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Research on the Needs of Communlty Based

Rehabilitation (CBR) for Disabled Persons

in Cambodia

Som-arch Wongkhomthong, M.D Somboon Kietinun, M.D Chongkolnee Chutimatavin, IVIA


Yasuhide Nakamura, M.D

ASEAI{ bestitute for Health Development

Mahidol University
1998

Funded by National Rehabtlttation Center for Disabled Persons JaPan

Research on the Needs of Community Based

Rehabilitation (CBR) for Disabled Persons

in Cambodia

Som-arch Wongkhomthong, M.D Somboon Kietinun, M.D Chongkolnee Chutimatavin, MA


Yasuhide Nakamura, M.D

ASEAI{ Institute for Health Development Mahidol Universitv 1998

Funded by National Rehabilitation Center for Disabled Persons Japan

The Needs of Community Based Rehabilitation (CBR) for Disabled Persons in Cambodia

By Som-arch Wongkhomthong, Somboon Kietinun, Chonkolnee Chutimatavin, Yasuhide Nakamura ISBN: 974-661-585-8

First Edition 1998 Printed by Printing Division ASEAN Institute for Health Development Mahidol University, Salaya Nakornpathom 7 3170, Thailand

Som-arch Wongkhomthong Research on the needs of community based rehabilitation (CBR) for disabled persons in Cambodia /Som-arch... [et al.] l.Rehabilitation-Cambodia. 2. Handicapped. 3. Research. tr. Title. wB320. JC2 5693 1998 ISBN : 974-661-585-8

Acknowledgement
We are grateful to the Embassy of Cambodia in Thailand and all these people who have been kindly helping us to make this study possible; H.E. Dr. Hong Them,

Dr. Eng Huat, Dr. Mao Tan Eang, Dr. Prok Pisith Raingsey, Mr. Keo Kim Thon, Mr.

Mao

sovadeio Ms.

Helen Pitt, Dr. To chlum seng, Dr. veh yutho, Mr. ung Nak,

Mr. Dudluy Turner, Dr. Ka Sunbannat, Mr. ung Say, and especially Dr. Khuon Eng Mony, Dr. seng Rattana, Dr. Phok chansorphea and Mr. Vong samnang who had
been

kindly arranging and accompanying us to conduct our interviews.

Som-arch Wongkhomthong Somboon Kietinun Chongkolnee Chutimatavin Yasuhide Nakamura

September 1998.

Executive Summarv

cross-sectional descriptive study

to identi$' the situation and needs of


disabled persons

community-based rehabilitation (C.B.R)

for

in

Cambodia was

carried out during August - September 1998. The research has specific objectives in

identiffing the general situation of disabilities and impairments, the situation


needs

and

of

community-based rehabilitation and possible af,eas

for

international

cooperation

for C.B.R. in Cambodia. The

research methodologies consist

of four
related

methods: literature review

of published and non-published documents of

organizations, data collection from structured questionnaires given

to Cambodian

health authorities, visits

to eleven institutions in Cambodia as well as personal

interviews of eighteen Cambodian authorities using unstructured questionnaires. The


results were summarized under six topics: basic statistics, C.B.R. services, the needs

of C.B.R., foreign assistance for C.B.R., the potential and limitations of

C.B.R.

models, and requests to the National Rehabilitation Center for the Disabled, Japan.

In summary, the research results show that Cambodia has the poorest health
conditions among Asian countries. The government's health budget is very low,
resulting in poor health services, in prevention and promotion, and poor accessibility and availability This is even more so

for services directed to the disabled.

The the

situation concerning disabilities

is

severe and may become more so due

to

existence of a lot of land mines in many places and the increasing number of traffic

accidents. People experience malnutrition, deficiencies resulting

in

blindness,

poliomyelitis and encephalitis. Presently, immunizations are not sufficiently covering


the population. Due to the Pol Pot Regime and long history of internal fighting, there

is an increasing number of disabled persons and an increasing shortage of manpower

in all medical fields, especially for handicapped, as well as in the social fields and
special educational fields. So the needs for Cambodia are not only community-based

rehabilitation but also a general need to assist in all medical fields, social fields, and
educational {ields in order to improve the entire health, social and educational system.

iii

Contents
Acknowledgements Executive sunmary
Contents

ii iii
iv
v
I
a

List of figwes List of tables


Introduction
Research objectives Research methodology

J J

Operational definition Models for CBR


Research results

3-6 7-9
9

I.

Basic information
1.1 Health situation 1.2 Competent authorities on the health services:

9-18 19-20

principle organization collaboration


1.3 Health policy and

Planning
with

20-22
22-26

disabilities 1.5 Administrative Division on the Rehabilitation services 1.6 Specialists in the rehabilitation fields 1.7 Main organizations of C.B.R. II. The actual condition of medical rehabilitation III. The needs of C.B.R. IV. Foreign assistance for C.B.R. Conclusion Recommendation
1.4 Actual conditions of people

26-28
32 32 36

46
46

48
48

ANNEX A: List of Organizations in the Field of Disabilities in Cambodia 49-55 ANNEX B: Medical

Rehabilitation Visits

56-64 65-68 69-78

ANNEX C: List of Interviewees & List of Institutional ANNEX D: Community-Based

Rehabilitation ANNEX E Summary of Recommendations References

79-96
96

iv

List of Figures

Page

Fig. 1. Main health problems of out-patient consultations by age


at health centers, Cambodia 1996

group

Fig.2. Main health problems of out-patient consultations by age group


in hospitals, Cambodia 1996 Fig. 3. Main causes of hospitalizationby age group in Cambodia,

13

1996 Fig.4. Organizational structure of the General Directorate of the Ministry of


Veterans Affairs and Social Affairs

15

29

Fig. 5. Organizational structure of the Rehabilitation

Fig.6. organizational

Deparftnent structure of the Disability Action council (DAc)

30

3l

List of Tables
Page

Table 1.Main health problems of out-patient consultations by


group at health centers, Cambodia 1996 Table 2.Main health problems of out-patient consultations by group in hospitals, Cambodia 1996 Table 3.Frequency and age distribution of main health
seen at in-patient hospitals.

age age

r0

12

problems
in

14

1996 Table S.Number of cases, causes of dealths, and case fatality rates
Table 4.Main health problems among in-patient hospital

16 17

at the I.P.D.
Table 6.National hospitals: main causes of hospitalization
death

and

1g

in 1996

Table T.Total number of disabled persons in Table 8.Final classification of confirmed

Cambodia polio cases by district

23 25

ofresidence

1996 Table l0.Services for disabled persons by province


Table 9.Mine and road accidents in Table l l.Statistics of disabled persons who have received

26
35

training

44

The Needs of Community-Based Rehabilitation (C.B.R) in Cambodia.

1.

Introduction
Disabled persons are one segment of the community. Most are not totally disabled and can still be provide potential man power. Even though they have lost some ability, either temporarily or pennanently, many still have other abilities which may be even better than the non-disabled if they are encouraged to do so.

Helander (1990) stated that around 5-21 percent of the total world population, 7.7o/o in developed countries and 45% in developing countries, had moderate or severe disability . If the world population were 276 millions there would be 93 million disabled persons (or one in three) living in developing countries.

In Thailand, the Health Research institute had done a survey of the health situation of those above five year of age in the population and found that 8.1 percent of the population was disabled out of the total population of 4,614,650 persons, excluding psychological disorders. United Nations has given guidelines for the disables as follows: 1. The disabled have the equal human's right as others so they should be supported, protected and given the opportunity of rehabilitation. 2. Due to disability, these people already have psychological and mental distress; thus they should have the right to ask for sympathy from the society. 3. If the disabled have better opportunities, they will be able to develop themselves and be useful to the society. 4. The disabled, after completing rehabilitation, will be responsible in
society and the country.

5. The disabled prefer to live freely in the general community

instead

of

in special places provided for them. 6. To rehabilitate successfully, it is important that all people concerned must give good cooperation and give them opportunities.

From 1982-1992, there were ten years of focus upon issues of the disabled, including prevention, rehabilitation, and equality. The Asian and Pacific region has joined to establish the LIN-ESCAP committee and declared in 1992 in Beijing that the years 19922002 will mark ten years of focusing on the issues the disabled in the Asian and Pacific region. The LIN-ESCAP is composed of 31 country leaders out of the 60 countries that declared the Proclamation on the Full Participation and Equity of People with Disabilities in the Asian and Pacific Region. Organizations of disabled persons exist such as "Selfhelp organizations of disabled persons" and at the world level such as the "Disabled People's Intemationd (DPI founded in 1981 and located in Canada includes all disables) and World Blind Union (WBU) and World Federation of the Deaf (WFD) which are single disability organizations. In Thailand there is a council for all disabilities called "The Council of Disabled People of Thailand" (DPT) and in Cambodia there is an organization called "The Disability Action Council" (DAC).

In Cambodia the health status of the people is amongst the lowest in Asia. Reliable mortality and morbidity data rarely is available in Cambodia - most are hospital
based and most of the surveys conducted in the past were small

in scale.

o o
o

Pregnant women receiving 1 ANC visit Maternal Mortality Rate Population with access to health services

44%
4731100000 live births

Rural Urban Source: Health Policy and Strategies 1996-2000

25% 80%

Acute respiratory infection (A2) and dianhea are the two major childhood diseases, together accounting for 50o/o of all pediatric consultations reported by public health
services. The number of poliomyelitis cases was reported as 300

in

1994

and 168 in 1995.

At least 750,000 children under five years of age are suffering from various forms of
malnutrition. The influx of vehicles is a major cause for concem of road accidents. Monthly hospital data show that there are 500 to 600 traffic accident admissions with the case mortalitv rate of 2.2Vo. Hospital admissions due to land mine accidents continue to claim 300 victims per month (statistics in 1995). The amputation prevalence rate due to mines is I per 236 person - the highest proportion of amputees in the world. Other principle causes of disability include mental disorders, poliomyelitis, meningitis, leprosy, tuberculosis, eye diseases (especially due to vitamin A deficiency) and middle ear infection, causing hearing loss. For those with disabilities under 15 years of age, 43Yo are caused by polio, ll.6% by mental disorders and 2lohby amputations. Due to the highly traumatizing events, such as prolonged war, the constant fear of mine injury, the dislocation of families, and the loss of relatives, have resulted in considerable psychiatric morbidity confirmed by studies among displaced Cambodians in the border camps. Large numbers are in need of psychiatric and counseling services for mental
disorders.

