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 ASK “ANY OTHERS?” IF YOU ARE NOT SURE IF A CERTAIN SIGN FITS IN ONE OF THE CATEGORIES. 28 Questions Did your child receive a DPT Hep B vaccination? CHECK YELLOW DATES THE CARD IMMUNIZATION AND RECORD Coding Mother reports immunization was given 1 Immunization date DPT3 recorded on the yellow card 2 Immunization not given 3 Record date of birth of child……… Record date DPT1 provided………. Do not know 9 Section 3: Utilization patterns of health services for immunization and MCH No. what were the reasons? Who came to tell you information about receiving immunization services? 30 31 Where did your child usually have vaccination? Others (please specify) ____________ 8 Don’t know 9 Health centre 1 (if 1.

3………………………………………………….Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 MATERNAL HEALTH 35 Where was the location of delivery of your most recent birth? Phnom Penh 1 Province 2 In this community 3 Other 4 Health Centre 1 Public hospital 2 Private clinic 3 If answer 2. Yes 1 No 2 IF NO SKIP TO QUESTION 42 Local authority 1 NGO 2 Church 3 Government 4 Other 5 Yes 1 No 2 36 Where was the place of delivery of your last child? DO NOT PROMPT 37 What was the main reason for choice of location for delivery? PROVIDE RANKING (1 – 3) Who assisted with the delivery? IF DELIVER AT HOUSE OR OTHER LOCATION 38 39 What was the main reason for choice of provider for your last delivery? PROVIDE RANKING (1–3) Do have an insurance card for receiving health care services? 40 41 Who provided the insurance card to you? 42 Do have a poverty status card (health card) for receiving health care services? 43 Who provided the (health card) to you? poverty card 44 How far is the nearest government health centre from your house? Do you know the health staff who works there very well? Do you know whether the staff has a daily immunization service that is provided at the health centre? 45 46 Local authority 1 NGO 2 Church 3 Government. 3 or 4. skip to questions 38 and 39 Home 4 Other please describe_____________5 1…………………………………………………. 2…………………………………………………. Midwife 1 TBA 2 Doctor 3 Other please describe_____________4 1…………………………………………………. 2…………………………………………………. 3………………………………………………….58 - . 4 Other 5 #________ Do not know 6 Not sure 9 Know very well 1 Know a little bit 2 Do not know well 3 Yes 1 No 2 .

Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 47 What was the type of illness last experienced by your child in the previous six months ? _________________________________________ _ 48 For this illness. 2…………………………………………………. 4…………………………………………………. 1…………………………………………………. 3…………………………………………………. 4…………………………………………………. birth spacing.59 - . 2…………………………………………………. who was the first choice for seeking treatment? What was the main reason for the first choice of health provider? 54 PROVIDE RANKING (1–5) . who was the first choice for seeking treatment? 49 What was the main reason for the first choice of health provider? Local pharmacy 1 Private clinic/hospital 2 Health centre 3 Public hospital 4 Other please describe_____________5 _________________________________________ ______ 50 PROVIDE RANKING (1–5) Have you used the nearest government health centre for child health consultation in the last three months? What do you like best about the government health centre? PROVIDE RANKING (1–3) Yes 1 No 2 IF NO. 5………………………………………… 51 52 What is the thing you dislike most about this health facility? PROVIDE RANKING (1–3) 53 For the last consultation for reproductive health (delivery. 5…………………………………………………. Local pharmacy 1 Private clinic 2 Health centre 3 Hospital 4 Other please describe_____________9 1…………………………………………………. women’s health. 4…………………………………………………. GO TO QUESTION 53 1…………………………………………………. 3…………………………………………………. 3…………………………………………………. antenatal care). 2………………………………………………….

Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 Qualitative research instruments Qualitative survey For the in-depth interviews and focus group discussions. Mapping of health service access by community members and health centre workers – participants were encouraged to physically map the community. diagrams) and working with small groups. RECOMMENDATIONS FOR IMPROVING ACCESS. private or public). local authorities and health centre staff. such as: 1. Making recommendations for improvements to health care access. The purpose of this line of discussion was to gain a deeper understanding of the social context and determinants of good health and health service access. which contains three main components: 1. This also enabled deeper understanding of the quality. LEARNING ABOUT SOCIAL NETWORKS FOR HEALTH. In the context of this study. participants were encouraged to lead the discussion through a range of PLA techniques. All three contained specifics for each category and the questions followed the main topic areas: SOCIAL CONTEXT FOR HEALTH. 3. daily living priorities of health. 2. Facilitators’ behaviours and attitudes (being sensitive to who controls the collection and use of information). 2. participants were encouraged to provide their own recommendations on improving health care service access. Methods that combine visuals materials (such as mapping. modelling. The principal approach in the focus group discussions was based on the participatory learning action (PLA) approach. its main features as well as health access points (whether traditional. . This topic area involved discussions about standards of living. This area of discussion focused on patterns of health care-seeking behaviour and communication in the community about health and health service use. Listing and ranking of main health problems (either through writing or pictorial representation). The purpose of this discussion was to gain a deeper understanding of how people learn about health services from their own community. Following on from the previous discussions.60 - . provider behaviour and the impact of cost on access. This area of discussion focused on why community members choose to use specific health services. food and education and the history and background of the community. 3. an open-ended questionnaire guideline was designed for mothers. Sharing (encouraging practices and behaviours that empower through local creativity and ownership of study process and findings). DETERMINANTS FOR SERVICE UTLILIZATION.

Mapping x physically map the community with local community members x map important locations x map where people go for health services. Focus group discussion with community members 1. Focus group discussion with health centre staff 1. Use poster with the following throughout the focus group discussion (FGD): List with symbols and detail the following: x frequency x seriousness x causes x solutions 3. Suggested solutions Select four topic areas for problem solving health improvement or improvement to health service access. . Listing main health problems and locate on map. Suggested solutions Select four topic areas for problem solving health improvement or improvement to health service access. especially for MCH in slum areas. Discussion of seriousness – put a star against the most serious health problems 4. Mapping x physically map community x map important locations x map where people go for health services. 2.61 - . Discussion of reasons for main health problems 5. especially if MCH related 2. Facilitator describes objectives 2. especially MCH-related services 6. especially for MCH. Listing and rank main health problems and locate on map x discussion of main health problems in the slum areas x discussion of reasons for main health problems x ranking of health problems in slum areas specifically 3.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 1.

000 displaced people who had lived in the refugee camps along the Thailand and Cambodia border and also in Thailand territory to repatriate. the first year of the Human Development Report. housing. The new owners appropriated many centrally located buildings in the city. The scarce professionals were allowed to occupy any vacant dwellings close to their new place of employment. including land ownership. the national reconciliation policy allowed about 200. After the Paris Peace Accord in 1991 and the establishment of the new government in 1993. The Urban Sector Group (USG) is a Cambodian NGO established in 1993 that works in 48 poor communities in Phnom Penh. Source 1993 1994– 2005 1996 1997 Introduction of the Health Financing Charter by the Ministry of Health. Cambodia’s Human Development Index (HDI) was calculated at only 0. a supplementary study of the Socio-Economic Survey concluded that “health care costs are simply unaffordable for the poor. One of the outcomes of the health sector reform project in the 1990s was the establishment of the Urban Health Project.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 ANNEX 2: LITERATURE REVIEW History of urban health service delivery in Phnom Penh Year 1979– 1990s Detail At the end of the Khmer Rouge rule. USG was originally established by a group of local and international NGOs working in Cambodia with the aim of helping squatter communities to address issues of poverty. returnees to Phnom Penh were able to occupy buildings on a first-come first-serve basis. In 1990. with no formal titles. additionally through the introduction of exemption schemes for the poor. designates restructuring of the health system based on primary care centres and referral hospitals with defined catchments and packages of essential services for each level of care. sanitation and solid waste disposal. Ministry of Health. placing the country at the “low human development” status. Thomas.takes up one third of all non food expenditure for a year for a typical person in the poorest quintile”. bilateral agencies started to become interested in urban health.62 - .501. legitimizes and attempts to regulate user fees for health services. quoted in D. basic infrastructure services. Social Development Priorities in Health Sector Reform Options. water. Health Coverage Plan 1996/ Guidelines for Operational Health Districts 1996 Health Coverage Plan Updated 2005. A . August 1999 439/99/DFID 1998 Back in 1998. which they then subdivided and started to sell. Even a single outpatient visit…. Development of the Health Coverage Plan by the Ministry of Health. As far back as 1997. Ministry of Health 1996 Socio Economic Survey 1997. They were mainly public officials and the few remaining professionals after the mass killing of all educated people in Phnom Penh.