Cambodia is an unfortunate country in South East Asia as it has long history of war, millions of land mines, an increasing number of road accidents, lack of basic health care, mal-distribution of health personnel, poor coverage of immunization, lack of access to health care services, and the absolute poverty of the majority of its citizens all contribute to the fact that Cambodia is a country with a high number of disabled people. In 1994

there were 122,740 disabled persons in Cambodia,2l,l92 had visual disabilities, 11,479 hearing disabilities, 90,000 physical or locomotive disabilities, and 21,479 psychological or behavioral disabilities. Even though many NGOs (more than 35) have been actively helping disabled persons in Cambodia, there still are inequities and inaccessibility in many communities. Thus, it is important to identify the needs of community-based rehabilitation in Cambodia.

2.

Resdearch Objectives

General Objective: To identify the situation of the disabled and the needs of community based rehabilitation (C.B.R.) programs in Cambodia Specific Objectives 2.1 To identify 2.2 To identify 2.3 To identif 2.4 To identiff 2.5 To identify

basic statistics community-based rehabilitation (C.B.R.) services the needs of Community-based rehabilitation foreign assistance for C.B.R. the possibility and the limitations of C.B.R. models.

3.

Research Methodology Cross-sectional descriptive study including: 3.1 Review of literature and documents 3.2 Structured questionnaires targeting concerned persons. 3.3 Institutional visits to observe certain activities as well as to gather some unpublished information: a total of 11 institutes 3.4 Personal interviews: A total of l8 persons were purposively selected and interviewed by using unstructured questionnaires concerning their direct involvement in disabilities and rehabilitation.

4,

Research Period August-September


1

998.

5.

OperationalDefinitions: Community-based Rehabilitation in Cambodia


Includes either the government or NGOs

C.B.R is characterizedby the active role of people with disabilities, their families, and the community in the rehabilitation process. In CBR, knowledge and skills for the basic training of disabled people are transferred to disabled adults themselves, to their families, and to community members. A community committee promotes the removal of physical and attitudinal barriers and ensures opportunities for people with disabilities to participate in school, work, leisure, social, and political activities within the community.

Rehabilitation

r o o

Restoration of form and function following an illness or injury. Restoration of an individual's capability to achieve the fullest possible life compatible with his abilities and disabilities. social, vocational, and educational potential consistent with his or her physiological or anatomical impairment and environmental limitations.

The development

of a person to the fullest physical, psychological,

ICIDH definitions (WHO 1980)

o o

Impairment in the context of health experience is any restriction or lack (resulting from impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. Disability, in the context of health experience is any restriction or lack (resulting from impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. Handicap in the context of health experience, is a disadvantage for a given individual resulting from an impairment of disability, that limits or prevents the fulfillment of a role that is normal (depending on age, sex, social and cultural factors) for that individual.

Disabilities can be divided in 5 groups as follows 1. Visual Disability 2. Hearing Disability 3. Physical or Locomotive Disability 4. Psychological or behavioral Disability 5. Mental or Leaming disability

visual acuity of any eye or both after using ordinary magnifying lens is equal or worse than 6/18 (20/70) to cannot see even light or visual field is narrower than 30 degrees. Hearing Disability those hearing frequencies at 500 Hz, 1000 Hz or 2000 Hz Visual Disability

average

5.1 Children under 7 year > 40 Decibel cannot hear


5.2 Others >55 Decibels so that they cannot hear or those who have abnormal impairment to understand or use speech language to communicate with the others. Physical or Locomotive disability those who have abnormal or physical impairment so that they can not do their own daily living or loss of limbs, upper or/and lower, or/and part of the body from amputation, paralysis, weakness, diseases of the joints or chronic pain, including chronic diseases of other organs, until they can not live in their normal daily lives as others do.

Psychological or behavioral disability those who have abnormal or psychological or brain impairments that create difficulties in emotion learning or thinking

so that they are not able to control necessary behavior to take care themselves

or live with

the others.

- Mental learning disability = those who have abnormal or mental impairment or


disability (WHO expert committee)

intellectual impairment so that they can not leam by usual methods.


Causes of

1)

2) 3) 4) 5) 6) 7) 8)

Congenital l.l Genetic e.g. mental retardation 1.2 Acquired e.g. wrong medication, intrauterine infection and during labor Infection e.g. Poliomyelitis, Syphilis Non-infectious e.g. locomotive system, back pain joint pain, abnormal bone, muscles, paralysis, heart diseases lung diseases, diabetes, deafness, loss of hearing, blindness, convulsion. Psychosis e.g. depression, obsessive-compulsive neurosis Alcoholism and other drugs addictions Environmental and accidents e.g. water, air and land transportation, warfare Malnutrition during pregnancy and extra uterine period e.g. congenital iodine deficiency Others e.g. toxic substances such as Mercury poisoning, lead poisoning,

Rehabilitation within health care services has traditionally been thought to involve the provision of therapy physical, occupational, and speech as well as special equipment. Traditional rehabilitation services are provided in various settings, for example, special institutions, hospitals, and out-patient clinics. In some countries, these services a.re delivered in people's homes. They are generally not provided in coordination with other services. Community based rehabilitation (CBR) enlarges the concept of rehabilitation to include all of the services that assist disabled people to develop their abilities.

o o . o

Physical therapy (PT) - Treatment by physical agents and physical methods. Examples are heat, cold, water, electric current, ultraviolet rays, exercise, traction massage manipulation, mechanical devices.

Occupational therapy (OT) - A system of medically prescribed activities, typically involving the use of objects to increase coordination, range of motion, power, and function, or for diagnostic, psychiatric, or other therapeutic purposes.
Speech therapy (ST) - Treatment of speech disorders such as aphasia due to cerebral lesions, dysarthria due to local organic lesions, speech defects after laryngectomy and other disorders of communication.

Prosthesis (plural prostheses) - From the Greek, freely translated as "placed instead" Artificial part of the body: tooth, eye, joint, digit,limb, breast, etc.

Orthosis (Plural, orthoses) - General term for a device applied to a patient, usually with a deficiency of the locomotor system, for a supportive, assistive, adaptive, preventive or corrective purpose. This excludes prostheses, which replace missing parts, but includes objects that may be known as braces, splints, collars, corsets,
supports, bandages, or callpers.

l) 2) 3) o

Major strategies for rehabilitation


Institution-basedrehabilitationservices Outreachrehabilitationservices Community-basedrehabilitation(CBR)

Service delivery system for CBR. 4) Community

5) 6) 7)

District Provincial National

Rehabilitationin as social issues

l)

Malfunction Direct services Curative Change PWDs Specialized By professionals Functional recovery

Traditional approach Individual issues

Disability-

- Approach

-services- rehabilitation

CBR Social issues Barrier in Society Social change Promotive Change community General By the community Break the social barriers

Specialists in this study apart from medical staff in special fields also include 1) The pychiatrist is the doctor who will assess the physical ability of the handicap as well as prepare him or her for rehabilitation. 2) The physical therapist rehabilitates according to the physician's order 3) The vocational guidance officer gives information for occupational rehabilitation and make the handicapped person understand their training choices 4) The social worker takes care of individual social, family and community problems and refer cases 5) The vocational training officer gives information and skill training, increases the physical ability and experiences of the handicapped to be able to work 6) The job exploration or job placement officer coordinates with other agencies to find the jobs for the handicapped.

7) Etc.

Model 1. Support team by handieapped people (Project PROJOMO, Mexico)


Rehabilitation team Main roles by handicapped people (supported by rehabilitation specialists) treatment, training, manufacturing equipment.

Sub-center of VRC

Sub-center of VRC

Village Rehabilitation Center (VRC) Supporting lives Mutual aid such as nurturing, The activities of community development

Model 2. Mobile rehabilitation unit Supplementation of C.B.R. Indonesia Community rehabilitation center at every district 3 month services

Suppiementation of the community rehabilitation center Out-reach services by MRU specialist team (Doctors, physiotherapists)

Activities of volunteers, community worken home visits, vocational training.

Independence of the handicapped Including economical independence

Model 3. Community volunteer system (Local supervisor system)

The Philippines

Local supervisor (LS)

Education

Instruction, management, psychological support

Specialists

Families training handicapped people

Specialists give one-week training to the local supervisors who are chosen by the village people

Model4. Volunteer systems with health care centers Thailand


Village health communicator, VHC, role of information giving Village health volunteer, VHV; provision of basic medical services (two-week training and ongoing training) VHCs and VHVs are chosen among the village people

VHV, VHC
Early detection and intervention to the Disabilitv

Handicapped people families

VHV, VHC will detect disabilities and report them to the health center. The health center will bring the handicapped people, their families and volunteers together to collect
information.

6. Research

Results The results are presenting under the following topics: 6.1 Basic statistics 6.2 Community Based Rehabilitation Services (C.B.R. services) 6.3 The Needs of C.B.R. 6.4 Foreign assistance for C.B.R. 6.5 The potential and limitations of C.B.R. models 6.6 Requests to National Rehabilitation Center for the Disabled, Tokorozama,
Japan

Basic Information 1.1 Health situation (1995) * Total population - age >15 - Size of the household * Women headed household t GDP growth * GDP * Life expectancy at birth

10.2
56.3% 5.6

millions.

21.2% 7.6% US$ 289 millions years.

56

) (weight by age) + Immunization of children, age one year, against Measles Polio DPT BCG * Pregnant women immunized against tetanus (T2 +1 Source: Ministry of Health.

* Infant Mortality Rate * Under 5 Mortality Rate * Infant low birth weight * Under weight (under 5

115/1000 live births 181/1000live birth 17% 39.8%

75% 80% 79% 9s%

33%

10

Table L. Main health problems of out-patient consultations by age group at Health Centers, Carnbodia, 1996 Health Problems N
Suspected 18,807

0-4 ,
19.95%

s-14
N
27,508 t82,726

>15
V"
28.60 27.60 29.80 32.20 22.70 23.50 37.00 0.00 26.20 29.08

Total
o

N
47,967 254,591

53.40

94,282
650,846

Malaria
Other Fevers Diarrhea

213,529
I 15,554

32.8t%
31.72%

39.20

l12,20l
148,858 5,381 IJ

t36,541
166,394
15,453
113

37.r0
35.00 63.40 4.40 I 1.80 0.00
49.70

364,296
459,885 24,087

ARI
Coueh

r43,633

31.30%

>2ld

3,253
55

t3.st%
22.82% 42.90% 0.00% 23.14% 29.07%

Polio
Measles Neonatal
Tetanus

24r
2,569
0

1,102
0

1,124
0

343
0

Others

Total

125,389 621,322

143,578 621,449

272,853
894,255

541,820

41.85

2,137,026

Main health problems of out-patient consultations (1996) by age group at health centers, especially those that may result in disabilities like poliomyelitis and measles which still occur in all age groups, even though the government has a policy on polio
eradication. For out-patient consultations in the hospitals (1996) by age group, measles is still prevalent in all age groups. (Tables and Fig. 1-4)

il

Fig.I Main Health Problems of Out-patient Consultations by Age group


Cambodia, 1996
a. Children under 5

at Health Centres

b. Children 5 to 14
OtheF t2%
Suspwted Malaria

B%

c. Adults >15 vears


Susp@ted Malari& t8,/e

Oths FeveB
t3vo

ARI
t2o/o

Source: August 1997 MOH

l2

Table

2 Main Health Problems


0-4
N

of Out-patient Consultations by age group in Hospitalsn Cambodia,1996

Health Problems

5-14
%
12.2 21.5 27.1 24.1 8.6
aa )). a t

>15 %
19.69

Total %
68.06 55.50 50.s3 54.00 79.28

N
17,062
48,1 13

N
58,967

Outpatients
86,635

Malaria
Other Fevers

10,606

44,910

Dianhea

ARI
Cough >21 day
Measles

35,602 76,746
1,922

29,405
69,837

23.02 22.38
21.91 12.13

I16,018
66,409 172,104 17,730 779
18,094

209,041

l3l,416
318,687

2,712
462

22,364
1,873 3,905 33,697 53,461

632
3,905

24.67 24.70

4t.59
53.70

Malnutrition Skin Infection GYN Infection STD (Males)


Others

7,218

21.6

8,322

53,461 57,109 238,713

r00.00
100.00

Total

t2.2 t7.8

73,184 249,097

15.57 18.58

9,939 339,630
853,1 3
1

9,939
469,923 1,340,941

72.27 63.622

For Inpatient Hospitals, the possible health problems which may result in disabilities are meningitis poliomyelitis, measles, mine accidents and road accidents which are prevalent in all age groups. Meningitis is prevalent in almost every province. (Table 5-7)

t3

Fig

II

Main Health Problems of Out-patient Consultations by Age Group in Hospitals, 1996

Othen
24% Cough >2lday

Children under

5
Malaris
40/r

Other Fcvers

lf/o

P/.
Malnutrition
2%

Skin infwtion
40/o

Dimha
lSYo
I

Other Fwrc

t9%

Cough

>2ldry
Skin Infwtion
3yo

llo

Other FeveR t4vo

t_

lo/o

cyn

lnfection 6%

cough>2tfiy 2%,

skin Infection
2%

t4

Table 3

Freguency and Age Distribution of Main Health Problems of Inpatients at Hospitals

Health Problems

0-4
N
o/o

5to
N 4,012
1,742

Totrl
14

>15

Inpatients
o/o

N
14,751 3,505

o/o

Malaria Dianhea
Dysentery

3,013 4,077 941

13.84 43.73

18.42 18.68

67.74 37.59
46.71

21,776

9,324
3,083

30.52

702
3,918 603

))

11

r,440
11,623
53

ARI
Dengue/DHF

7,204
777 408
5

3t.67
54.22

17.23 42.08

5r.10
3.70 25.29 28.57 4.08

22,745
1,433 858

Meningitis Polio
Measles

47.55 21.43

233
7 39

27.16 50.00 39.80

2t7
4

t4
98

55

s6.t2
100.00

Neonatal tetanus
Tetanus

24

t5.29
0.09

29 79

18.47

104

66.24 99.35 100.00 89.29 82.66 77.00

t57
14,250

TB Gyn-ob Mine accidents


Road Accidents
Others

l3

0.55

14,158 19,107

19,r07 2,419
7,222

22

0.91

237

9.80
14.58 13.00

2,159 5,970
50,012

t99
6,494
23,237
r

2.76 0.00

I,053 9,444

64,950
167,442

Toal

13.88

2l,0gg

t2.60

r23,107

73.522

l5
Fig

III Main Causes of Hospitalisation by Age Group,

Cambodia, 1996

I
I

a. Children Under 5
Malaria
136/o

t-

b. Children 5 to 14

Road Accidenh
syo

Mcningitis

Dengue/DIIF

tvr

lVr

Minc accidcnts l'/o

ARJ

't%

TB
tgyo

Road

A@idot!
4vo

Minc rccidenh

Gynob
l5o/o

2'/.

t6

Table 4 : Main Health Problems among In-patients at Hospitals in 1996


Provine
Svay Rieng

0ther
2,648
4,0t 0
5,161

Sholera

DHF
t4
218

dvsent., cyn-ob
51

ARI

mslarir

meningitir
63

AFP

TB
1,t39

Total
6,968

I,1 50

|,t62
1,356

5t2
381

Prey Veng Kandal


Phnom Penh'

t5

469

lr4
120

1,349

)J
23

1,002
1,099

E,750

ll9
4
100

612
470
1,060

886

1,199

144

9,363

8,142 ? tot
2,039

405

zt
430

209 2,320

437

195

203
145

10,086

Kampong Cham Kampong Chhnang Kampong Speu Takeo Kampot


Sihanouk

6l
30

3,052
560 824

a)7
166

1,129 388 404

7,0t 5 4,761 5,469 9,398

297 458 466

t04

I,163
929 745
I,1 26

l4
25

t,965 4,820
3,684

f)

t79
92

630 544

23

|,4',13

74

I,l6l
778 I

106

746
277

t75 6l

|,287
358

I,416
360 903

JJ

9,35l
3,219

Ville

I,891 324

38

2l

zt)
2l

KohKong
PurSat

ll5
215 798 554
364

9l

l5l
1.245 s7

t63

t,113
7,869 16,908 9,E42

2,684
6,813
4,81 I

324

52

lt9
256
221 208

|,t76
2,4't2

|,447

30 152

577

Battambang Bantey Meanchey Siem Reap

JJ

3,7

t,728
382 3,069 655 993

899

49 115 98

222 69
29
11

|,002
683 913 229
633

I,503
1,608

t20
42

978

4,787

t,w2
877 102

t2,u7
7,765
3.563

Kmpong Thom
Preah

3,418
1,126
3,283

379 432
401

r36
80

|,244
564 869 203

l6
20
IJ

Viher

Kratie

52

lll
62
100

2,40s
883

tt2
4

7,880

ltung Treng
v{ondulkiri

9?7 120 822

l0t

t93

6 251

2,432
1,491

2t0

t20

661

29
J

tattanakkiri (ep
Rubber Plantation

t0l
39 450 764 t,433

7l
l 270 3,083

7l
5

l8l

829

66

2,t44
273

lt6
|,254
72,087

7l
89'l 22.745
I

245

^875

4,997 t64,225

Iotal

9,324

19,t01

21,776

858

t3,045

* Not including data from the National Hospital


Tuberculosis : Data from National Commitee of Tuberculosis (lnctuding PT, Extra pT and TB with BK-) KEP is including in Kompot for tuberculosis data Plantation is including in Kampong Cham for tuberculosis data

l1

Table 5 : Number of Cases, Causes of Death and Case Fatility Rates at the IPD

Health Problems
Malaria Dianhoea Dysentery

Cases 2177C

Deaths
764
86

CFR%
3.5 0.9 1.4

9324
3083 22745 1433
858

42 554
73

ARI
Dengue/DHF

z..l
5.1

Meningitis
Polio
Measles Neonatal tetanus

t47
c

t7.l
c
a z

t4
98

2 2

28.6

TB
Suspected Acute Severe Diarrhoea

|42sA 764 t9107 2418


7222 64343

232

t.6 2.4 0.4 4.7

l8
68

GYN-OB Mine Accidents


Road Accidents
Cthers

lt4
143

1523

2.4

* Not including data from

the National Hospital

Top ten causes of death: malaria, ARI, TB, meningtis, road accidents, mine accidents, dianhea, DHF,

GYN-OB and dysentery. The case fatility rate is highest among neonatal teanus28.6%o followed with DHF 5.lolo, mine aecidents 4.?%o,malaria3.So/o,others and suspected acute severe
diarrhoea and

AN

2.4o/o

meules and road accidents

2o/o

(Table

y)

l8

Table 6 : Main Causes of Hopitalizationn Number of Cases and Death in National Hospitals i

Causes

MCH
Cases

NPH
Cases

CALMETTE
Death
Cases 27

KOSAMAK
Cases

NORODOM
Cases

Death

Death
2
15

Death

Death
28

Malaria

394
3,31 I

ll
240

\)
1,728
1,622

l9l
4
61

ARI
Diarrhea Cholera

99 6

76

74

934

I l8

89

t I

2t
687

2 z

Iyphoid Fever
Dysentery Dengue Fever

984
89

14l

39

134

t9l
402
24

t2
9

l3

343 76

)
54 87

t9

Meningitis
Acute Flaccid Para,

ll0
I9

t7
2

tt

t2

ll
2
30

4l

AIDS
Traffic Accidents Mine Accidents
Others

30

217 545 1,194


140

t4 It

7l
5

t23
T2

5t
I1,619
17,688

3,552
299

9,068

2,660
I

4,714
77

Iotal
Note:

8,476

r39

r0,396

l8

4,t08

5,412

49

MCH : Matemal and Child Health Hospital


NPH : National Paediatric Hospital

t9

1.2 Competent authorities on health services of principle organizations and collaborations.

Health Care is the responsibility of the Ministry of Health, except for the care of Ministry of Social Action as well as under the Ministry of Defense and the Ministry of the Interior. Occupational health is under the Ministry of Industry and plantation workers and farmers are under the Ministry of Agriculture.
the physically handicapped which is under the responsibility of the

The national health system is organized into four levels: central, provincial, district and commune levels.
The Ministry of Health funds and directly administers the following central institutes and hospitals: . The National Malaria Center (CNM) o The National Center for Hygiene and Epidemiology (CNHE) o The National Tuberculosis Center (CENAT) o The National Institute for Public Health (newly established) o The National Center for Maternal and Child Health o The Center for Venereology (STD) Training Institutes o The Faculty of Medicine, Dentistry and Pharmacy. o The Ecoles des Cadres Sanitaires Secondaires (ECCS) o Four Regional Training Centers

Hospitals:
Calmette Hospital, Preah Naredom Sihanouk Hospital, National Paediatric Hospital, Preah Kosomak Hospital (17 April) - surgical, December 2 Hospital -ENT and National Blood Transfusion Centre (CNTS), January 7 Hospital - women, Kuntha Bopha Hospital - children.