with high levels of unofficial charges. After the study. the Municipal Health Department lobbied hard for financing and official status of the health rooms. x The private medical sector is the first choice of treatment source for the population of Phnom Penh but is largely unregulated and of dubious quality. Urban Health Project Briefing papers –7 Options. The staff also assisted to administer the health equity fund. An Urban Health Project Management Unit was based in the Municipal Health Department. x The richest of those living in the two communities estimate they can spare a maximum of 5. However. The main findings were: x Poor people felt that government staff ignored their needs. Due to management issues internal to the organization. with services provided through government health staff supervised by the MHD. who live in inadequate housing conditions. Phnom Penh Urban Poverty Reduction Project (CMB/00/003): a UNCHS/UNDP/UK. These were small facilities based in the slums. A demand-based baseline survey was conducted in two communities in 2001 (Tonle Bassac and Boeung Kak). But this strategy was not ever integrated within the health sector strategy. the Urban Health Project set up ‘urban health rooms’. The term ‘urban poor’ is used to describe families who claim some form of occupancy rights but who are economically poor. Vickery. Phnom Penh: United Nations Centre for Human Settlements. the health equity fund function of the USG was then taken up by Apiwat Krusaa (Family Development – a local NGO). quality and affordability. the word is usually avoided in official documents. x The poorest of the poor have no money for healthy care. x Fee exemption schemes did not work in the communities.000 riel per day for health care. MHD/DFID/WHO 2002 2001 2001 2001 The Urban Health Project was officially started in 2001with funding through the UK Department for International Development (DFID) and Options consultant services. 2000 DFID-supported project . The health equity fund became independently managed by the Urban Sector Group. They provided basic treatment free of charge for slum dwellers. because squatters translates as ‘anarchists’ in Khmer. The first (or one of the first) health equity funds was established in the period 2001–2002). poor environment and lack of access to basic services. the term ‘squatters’ describes people living on land and in buildings over which the government claims ownership.” 2000 M. At the time of the health equity fund and health rooms. The aim was to explore alternative models of service delivery for health care for the urban poor. Review of Health Services for Urban Poor .63 - . Slingsby. It was mostly a qualitative study.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 baseline demand survey was conducted in 2000 in five urban slums. Some of the strategies applied in the program implementation were as follows: x Establishment of ‘health rooms’ in communities as primary care C. “In Phnom Penh. x The cost of health care is the most common cause of poverty and homelessness. Staff at these facilities (who received incentives) also assisted in referring patients to the municipal hospital. with data on access.Draft Project Proposal.

In 2001. It is further projected that in the next 30 years. 5 per cent along roadsides. staffed by municipal health employees with performance payments. Western Asia (33. lived in slums.16 to all public health facilities in 1999. in contrast to 6 per cent in more developed regions. Vol.000 people) live in 502 low-income settlements within Phnom Penh’s seven municipal districts. In October 2003. prevention of poverty and prevention of cost of $1.228. 9 per cent on rooftops of downtown buildings. Adding these would raise the total to about 450. Knowles. the global number of slum dwellers will increase to about 2 billion if no concrete action is taken. 420/99/DFID. funding it for one year until September 2004. The majority of them were in the developing regions. in partnership with the Municipal Health Department of Phnom Penh. x Establishment of local financing schemes (health equity funds) with poverty identification schemes.000 per capita of government expenditure on poverty alleviation schemes. 924 million people.000 people or about 40 per cent of the city’s 1. University Research Co Ltd. 63) DFID approved a 12-month extension to Health Services for the Urban Poor Project (HSUP) in 2002. A final evaluation indicated that health rooms became the first choice of health provider for 66 per cent of residents (who previously used private practitioners). In addition.6 per cent of the world’s urban population.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 and referral points. An Economic Evaluation of the Health Services for Urban Poor Component.” (p. An assessment of the status and numbers of the poor in 2001 established the following: “About 35. October 2001. there are growing numbers of poor tenants who rent makeshift shacks around the factories or who live in crowded sub-divided rooms in the city centre or in isolated but insecure circumstances. the Urban Sector Group took responsibility for implementing the equity fund of the Urban Health Program (UHP). provided USG’s equity fund with a grant. 2002 2003 Global Report on Human Settlements 2003 UN Habitat .000 was identified for health equity funds. compared with the city wide average of 0. Component Options. 2002 2001 Environment and Urbanization. A final evaluation raised ethical implications of creating highly subsidized services and then withdrawing all support at the end of project. The Asian Coalition for Housing Rights 2002 Extension of Health Services to the Urban Poor 420/99/DFID.1 per cent). In 2002. Estimates for Phnom Penh range from 20–30 per cent. and 40 per cent on open land. the UN released a report on urban slums. Five per cent of these families live along railway tracks.1 million population. x Development of ‘user group’.4 per cent). 420/99/DFID. with scale-up costs over a three-year period estimated at $320. 2001 2001 An economic evaluation of the Urban Health Project (health services component) established the following: x Health rooms are heavily used by a predominantly poor population. accounting for 43 per cent of the urban population.000 families (180. Population served by the two health rooms was making about 1. x A target population of 200. 26 per cent on river banks and along canals. The urban population in less developed J.64 - . x Benefits of the equity fund were noted: increased access to treatment. Eastern Asia (36. In 2003. or 31. 2001 Extension of Health Services to the Urban Poor. mostly in the form of mothers’ club to advocate for and promote community health.8 visits per person annually. 13 No 2.