There are 19 provinces, 2 municipalities and 176 districts. The administrative organization of the provincial and district health system follows the central administrative system. In each province and district there is health service. It is headed by the provincial director. The Department of the Health Services at this level are similar to those in the MoH which include pharmacy, a hygiene and epidemiology station, planning and statistics, finance and budget, and administration. At the district level, there is a District Health Officer, responsible for both curative services at the district hospital and health services in the communes and villages of the district. At this level, there are also officers responsible for various programs, i.e. malaria, tuberculosis, maternal and child health.

In 1995, the MOH approved a new health system for the organization of provincial, district and commune health services. This was based upon a redefinition of the criteria for the location of health facilities together with a definition of a basic minimum services package to be offered at each level organizedby the Ministry of Health. This Plan entitled the health coverage plan to be based upon equitable geographical access to basic health and referral services for the population in order to optimize the allocation of scarie health resources. At the prouinriul level, this will

20

result in two levels. The first level is a provincial level and the second level is a referral system which is based upon the health centers surrounding a referral hospital. Low levels of literacy and of awareness of the basic principles of health and hygiene, including child care, prevent people from making the right decisions to order to avoid or to manage health problems. In addition, the absence of reliable information to assess public health problems stands in the way of effective action to address them.

Human resource situation


1975-79 the Pol Pot regime devastated the Cambodian professional classes, including health professionals. Only 50 medical doctors remained after the fall of the Pol Pot Regime. To fill in the gap of health human resources, in the early 1980's a "creash course" training was provided, mainly focusing on curative care. The poor quality of this training partly explains the inadequate technical capacity of the public health services today. There are currently 23,270 health workers at all levels who are employed by the MOH (17,964) as well as other government agencies. Two thousand of these workers were trained at the border camps. The various categories of health workers include 1,201 medical doctors, 1988 medical assistants, 47 dentists, 321 pharmacists,3,l06 secondary nurses and 1,316 secondary midwives.
Expanded programs on immunization, pharmacy, etc. to provide staff for health care in the hospital were put into place. The number of staff at this level range from 15 persons to more than 30 in larger districts

In

At the commune level, there is a cornmune committee in which one member is given responsibility for health matters. This committee is responsible for appointing three health workers: a primary nurse, a primary midwife and a tradiiional healer. Traditional birth attendants exist within communities and additional training has been taken on by non-governmental organizations. However, there is no formal strucrure for their integration into the regular health system. Now, the Ministry of Health is undertaking a process of rationing health services resources in the district/ commune levels, basing this on population size rather than strictly administrative boundaries.

1.3 Health Policies and planning:

the present policies by central and

local governments The Royal Govemment of Cambodia (RGC) affirms its mission to improve the health and well-being of all Cambodian people: 1) The RGC recognizes both public and private health care systems; 2) Giving special attention to health education, preventive and curative health cares for people living in the rural areas by organizing health centers and maternity services; 3) Reducing infant and maternal mortality rates through mother and child health care; 4) controlling communicable diseases, especially malaria, tuberculosis, dengue haemorrhagic fever and acute respiratory infections; 5) controlling the spread of sexually transmitted diseases, especially

HIV/AIDS;

6) Improving the supply

and distribution of drugs for people,

if possible, by

2l

organizing local drug production using local raw materials; otherwise by better management of international tendering, procurement, importation and distribution.

After developing the health policy and strategy, the Ministry of Health had a longterm perspective in developing the health services in the country. Significant investrnent by the govemment and its partners has been made in the development of both policy as well as the management and planning capacity within the MOH. At the end of 1995, the new health coverage plan for the provincial and district levels was also formulated. Additional investment has been made in a number of priority health programs, with varying degrees of success. In the implementation of the National Programs for Rehabilitation and Development, the Royal Government chose the Ministry of Health to be a pilot ministry in the reform and the development of the health sector. This is guided by the overall public administrative reform program.
The reform process contains 5 specific components: Strengthening the management of the health system, - Developing a new health information system, - Human resource development and health government staff management, - Resources coordination, - New health financing mechanisms.

The overall aims of MOH are to: 1. Meet the critical needs of the people, especially in health education and promotion, preventive and essential curative services, particularly for those living in rural areas. Provide a cost-effective standard of health care for women and children, especially through immunization, birth spacing, antenatal care, safe delivery, essential obstetrical care and essential clinical
services. Reduce the burden of communicable diseases, especially malaria, tuberculosis, STD/HIV, dianhoeal diseases, acute respiratory infection and dengue haemorrhagic fever. 4. Monitor, coordinate and distribute equitably the resources from international and non-governmental organizations. Ensure sustainable development with considering ways to generate revenues at the communitv level.
a J.

Health policies and strategies are designed to develop an affordable and rational health service that will meet priority health needs as well as to ensure access to these services by the majority of the people of Cambodia, particularly those living in rural
areas. They are:

Extend basic health care services based upon a cost-effective, but essential minimum package of curative and preventive health services covering all communes in the country; a system that will be based on the "District Health System Approach" which is successful with community participation;

22

o . o o

Promote women and child health through birth spacing, good nutrition and hygiene practice within the family through the improvement of the delivery of essential maternal and child health services; Reduce the incidence of communicable diseases, particularly malaria, tuberculosis, sexually transmitted disease and HIV, diarrhea, acute respiratory infections, diseases preventable by immunization and dengue fever; lmprove the quality of hospital services in Phnom Penh and at the peripheral level; Upgrade the professional capacity of government health staff; Ensure an adequate and secure supply of drugs throughout the health system; Ensure the full participation of both private and public sectors in the delivery of health service and appropriate regulatory frameworks to raise service standards.

OVERALL OBJECTIVE OF'THE RGC IN SOCIAL DEVELOPMENT

1. 2. 3.

Reduce maternal mortality rateby 40Yo Reduce child mortality rate by 30% Reduce prevalence of malnutrition by 50%
2OOO

TARGET FOR THE YEAR

Despite the immense health problems, some progress of strategic value has been made in recent years. Immunization services are now increasingly available. Although inadequate to meet the need, a basic supply of essential drugs reaches even the remote commune health centers. District and commune level health services are already operational in some areas. The first steps are now being taken towards reviewing how basic health services, e.g. Minimum Package of Activities (MPAs) for Health Centers can be accessible and available at the community level.

1.4 Actual Conditions of people with disabilities As it has been mentioned earlier that the last actual census was done in 1964, since then there has not been another census and the current statistics are very poor. No nation-wide statistics have been collected. Data is primarily obtained from the hospitals, institutes and health centers. For disabled persons, data mostly comes from only those who come for services with the govemment or NGOs' Thertefore, it should be recognized that the statistics come from estimations which may result in under-estimations. In 1994, the American Red Cross, the National Rehabilitation Seminar, the Ministry of Social Affairs, and the Labor and Veterans Affairs reported that there out of a population of 8,830,176, there were 21,192 amputees, 7,947 paraplegics or tetraplegics,17,66a persons with polio, 3,532 hemiplegics, 16,777 deaf people 2l,lg2 blind people, , 1r,479 mentally handicapped, and 1,766 lepers and an additional 22,075 vnth other disabilities totaling 122,739 disabled persons.
Four principle surveys have been done using the ICRC survey instrument: Phnom Penh, Bantear Meanchey, Kompong spen and Kampong Som. These were conducted by ICRC/MLSA (first two), Am RCA4LSA and CT. Comparisons will only be considered for the results from the first three surveys because coverage data is available. The Phnom Penh needs assessment was known to include IOO%

of all known groups, sub-districts, and districts surveyed in the Phnom Penh urban area. The Kompong Speu needs assessment surveyed 99J% of known villages at the end of 1992. The Banteay Meanchey needs assessment was conducted in only 82% of the known sub-districts (Khums); 18% were
inaccessible due to logistic and security problems.

From the analysis of the various surveys, the results of numbers of disabled people in Cambodia are as follow:
Table 7 : Total number of Disabled People in Cambodia Area Phnom Penh
612,315 7,191

Banteay Meanchy
350,000 4,273

Kompong
Spen

Kompong
Som 40,000 1,000

Pursat (one

district
only)
86,000

Population No. of disabled people

465,73r 8,252

1,320

Source: AmRC Rehabilitation Survey, American Red Cross and World Vision The ADD report cited the following comparative statistics concerning each of the identified disability groupings: amputees, blind, polio, mental health, deaf, paralysis, leprosy and "other," using statistics from ICRC/IV{LSA, AmRC, and cr.2' From the figures of ICRC/Ir4LSA and AmRC, a projection of the number of disabled people have been made (see Table 4) using the average of l.39Yoof the total population being disabled. From this percentage, and using the most recent population figures from NIS, it was estimated that there are approximately 136,000 disabled people in Cambodia.

Blind
There are currently 90,000 blind people in Cambodia,60Yo caused by cataracts. Other causes are glaucoma(10%o), corneal scar (10%), and others (20%o).22 There are also

many people with refractive errors that are not corrected by reading glasses due to lack of funds. Amputees
Statistics given of the prevalence of amputees in Cambodia differs according to the criteria for inclusion, and the sources of data used for the estimation. A report by Physicians for Human Rights and Asia Watch23 reported at the end of l99l that the prevalence of amputees is at 36,000 with 120 new amputees arriving every month to P & O centers to seek treatment.

Recently, ICRC reported that there are approximately 20,000 to 25,000 amputees in Cambodia now, with 100 new amputees each month.to This projection is tased on records that were available at the Mongol Borei Hospital, Banteay Meanchey

24

Province from 1 January, t994 to September 30, 1995 (a 2l-month period). Total mine injtrriesAJXO victims for that period (soldier and civilian) were 567 (or 27 victims a month on average). Out of this number,240 victims required amputation (42.3% of total), 84% lower limb amputation in 1994 as opposed to 80% in September 1995; upper limb amputation was l6Yo and 20% for 1994 and 1995 respectively. The ICRC statistics is only based on the number of hospitalizations due to mine injuries. The breakdown of military and civilian for this period was about 2 to 1.25 According to the most recent reports of MAG, from the period of June-August, 1995 (three month period), there were 156 mine victims in Battambang, 129 people in Banteay Meanchey, 98 in Kompong Thom giving a cumulative number of 383 for that period. As a comparison, ICRC showed that for the same period, there were 30 mine victims requiring amputations admitted at the Mongol Borei Hospital in Banteay Meanchey. ATnRCA{LSA estimates that there are 21,194 amputees, excluding retumees, by using the average percentage of amputees found in the Phnom Penh, Banteay Meanchey, and Kompong Speu surveys, with an additional minimum of 200 new amputees per month nation-wide, especially during the heavy conflict periods.26

Mental Illness From extrapolation of figures from three surveys, it was found that 0.13% of the population was mentally ill. As the surveys did not include psycho-social problems as a criteria formentally illness, it is difficult to assess the prevalence of psycho-social trauma brought about by years of civil unrest, the genocide of the Pol Pot regime, and the uprooting of massive numbers of people during times of conflict that has plagued Cambodia for the past three to four decades.
Polio
There are approximately 20,000 people with polio in Cambodia,

with varying degrees of disability severity. Statistics from a report by Redd Barna showed thatbetween2454% of disabled children in Cambodia are suffering from this condition.2t The AmRC survey cites a figure of 77,660 people with polio based on their projections.
Deaf
Deafness is one of the main causes of childhood disability. In surveys that have been conducted in a few provinces, 0.19% of the population were found to be deaf, Among those disabled in Cambodia, between 10-19% are due to deafness. The main causes of deafness are untreated ear infections, complications from measles, and congenital

deformities.

Paralysis Using data from three provinces, it is estimated that 0.09% of the population are para/tetraplegics, and0.04Yo are hemiplegics. Between 6 13.2% of disabled persons have paralysis. The causes for paralysis varies; among them are spinal cord injuries

25

due to bullet wounds, falls and stroke, congenital deformities and other types of injwies. Table

8 Fina classification of confirmed oolio


District
Ramduol
Svay Reang (PT) Romeas Hek

cases Par
I

bv district of residence
Death
0 0 0 0
0 0 0

Province
Svay Rieng

witd
Virus
0 0 0

Residual

Lost to F-up
0 0 0
0 0

Total
I I
2 2
1

I
2

Pray Veng

Kg. Leav
Komchay Mear Kanh Chreach
Mesang Peam Ro Preah Sdech

I
0 I 0 0
0 0
0

I I
1

I
0

2
0
2
1

Sithor Kandal Kandal


Khsach Kandal

Muk Kampoul
Ponhea Leu
Saang

I
2 0

I
1

Phnom Penh

Chamkar Mon Don Penh

ToulKork
Kampong Cham
Rusey Keo Batheay

0 0
2 0

2 0

I 0 0 0 0 0 0 0 0
0 0 0 0

0 0 0
0

)
1

I 2
I

I
0 0

2
1

I
0 0
0

2
J

I
2

I
0

I
J

I
2

Kg.Siem Kang Meas Memot Krek Kampong Chhang Kampong Speu


Baset Phnom Sruoch

0 0

2
I I

0
0

I
0 I
0 0

0 0

0 0 0 0

2 I

I
I
0

I
0 0

0
0 0
0

I I
0 0
1

Takeo

Oudong Bati

I
0

I
0 0

Angkor Borey
Kampot
Sihanouk Ville

0 0
0

Angkor Chey Mittapheap Prey Nup

I
0 0

0 0 0
0 0 0

I
I

0 0 0 0 0 0
0

Koh Kong
Pursat Battambang Banteay Meanchey Siem Reap

Krakor
Bakan Battambang (DC) Smach Meanchev

I
0

I
2

0 0 0

2
2
2

0
0
0

2
0

Kampong Thom

Thmar Puork Chi kreng Barey


Brasat Sambo Stoung

0
0

I
0
0 0

I 0 0
0

I
I
2

z
0 0 I
I

0 0

I
0 0 0 4

0 0 0 0 5

l
0

Preah Vihear

Kratie
Stung Treng

Chhloung Kratie Thala Bariwatt

I
0

I
I

I
0

Mondulkiri Total

l5

37

6l

Source: EPI

26

Table 9
No.

Mine and Road Accidents in 1996


Province Mine Accidents
Cas 9
60
6

Deces
0
a

Road Accidents Deces Cas

I
2.
3.

4.
5. 6. 7. 8. 9.
10.

n
t2.
13.

14.
15. 16.

t7.
18.

19. 20.

Svay Rieng Pray Veng Kandal Phnom Penh Kampong Cham Kampong Chhnan Kampong Speu Takeo Kampot Sihanouk Ville Koh Kong Pursat Battambang Banteav Meanche Siem Reap Kampong Thom Preah Vihear Kratie Stung Treng

n5
355 652
23

2
5

0 0
10 0

t34
84

996 393
511

0 24

u
t4
a J

92 22

I
0
a

580

tt2
34 42 84 608 405 408
155 115

0 2 J

721 330
85

10

27 2

3l
19

260 564
351

)
l4
I2
I
4 0

34
6 0 0

526 394
54
178

2l
5

2 I
0

29
J

2t.
22. 23.

Mondulkiri Rattanakiri
Kep Plantation

9
0 0
13

I
0 0
0

38
5

2
0

59
71222

2,418 Source: Planning and Statistics Unit

Total

tt4

r43

1.5

The Administrative Division of the Rehabilitation Services: relationship among administrative organizations and work responsibilities schedules

The Ministry of Health's role is primarily concerned with curative and preventive services in regards to disabilities. The Ministry of Social Affairs, Labor, and Veteran Affairs (MSALVA) has responsibilities concerning rehabilitation also but due to budget constraints, most of the work is done and paid for by 35 NGOs (see annex in Sept. 1995 of the Directorate). The Social Affairs section of MSALVA initiated a joint minishy-NGO process to develop a common strategy for the continuation, development and coordination of appropriate programs, services and support for disabled people. There were six essential steps as follow: 1. Formation of Task Force 2. Assessment of the current situation of the sector 3, Generation of Guiding Principles 4. Analysis of information and identification of main issues 5. Prioritization of the main issues 6. Development of recommendations and action plans

27

Five sub-committees met regularly, following the guidelines developed by the Task Force coordinators. Once a month, one representative of each sub-committee, representatives of the four largest NGO's, the executive director of the Cambodian Disabled People's Organization, several other resource persons, and MSALVA representatives from several departments (approximately 25 people) met to review the progress of each group, bring up topics for discussion, and keep everyone mutually
informed. Development of the Guiding Principles was a crucial step for the Task Force. The 14 statements are meant to guide the sector, so that all programs and activities move forward in the same direction, rather than working at counter-purposes, as is possible when 35 agencies have the same target group.
The main issues identified by the sub-sectors are:

Children with Disabilities o Prevention of primary and secondary disabilities o Integration of disabled children into mainstream education and society o Parent and caretaker education on disability issues o Advocacy for disabled children's rights o Services for orphaned and abandoned disabled children o Coverage, sustainability, and sub-sectoral participation Community Based Work with Disabled People (CWD) o Adherence of programs to the Guiding principles o Expanding geographic coverage and all ages and types of disabled people o Training Rehabilitation Workers to be generalists r Sustainability of the programs o Development of a national CWD strategy
Prosthetics and Orthetics o Staffing issues: improving the skills of technicians in hiring and salaries based on merit o Quality of services: establishing minimum standards and bringing each workshop up to that level o Sustainability of the services o Coverage and avoidance of overlapping, duplication, and competition for clients o Participation and cooperation within the sub-sector Blindness and Visual Impairments o Training of Rehabilitation Workers in skills necessary for helping rural blind people o Increasing public awareness of the capacities of blind people o Education of blind children and their eventual integration into normal schoois o Low vision verses blindness and the different interventions required o Empowerment of blind people through association o creating links with other ministries for comprehensive services

28

Vocational and Skill Training r Evaluating and developing appropriate pre-training activities o Improving the quality and range of skills taught o Sharing successful methods in post-training follow-up among NGO's o Effectiveness of the programs in leading disabled people into the work force o Integrated verses segregated training for disabled people Sub-sectoral issues: projected needs, cost effectiveness. Coverage, MSAVA responsibility and capacity
The Ministry of Industry and the Ministry of Education also have responsibilities in rehabilitation. MSALVA, in collaboration with NGOs, has established the Disability Action Council (DAC) as a coordinating body to enhance the effectiveness and the sustainability of the programs for disabled people among the many involved NGOs and ministries. Agencies need to contact MSALVA and DAC before starting or canying out new services for disabled people. Ms. Helen Pitt has been appointed the Executive Director.

At the MSALVA, the Department of

Rehabilitation has responsibilities in administering, implementing, managing and following-up the policies and programs of the Royal Government conceming the rehabilitation sector and vocational rehabilitation. It also has a role in the integration of the disabled into the community, ensuring that disabled people have equal rights of obtaining social, economic and
cultural benefits.

k
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RI

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32

1.6 Specialists in rehabilitation fields : kinds of specialties.


Specialists in rehabilitation fields

* Orthopedic Surgeon * Eye specialist * Physiotherapist

* Social worker * Educators


*
Nurses

Psychiatrist

1.7 Main organizations of C.B.R.

MSALVA is the main organization responsible for C.B.R. but because of its very limited budget, MSALVA can only coordinate with the NGOs that are doing the communitybased rehabilitation and/or out-reach programs. (Annex: A)
Community- Based Rehabilitation Services (C.B.R. Services) Mine victims appear to receive much attention from the NGOs which have centers for orthotics and prosthetics. This is followed by eye disabilities and deafness as there is a school for the blind and vocational training. The mentally disabled and the elderly appear to receive less serives and are just beginning to be established. There programs are listed as follows:

ADD AFSC
ALIMCO

AMDA AmRC cDPo

AAR.CC

APHEDA

CFDS CMAC CT
CIOMAL

Community-Based Rehabilitation (K. Speu) National School for Prosthetics and Orthotics. NSPO (Phnom Penh) Community-based program in Kompong Som Prosthetics and Orthotics Workshop (K. Thom (planned)) Mental Health Project (Phnom penh) P&O workshop (Kompong Speu) Vocational Training Vocational Training Center (Kien Kleang) Wheelchair Manufacture and Distribution (Kien Kleang) self-Help Group of disabled people in cambodia, Advocacy for disabled persons (Phnom Penh) Social work for vulnerable families Mine Clearance and Mine,A.wareness Programs (Battambang and Kompong Thom) Calmette Limb Center Sihanoukvillage Limb Center NSPO (Phnom Penh) Community-Based Rehabilitation (Kompong Som) National Leprosy Control Program (Phnom penh)