in many cities. UNCHS provided supplementary funds to the Municipal Health Department to extend project activities to relocation sites (Extension of Health Services to the Urban Poor 420/99/DFID 2002for populations from Tonle Bassac and Chbar Ampeu. it is not unusual for them to have incomes that exceed the earnings of formal sector employees. will be provided with a Priority Access Card (PAC). there are more poor people outside slum areas than within them. On the one hand. Evaluations of the Urban Sector Project was conducted in 2004. still supports the health equity fund through local NGOs. and some people of reasonable incomes live within or on the edges of slum communities. User groups and mothers’ clubs were also established. now they go by the name of Family Health Development and from October 2003 until June 2008 they operated with funding from the USAID-HSSC project.There have always been difficulties accessing financing for the health equity fund.” An final evaluation of the Urban Health Project identified the following service features/strategies that worked: x providing services at hours that allow the poorest to attend x involving users in the management of services x establishing affordable charges and eliminating unofficial payments x providing exemptions for those who cannot afford the fees x improving access to second-level care by removing finance. but the relationship is not always direct or simple. slum dwellers are not a homogeneous population. Even though most slum dwellers work in the informal economy.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 regions increased by 36 per cent in the past decade. On the other hand. 2008 2004 Consultation Notes . Vickery. 2003 2002– 2003 Extension of Health Services to the Urban Poor 420/99/DFID. the health rooms could not be financially sustained despite the documented successes in use and coverage. identified either through the pre-identification process or through a post-identification process followed by a field verification visit. Through the proposed project. through the University Research Council. The US Agency for International Development. 2003 C. The main barriers to sustaining the programme include lack of financing and inability to convince decision makers of the need to integrate the health room into the health system. The card can be used by any member of the family listed during the identification process to access services at the Municipal Referral Hospital. following fires that destroyed the settlements. The MHD opened a new health room at Anglong Kngan with the support of UNCHS and also to the Samaki relocation site. Apiwat Krusaa. health rooms and municipal health staff. CPA1 referral hospital or health centres that have a contract to provide services with the health equity fund.65 - . Although health posts have been set up. poor households. Project activities continued at Boeung Kak Health Room and despite funding shortages. Financing therefore remains project dependent. transport and institutional barriers to care. 2002 2003 Proposal. Slums are not homogeneous – “Slums and poverty are closely related and mutually reinforcing. such as Apiwat Krusaa (Family Development). An Urban Health Task Force was also established under the chair of MHD. The health equity fund has been operated by a local group who formerly worked under an NGO called Urban Health Sector Group. Health Systems for the Urban Poor Final Report Options.