JJ

COERR CWDA DPI ECCS FFAC FSUN HT HI


COFRAS

Skills Training Projects Prosthesis Proj ect (Sisophon) Demining Operations (Siem Reap) Vocational Training Support for CDPO, advocacy for Disabled Persons (Phnom
Penh)

HKI
HELPAGE

IPA/VAF

ICRC IOM IPSER JSRC JRS KCDI

School of Physiotherapy (Phnom Penh) Handicapped Children Program (Phnom Penh) Prosthetics Workshop (Phnom Penh) De-mining Activities (Siem Reap, Banteay Meanchey, Pursat) Prosthetics (Six Provinces), wheelchair production and distribution, and Foot Factory Center for Spinal Cord Injuries (Battambang) PRES social and economic rehabilitation (8 provinces) National School of Physiotherapy Sports for disabled persons Support for CMAC Primary Eye Care program Vitamin A Nutrition Programs (integrated with NID 1996) CambodiaOpthalmicProgram(Battambang) P & O & Feet Workshop (Kien Kleang) Wheelchair Production (Kien Kleang) Outreach Program (Prey Veng, Kandal, Stung Treng, Rattanak Kiri)

P&OWorkshop(Battambang) P & O Component Factory (Phnom penh)

MLI MDM MED MAG

Medical residency in Psychiatry @hnom penh) Community-Based Mental Health program (K. Speu) Vocational Training Center (Battambang) Handicapped Training/Outreach program (Kandal) Wheelchair Production, distribution and follow-up community-Based Mental Health project, REACH (Resource Education and Community Healing) Cultural programs Khanta Bopha Disabled children's medical services (phnom penh) Hospital Krousa Thmey School for the Blind Maryknoll Community-BasedRehabilitation(phnompenh,Takeo) Blindness Program (CBR) (Phnom penh) Wat Than Skills Training (Phnom penh) Mental health program (Phnom penh) Surgical assistance-plastic surgery (phnom penh) Support to Eye Units and Eye Camps Mine Clearance and Mine Awareness programmes Mine Victims Surveillance System (Battambang)

KBS

34

NCDP
Rehab SER

Craft VANTS SAO SKIP TEHO UNDP UNICEF


UCC Wat Than

Resource

Rehab Center
wHo
WVI

Center and Handicraft Retail Outlet (Phnom Penh) Handicraft Production and Sales (Phnom Penh) Vocational Training (Phnom Penh) SCOPE Eye Care Program (Phnom Penh) Vocational Training (Pursat) Vocational Training (Phnom Penh) Trust Fund for De-mining Technical assistance Education, Children and Women Services support Funding for capacity building projects Expanded Program on Immunization Vocational Training Handicraft production Skills training Physiotherapy Literacy (Phnom Penh) Polio Eradication Program Expanded Program on Immuni zation (country-wide) Vocational Training Center for Disabled Persons Extension Program (Battambang)

35

Distribution of Services for Disabled Persons bv Province


Table 10 : SERVICES FOR DISABLED PERSONS BY PROVINCE
Provinces/

Municipality

P&O Workshop/

Comm. Based

Vocational

Eye

Paralysis
Centers

Rehabilitation

Training
Centers

UniUVisual

Hand CrafU
Income

Fitting
Center

Impaired

Generation

Svay Reng Prey Veng I


see P.P.
a J

I
2
J

Kandal Phnom Penh K. Cham K. Chhnang

I
5

K. Speu
Takeo

Sihanoukville
Pursat

Battambang Banteay Meanchey Siem Reap K. Thom


Preah

I I t I I I I I
I
2

2 2 I I 2 2
2

I
I

Vihar
I

Kratie
Stung Treng Rattanak Kiri

I
I

Mondul Kiri Kampot Koh Kong

SELF-HELP GROUPS AND LOCAL NGOs


The importance of the participation of local groups in advocating for the rights and provision of services for disabled people could not be over-emphasized. Closer collaboration of local self-help groups with the govenrment would allow for better coordination of programs and ensure that the needs of disabled persons are truly met at all levels. Strengthening the capacity of local initiatives will also improve the sustainability of programs and services that are currently being provided to disabled persons in
Cambodia.

36

Policies for people with disabilities

The actual written policies are not available since the MSALVA and the partner NGOs have just finished the formation of their task force and recently appointed Ms. Helen Pitt as the executive director of DAC. The policies will be produced after the next workshop. Cunently there is only a sunmary of recommendations which were presented by the MSALVA Task Force and DAC on Disability Issues. (See Annex A) The Ministry of Health focuses their policy on prevention, which include the eradication of poliomyelitis, the reduction of vitamin A deficiency, the reduction of the severity of ear infections as well as out-reach to the community to provide both curative and preventive services. A more important policy issue concerns personnel development in all specialized fields dealing with preventive, curative and rehabilitation of disabilities, such as orthopedists, eye specialists, ENT specialists, general surgeons and nurses in special fields. However, there are limitations due to budget constraints in the areas of activities, materials, facilities and equipment.

II.

The present conditions of medical rehabilitation

As mentioned earlier, the government has budget constraints as well as a lack of facilities and services. Thus, most of the medical rehabilitation is being done by the NGOs (see Annex B; names, position and address are in Annex C). The government has interviewed concerned persons regarding policies and planning in the area of medical rehabilitation but limitations still exist.

Ministry of Health - Results of some interviews: Interviewee: Dr. Eng Huot


"The Ministry of Health (MOH) is cooperating with MSALVA and NGOs concerning the rehabilitation of the disabled and is focusing more on curative and preventive matters. At present, the MOH is at the stage of reforming - the needs are emergency support health centers and for hospitals to improve their referral system. For community-based rehabilitation, the needs are the training of first aid to volunteers, women's groups, and the Red Cross as well as the training of TBA on EPI and delivery. The most common causes of disabilities are mine accidents and road accidents; polio, Japanese encephalitis and birth trauma also are cornmon problems. EPI coverage is at 70-8A% but for Encephalitis it is very low - as low as only 2-3%. The Cambodian government's policy is to eradicate polio but last year there was no budget for either this or for encephalitis. Thus, there are also budgeting needs for EPI.."

5t

Interviewees.

Dr.Mao Tan Eng.


Dr.Seng Rattana

Dr.Prak Piseth
"The Ministry of Health is concerned with the disability matters focusing on preventive and curative services. The MOH is reforming to improve the quality of services by setting up and improving the referral system in the local communities, the health centers, and the provincial hospitals. The most common causes of disabilities are mine accident, around 300 - 400 cases/month along the border, and road accidents. For rehabilitation of mental disorders, visual disorders and elderly there are no actual statistics. There are subcommittees taking responsibilities on these matters under MSALVA and the NGOs. Basic statistics are in the reports of 1995. In 1996, they were given to the interviewers."
The needs for C.B.R are:

Budget

for: - Training personnel at all levels, especially specialists


- Refenal system - Transportation

Needs for Team Training:

Basic Surgery Surgeons Orthopedists Psychiatrists Anesthesiologists Improving the entire referral system Surgeons for each health facility Eye C.B.R. Situation

At present in Cambodia, there is only one trained ophthalmologist, 22 eye doctors and 60 nurses providing eye care, the majority of whom have undergone practical training in ophthalmology in the country, where there has been no training program. A few have been trained for short periods in other countries such as Vietnam. Some eye doctors had attended surgical training update courses. Also, nurses have been trained as ophthalmic nurse trainers in Thailand with the support of CBM. Eight optometrist technicians and dispensers have been trained by Southeast Asian Outreach 4 in Phnom Penh, 2 in Baffambang, and I each in Svay Rieng and Prey Veng provinces. Health Center staff have
been trained on primary eye care.

There are only 7 functional eye units country.

in 5 provinces out of 22 provinces in the whole

38

Cunent statistics showed that there are an estimated 25,000 outpatient consultations for eye cases in all of the eye units in the country (1996). The cataract surgical rate has increased from 67 cataract operations/million population per year in 1993 to 280 in 1996, including out-reach eye care services. The common eye diseases seen in eye clinics are age-related cataract/aphakia (26%), conjunctivitis (16%), diseases trauma/eye injuries (9%), trachoma (8%), corneal abnormalities (7Yo), pterygium (5%), glaucoma (5%), reading problems (5%), and posterior segment problems (4%). Surveys conducted by Helen Keller International in various provinces in Cambodia in 1993 showed that vitamin A deficiency is a problem. However, vitamin A distribution has been incorporated into the national immunization days organized by the EPI program of the MOH. Helen Keller International and Help Age International have been involved in the training the trainers, health center staff and village volunteers in the provinces. About 350 health workers have been trained in Kandal and Battambang provinces. International Resources for the Improvement of Sight (IRIS) and the Mekong Eye Doctors in various provinces have supported extended outreach eye care services by their guidance. These services will be implemented by various NGOs.
There are a number of private eye care clinics, including optometry clinics, which are located primarily in Phnom Penh and a few in the provinces. These clinics are run by either local doctors/nurses or expatriates from neighboring countries. Only a few are equipped with the modern facilities.

National Sub-Committee for Prevention of Blindness


The National Sub-Committee for the Prevention of Blindness of the Ministry of Health was established in 1994 as part of the MOH coordinating committee. Its role and responsibility is to develop a National Plan for PBL and to provide technical advice to the Ministry of Health in implementing the National Plan.

In 1995, the National Sub-Committee for PBL launched a drive in its PBL activities. With assistance and advice from expatriate ophthalmologists, who are working in Cambodia, and WHO PBL consultant from WHO regional office, the National Sub-Committee has developed a master plan and its first five years plan of action for PBL in Cambodia. All of the major actions in the plans are integrated into the Ministry of Health's national health
coverage plan. The master plan of action and the national plan for eye care development in Cambodia aim to provide eye care services in each region of Cambodia and to reduce blindness to less than 0.5% prevalence by the year 2005. Human resource development is considered the top priority in these plans. In addition, the plan also covers the development of facilities/ materials, sourcing of financial resources, management and specific control of locally endemic diseases for the different levels of eye care. The strategic approach to implementation is based on an integration of primary eye care (PEC) into primary health care (PHC). The Ministry of Health, provincial and district health authorities and the

39

National Sub-Committee for PBL, with assistance from Ios and INGOs would play an important role in the implementation of the plans.

To this end, various workshops has been organized in the prevention of blindness to stimulate interest among the policy makers and the population. It is hopeful that PBL is gaining increased priority and attention within the Ministry of Health.
as well as a standard list of equipment and supplies for the various eye units have been developed. A treatment guideline for eye diseases within the health centers and referral hospitals has also been developed. An eye care information system for monitoring and supervision of PBL activities is cunently being developed. The national sub-committee has been in the forefront in these activities, especially in aid coordination and is a model for other MOH sub-committees.

A national essential drug list

In the past, WHO had sponsored the activities of the sub-committee. Currently, a "blind fund" had been set up by the various NGOs involved in eye care in the country to support the office of the national coordinator for PBL since there is limited funding of the national sub-committee for PBL's activities from the MOH. This fund has provided for the administrative and other linancial costs incurred by the office in its work of coordination and monitoring of eye care activities in the country.

International Non-Governmental Organizations Involvement


Cambodia.

in Eye Care in

There are currently several INGOs involved in eye care in Cambodia. This includes Christoffel Blinden Mission, Help Age International, Maryknoll, Mekong Eye Doctors, Helen Keller International, and IRIS (International Resources for the Improvement of Sight). Several other INGOs have expressed their interests in working in Cambodia.
The presence of INGOs can be traced back to the period of war within the country and has been not only in rescue operations involving emergency surgery, but some organizations have engaged widely and deeply in particular areas like training basic eye doctors (BEDs) and basic eye nurses (BENs) and in rehabilitation. They have been working side by side

under mutual coordination of the national PBL coordinator and the MOH to implement their different programs. They have also been deeply committed to continue ro promore and assist in the implementation of the major actions in the master plan for eye health development in Cambodia.

Most of the NGOs are involving in community eye care, prevention and training in different provinces. Supporting manpower development such as doctors and nurses to be trained in Thailand, India, Japan and other countries.

40

The Needs of Eye C.B.R.

Future Eye Care In Cambodia


The main objectives of the master plan and the first five year plan of action are to provide basic eye care for all Cambodians, to eliminate locally endemic blinding conditions and to reduce avoidable blindness to less than 0.5% by the year 2005. To achieve these objectives, the following priority action programs are planned provided that support is available:

Manpower development

o o o . o

Training Training Training Training Training

of Ophthalmologists of basic eye doctors of basic eye nurse eye care personnel in refraction and orthoptics of health workers in primary eye care

Facilities development

o . o o

Establishment of eye units in the provinces Provision of standard equipment and instruments for eye care Establishment of an optical workshop Establishment of a national eye center for training and research

Management and specific control of locally endemic diseases

o . o o o

Cataract prevention programs Eye health education programs Outreach eye care services

Community-based rehabilitation of the ineversibly blind Information system development

Constraints

o o o o

Limited budget within the Ministry of Health's annual health budget for eye care

services. Funds for training programs for eye care workers, for establishing eye care facilities, and equipment for implementing eye care services in the provinces. Lack of training programs in the country for training of eye care personnel. Lack of motivation of existing eye care personnel due to the poor government salary. This is linked to the inability of eye care personnel to refuse to work in the

provinces. o Poverty and difficult socio-economic conditions of the population.

il at

Conclusion
Cambodia, despite many years of turmoil is poised to improve the quality of life of its citizens through reducing the number of blind people and preventing blindness in the country. However, there is a lack of eye care personnel and facilities to provide eye care services in the provinces where 85% of the population lives. Support would be required for training of eye care personnel, development of eye units in the provinces, control of blinding eye diseases and rehabilitation of the blind.

Interviewees: Dr. UCH YUTHO National Eye Health Coordinator DT.CHHUN SENG Vice-director Preah Ang Doung Hospital Chairman of the Sub-Committee for Prevention of Blindness DT.UCH Yutho, as National Eye Health Coordinator, coordinated with Laos, Thailand, vietnam, 30 NGos, the University of Tokyo, and wHo to carry out 2 workshops..
cataract is the first priority as it accounts for 60-70Yo of all blindness. Maryknoll / CBM is dealing with community-based rehabilitation, skill training for the blind adults, establishment of Takeo Eye unit and training of basic eye doctors and
ntrrses.

o o

There are 60 blind children under the care of NGOs - New Family has 42 children in

of blindness in children are eye injury, malnutrition, congenital glaucoma . Helen Keller International is supporting vitamin A intake and nutrition . Help Age Intemational: Primary eye care activities - Recognition and treatment of conjunctivitis lid infection - Recognition of initial treatment and referral for comeal ulcer, trichiasis - Recognition and referral for cataract, pterygium and visual loss Eye health promotive and preventive activities - Case finding and referrals - Health promotion and education of target groups in the community Cooperate with NGO.
Battambang. The most common causes

42

Srihanhuk Hospital Psychiatric Department Interviewee: Dr.Kasur Bonat Mental Health Before 1975 there was one mental hospital in Kandal, 9 kms. south of Phnom Penh, staffed by psychiatrists. During the Pol Pot regime, which began in 1979, many of the patients were killed and the hospital was closed. In 1980, the hospital was reopened at Srihanhuk hospital with help from WHO, Vietnam, and Russia to develop/mental health services. ln 1992, the government tried to integrate mental health into its medical curriculum but was not successful. It was only successful in staffing outpatient services with 2 psychiatrists. Others were receiving on the job training supported by Norway (IOM). Japan (AMDA). AMDA has ceased support for this program while IOM is expanding its support. In March 1992, the Mental Health Sub-committee was established and Dr.Kasu Bonat has been appointed as the chairperson. Dr.Kasu Bonat himself has 2 years of training in France and the U.S.A. In 1994, psychiatry was introduced to the faculty of medicine. G.P. training on psychiatry consists of 92 hours of theory and practical experience in primary care. The U.S.A. trained 2 doctors, 1 medical assistant, and 6 social workers for 2 years resulting in a total of 50 health personnel in mental health. This group will train another 50 personnel in Siam Leap and open another outpatient clinic in the provincial hospital in Siam Leap Last year an Outpatient Department was opened at Battambang. There is one Korean medical doctor in the hospital who has trained 15 staff and I doctor.
The education for handicapped children For the education of handicapped children, the government still does not have much of a role. The interview of Mr.Ung Say Chief of Bureau of External Relation and MR.MAO SOVADEI Child Welfare Department MSALA follows.

Ministry of Education, Youth and Sports Interviewee: Mr.Ung Say


Chief of Bureau of Extemal Relations

"The Ministry of Education, Youth and Sports would like to be involved with special training for various disabled groups as well as teaching these groups in primary and secondary schools as well as integrating them into ordinary schools. Due to the lack of monies in the budget, there is no policy to implement this. Thus, the Ministry of Education is not doing much in this area, only receiving reports from NGOs that run schools for the blind or the deaf. The Ministry of Education also collaborates with the Ministry of Social Affairs, Labor and Veteran Affairs.

43

Interviewee: MR.MAO SOVADEI Child Welfare Department

In 1993 there was one NGO center called FFAC (Friend for All Children) which conducted rehabilitation for disabled children. This NGO closed down, so the children were transferred to the government. Due to budget constraints, the government could not do much except provide food and shelter. There are currently 45 disabled children, aged 8-15 years old with the following disabilities: - accidental brain trauma - Polio myelitis - Psychosis.
At present, there is a new NGO named "New Family" cooperating with the Ministry of
Social Action, which is caring for these children.

The government's problern not only involve budget constraints, but also more than 100 children being left in front of the center as well as the increasing number of street children The needs include a budget for: - Children's shelter and food that include disabled children as well as street children - Training personnel - Training and education for disabled children - Support for'oNew Family"

The conditions of employment and vocational training for handicapped


These are being done by NGOs in collaboration with
as follows:

MSALVA. The results of training

are

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45

The current conditions of the supply the demand of prosthesis and orthosis are quite enough but there are some problems with registration as follows: Interviewee: MR. Dudley Turner, Manager Chief Prosthetist Hospital

/ Orthotist, Calmette

The Cambodia Trust (CT) is a registered British charity established in 1989 to bring humanitarian relief to Cambodia. Its major initiative has been to promote the well being of Cambodian mine victims through the supply of artificial limbs. After 5 years of dedicated service, the Cambodia Trust has delivered and fitted over 8000 prosthesis and 1200 orthosis to Cambodian disabled persons.

MISSION STATEMENT
The Cambodia Trust Limb Project works closely with the Ministry of Social, Labor and
Veterans Affairs, the Ministry of Health and other prosthetic agencies to:

o . o

Provide free delivery of prostheses and orthoses to disabled persons in Cambodia. Transfer Prosthetic Orthotic skills to Cambodian people through an ongoing training Promote and encourage all appropriate activities which seek to raise the status disabled people in Cambodia.

process.

of

The trust cooperates with the Ministry of Social Action and the Ministry of Health and has

strong links with the military and other NGOs, including Japanese Handicap Intemational which supports technical and equipment needs. The Nippon Foundation also supports the trust. There are (in Phnom Penh, Sihanoukville, Kampong Chnang and Kean Svay) four Trust clinics have been established, all of which provide free artificial limbs and rehabilitation to amputees.

The trust has also initiated and now co-nrns the Cambodian School of Prosthetics and Orthotics, based in Phnom Penh to train 60 Cambodians to be prosthetists. The school's graduates will ensure that the Trust's clinics and rehabilitation programs will be sustained by Cambodians for Cambodians.

CAMBODIA TRUST'S FIELD ACTIVITIES


Manufacturing and delivery of free Prostheses and Orthoses. 2. Implementation of Women and Children Outreach programs in Kandal, Sihanoukville, Koh Kong and Kompong Chnang. 3' Provision of career development for Japanese ProsthetisVOrthotists received from Hope (Humanitarian Orthotics Prosthetics Endeavor).

l.

46

4. Joint management and fiscal control of the CSPO (Cambodian School of Prosthetics and Orthotics). 5. Provision and direct assistance for post-injury treatment to landmine casualties in Preah Ket Mealea hospital with appropriate follow-up in 317 centers (Kien Svay). 6. Foundation and technical support to CAAA (Cambodian Association of

Amputee Athletes). Cambodia Trust does not do community-based rehabilitation itself but collaborates with Unicef and other NGOs for outreach programs that work closely with C.B.R. outreach in case finding of amputees and persons with polio as well as doing follow-up and teach staff of C.B.R.

C.B.R. needs are

as

follows:

1. Improving the disabled persons'registration since requests are often repeated; this is due to their lack of I.D.'s. 2. Improve the levels of knowledge of the C.B.R. staff.

III.

The needs of C.B.R.