Apiwat Krusaa.66 - .Health Service Access Among Poor Communities in Phnom Penh 2009 2005 2006– 2007 2007 The Municipality of Phnom Penh Conducts a statistical survey of the population. Main characteristics: Poor households are identified. 2–4 persons at 20. 5–7 persons at 24. iii) the very poor. Dr Peter Leslie Annear (RMIT University) et al. Sky Health Insurance (initiated by GRET with support from GTZ) established a pilot project at one site in 2005. ii) unstructured housing developments. including six in which HEF is provided (Anlong Kngan. which required a nationwide campaign to reduce the risk of further transmission. poverty stands at 12 per cent of the city population. Cham). . but still an estimated 30 per cent of the population lives below the poverty line. “Officially. and 8 and more persons at 28.000 in 109 villages of Phnom Penh were identified as high risk. The card can be used by any member of the family listed during the identification process to access services at the Municipal Referral Hospital. This followed the detection of a vaccine derived polio case (and documented lower EPI coverage) in the slum area of Tonle Bassac. Criteria for high risk was not clearly identified. Tboung (with six health centres) and Lech (with six health centres) and a total of 21 health centres. Family Health Development designs are a new proposal for extension of health equity fun system (USAID HSSC).000 riel. leading to sharp rises in fuel and food prices. Bori Kila. The poorest areas include a total of 22 different recognized squatter settlements.000 riel. iv) minority groups (Vietnamese. has pushed many families below Municipality of Phnom Penh Ministry of Health Consultation Notes 2007 Study of financial access to health services for the poor in Cambodia Phase 2: In-depth analysis of selected case studies. Development by Ministry of Health of National Guidelines Health Equity Funds. Cambodia had experienced three years of double digit economic growth. In the process of this campaign effort and implementation of at-risk strategy. either through the pre-identification process or through a post-identification process followed by a field verification visit. Beoung Kak. The SKY Health Centre is located within the Municipal Hospital. Samake.” The Phnom Penh Municipal Hospital is the referral hospital for the four Operational Districts of Kandal (with four health centres). the National Immunization Program. although the following criteria for classification were identified in interview – i) low coverage. Anlong Kong. in partnership with the World Health Organization and other partners developed an at-risk strategy for slum areas of Phnom Penh and other parts of the country. Funding provided by AFD (Agence France Development) from 2007.” As part of the programmes for child survival and immunization. 2007 2008 2008 Proposal. CPA1 referral hospital or Health Centres which have a contract to provide services with the health equity fund. 347. are provided with a Priority Access Card (PAC). In 2007. The initiative also involves the establishment of village user groups.000 riel. UNICEF and the NIP (National Immunization Program) partner with the MHD will undertake a study of health service access in selected communities as well as identifying strategies for improving communication and access between at-risk communities and government health services. Tonle Bassac). “Monthly premiums are charged pro-rata according to family size: single person at 16. 2008 2008 Consultation notes and literature sources.000 riel. Cheung (with five health centres). The international economic crisis.

the possible reasons for the large numbers of females in these two areas in the de facto count could be: i).5 per cent in 2008. 2008) Municipality of Phnom Penh= 20 per cent (Municipality. specifically 2.Health Service Access Among Poor Communities in Phnom Penh 2009 Health Service Access Among Poor Communities in Phnom Penh 2009 the poverty line status. and health care (Urban Health Project 2002).3 per cent (Phnom Penh. 2007) Urban poor = 19. August 2008 2008 . 2002) 2008 General Population Census of Cambodia 2008 Provisional Population Totals National Institute of Statistics. But new rural migrants sell land and are replacing populations that leave the slums.. Oddar Meanchey. Growth rate for urban areas is 2. Mondul Kiri. Urbanization has increased over the past decade. etc. Subject to confirmation by age and migration data. Most of the urban poor live in slums and squatter settlements.000) (UN Habitat. depress the sex ratio of urban Cambodia as a whole. Stung Treng. Ta Khmau etc. without adequate access to clean water. By 2035. The 2008 census in Cambodia indicated that the proportion of urban population in Cambodia was 19.2) and Kandal (88. the proportion is projected to reach 50 per cent. sanitation. The provinces of Phnom Penh and Kandal. Urban Phnom Penh and urban Kandal with their large female populations.55 per cent and rural areas 1. slum areas are still being relocated. This is contributing to very low sex ratios in the urban parts of Phnom Penh (88. Average household size in Phnom Penh is 5.1 people. In other cases. ii) sizeable out migration of men to provinces like Battambang. some populations are moving out of slums. The population has grown 32 per cent in Phnom Penh in ten years.0). The Asian Development Bank recently announced a $30 million food security fund for the slum areas of Phnom Penh.82 per cent).67 - . Largescale migration of younger women to work in garment factories in Phnom Penh. Ratana Kiri. Ministry of Planning Phnom Penh. The proportion of urban population according to the new definition of urban areas has increased from 17. Cambodia.7 per cent (241. particularly their urban areas.5 per cent. Preah Vihear. have been attracting a large number of young women who take up jobs in garment factories. National Immunization Program = 16 per cent (NIP. About 20 per cent of the poor now live in Phnom Penh and other urban areas. In some cases. 2005) Urban poor =12 per cent (Annear et al. between 1998 and 2008.4 per cent in 1998 to 19.

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