As the govemment is having budget constraints and the Pol Pot Regime had reduced previously existing resources, Cambodia has a shortage in all areas, including personnel, facilities for services and health promotion and prevention activities. This is true even more so for services directed to the disabled; there is a lack of training for personnel, including specialists, vaccines for immunization, community activities, information, network systems, vocational training, and so on. The situation of prosthesis and orthosis is perhaps better off than other areas as there are NGOs that are already trying to cover this area. For visual and mental disabilities, Cambodia already has a plan but it is not well implemented as of yet. The Ministry of Health, Ministry of Social Affairs, Labor, and Veteran Affairs and the Ministry of Education need assistance to address rehabilitation issues. It is advised to deal with DAC which is working as the coordinating body (See Annex D&E).

IV. Foreign assistance on C.B.R.


There are at least 35 NGOs assisting the disabled and most of these NGOs have either outreach programs or community-based rehabilitation programs (see Annex A). The Cambodian govemment has formed the Disabled Action Council (DAC) to be the coordination body for rehabilitation and has appointed Ms. Helen Pitt as Executive Director. She has been working with Ministry of Social Affairs, Labor, and Veteran Affairs (MSALVA) as a consultant in the social aspects before coordinating with MSALVA and NGOs to organize their task force. They came up with many documents such as a national strategy, rehabilitation costs, and data on the situation of the disabled in Cambodia..

47

MSALVA and the NGOs work together in the area of disabilities to

assure

sustainability, coverage, equity and to avoid repetition. In September 1995, the Directorate of Social Affairs of MSALVA initiated a joint ministry-NGO process to develop a common strategy for the continued development and coordination of appropriate programs, services and support for and with disabled people.

48

Conclusion The health statistics show that Cambodia has the poorest health conditions among Asian countries. The government's health budget is very low, resulting in poor health services, in prevention and promotion, and poor accessibility and availability This is even more so for services directed to the disabled. The situation concerning disabilities is severe and may become more so due to the existence of a lot of land mines in many places and the increasing number of traffic accidents .
People experience rnalnutrition, deficiencies resulting in blindness, poliomyelitis and encephalitis. Presently, immunizations are not sufficiently covering the population. Due to the Pol Pot Regime and long history of intemal fighting, there is an increasing number of disabled persons and an increasing shortage of manpower in all medical fields, especially for handicapped, as well as in the social fields and special educational fields. So the needs for Cambodia are not only community-based rehabilitation but also a general need to assist in all medical fields, social fields, and educational fields in order to improve the entire health, social and educational system.

Recommendations

Of the four models proposed earlier in the operational definition, Cambodia probably could follow the Indonesia Model since they still do not have enough specialists in Cambodia. The other models would be inappropriate since Cambodia currently has no village rehabilitation team as in the Mexican Model, lacks a local supervision team as in the Filipino Model, nor has village volunteers such as the Thai Model. Any foreign aid should be directed to help improve the whole health system. For the disabled, it is most important to start with personnel development, including in the medical field, the social field, and the educational field, emphasizing communitybased rehabilitation to ensure coverage, sustainability and equity. The second priority is to raise funds for equipment, transportation and oporational costs. It is advisable to contact the Ministry of Health concerning the medical field, the Ministry of Social Affair, Labor and Veteran Affairs and the Ministry of Education for other fields. It is especially important to contact DAC, the coordinating body for services for the disabled. Pascale Laurant, at the American Red Cross in Cambodia had prepared the costs for rehabilitation, which is available at DAC.

49

ANNEX: A
LIST OF ORGANIZATIONS IN THE FIELD OF DISABILITIES IN CAMBODIA
L

ADD (Action on Disability and Development) 3, Street 384, Sangkat Toul Svay Prey I,
Khan Cham Car Mon. Phnom Penh Tel no: 812632 Fax no :64697

2.

AFSC (American Friend Service Committee) 30, Street 352,Chamcar Mon. Phnom Penh Tel no :26400

Faxno:23-62400 PO Box 604, Phnom Penh


3.

ALIMCO (Artificial Limbs Indian Manufacturing Company) (Have not opened an office in Cambodia yet)

4.

AMDA (Association for Medical Doctors in Asia) 139, St. 286, Toul Svay Prey II.
Chamcar Mon Phnom Penh Tel no:018-810284 Fax no : 810-284 PO Box 541, Phnom Penh

5.

APHEDA (Australian People for Health Deucation and Development Abroad) l0E, Street 302, Chamcar Mon.
Phnom Penh

Telno:26034 Faxno:26034
PO Box 915, Phnom Penh
6.

AmRC (American Red Cross) PO Box 535, Phnom Penh Tel no : 62105,810254 Fax no : 810254 PO Box 535, Phnom Penh

50

7.

AAR. CC (Association to Aid the Refugees Cambodian Committee) 249.5t.62, Boeng Keng Kang
Phnom Penh Tel no : 18-810232 Faxno 810232 PO Box 141, Phnom Penh

8.

CDPO (Cambodian Disabled Peoples Organization) 15, Street 294, Phnom Penh Tel no :62232 CFDS (Cambodian Family Development Services) 228,5t.213, Skt. Veal Vong, Khan 7 Makara, Phnom Penh Tel no :015-913223

9.

10.

CMAC (Cambodian Mine Action Center)


22, Street 122, Quartier Meathapeap, District 7 Makara, Phnom Penh Tel no : 50083/84, 015-913845 Fax no : 60096 PO Box 166, Phnom Penh

11.

CT (Cambodia Trust) Calmetter Hospital/Moniving Blvd. Phnom Penh Telno 27067

Faxno:27076 PO Box 122, Phnom Penh


12.

CIOMAL
6, Street 604, Bocung Kok 2, Khan Toul Kok. Phnom Penh Tel no : 68184 Fax no : 68184

13.

COERR (Catholic Office for Emergency Relief and Refugees) 30 st.232, Phnom Penh Tel no :64306

Faxno:64306

5l

14.

COFRAS (Companie Francaise De Service Specialise) Wat Bo Village. Siem Reap Tel no : 015-911-975 PO Box 134, Phnom Penh CWARS (Cambodian War Amputees Rehabilitation Society) CWARS Pursat, Pursat Town

15.

Telno:27338 Faxno:27330
PO Box 635, Phnom Penh
16.

CWDA (Cambodian Women's Development Assocation)


DPI (Disabled People's Intematioal)
15, Street 294. Phnom Penh

t7.

Telno:62232
18.

FFAC (Friends for all Children) 63, St. 315, Tuol Kork, Phnom Penh

Telno:68124
Fax no : 60104 PO Box 806
19.

FSI.IN Monivong Blvd., Phnom Penh

20.

HT (Halo Trust)
248, St. 398, Boeng Keng Kang Phnom Penh

Telno:364063
Fax no :64149 PO Box 33, Phnom Penh

2t.

HI (Handicap Intemational)
53, Samdech Sothearos, Phnom Penh Tel no : 015-91 1455

Faxno:26270
PO Box 838

52

22.

HKI (Helen Keller Intemational) 74,5t.456, Toul Tom Pong.


Chamcar Mon, Phnom Penh Tel no :26312126746 Fax no :

23.

HELPAGE (HelpAge International) 9, Street 228 Phnom Penh

Telno:26076 Faxno:26076
PO Box 525 24.

ICRC (International Committee for the Red Cross) Sl. Blvd Samdech Sothearos. Skt Tonle Bassac. Phnom Penh Tel no :26160162096 Fax no : IP (Indochina Project) A/eterans Intemational Street 178. Phnom Penh Tet no :27204

25.

Faxno:810267
PO Box 467, Phnom Penh

26.

IOM (Intemational Organization of Migration)


45, Street 310, Phnom Penh Tel no :810256126532

Faxno:26423
PO Box 435 27.

JSRC (Japan Sotoshu Relief Committee) 32, St.288, Skt. Olympic, Chamcar Mon, Phnom Penh Tel no :810240164229

Faxno:26924
PO Box 2, Phnom Penh

28.

JRS (Jesuit Refugee Service)

96, St. 592, Tuol Kok Phnom Penh Tel no :68021, Fax no : 68165 PO Box 880, Phnom Penh

53

29.

Khanta Bopha Hospital Phnom Penh Khemara National Road # 5, Mithapeap Village. Srok Russey Keo, Phnom Penh Tel no :60134 Fax no : 60134 Krousa Thmey 4, St.261 Tuk Laak, Phnom Penh Tel no :66184

30.

31.

32.

KBS (Khmer Buddhist Society) Kompong Speu

Telno:26746
aa JJ.

KCDI (Khmer Cultural Development Institute)


Maryknoll

34.

I St. 360, Chamear Mon Phnom Penh Tel no : 2601 I


Faxno:26012
PO Box 632, Phnom Penh
35.

MDI (Medicin DeL Espoir International)


2. St. 135, Phnom Penh Tel no :

36.

MDM (Medecins Du Monde)


Calmette Hospital, Phnom Penh

37.

MED (Mekong Eye Doctors) Bangkok Regional Office

38.

MAG (Mines Advisory Group) 201, Preah Sisowath Blvd.


Phnom Penh Tel no :60495, Fax no : 60480 PO Box I I I 1, Phnom Penh

54

39.

NCDP (National Center for Disabled Persons) 3, Norodom Bolvd., Phnom Penh
Redd Barna

40,

9,5t.322, Boeng Ken Kang


Phnom Penh Tel no :62143 Fax no : 68025 PO Box 34, Phnom Penh 41.
Rehab Craft 26, Stree 302

Boeng Keng K*g, Phnom Penh

Telno:27612
(c/o Maryknoll) PO Box 632
42.

SERVANTS (Servants to Asia's Urban Poor) 3, St. 374, Tuol Svay Prey l, Phnom Penh Tel no :64461 Fax no :64461 PO Box 538, Phnom Penh
SAO (South East Asian Outreach) 40, St. 432, Tuol Tum Pong, Chamcar Mon, Phnom Penh Tel no :64354 Fax no :64354 PO Box 85, Phnom Penh

43.

44.

SKIP (Stiftung Kinderdorf Pestalozzi) 9,St.228,Boeng Raing


Phnom Penh Tel no :27807

Faxno:27807
PO Box 90 Phnom Penh

45.

TEHO Kampuchea Krom Blvd., Sangkat Phsar Depo 3, Phnom Penh Tel no :66145, Fax no :66145 PO Box 1039

55

46.

TINICEF (United Nations Children's Fund) 11, Street 75, Sraschark Quarter, Phnom Penh Tel no :26214115,27957

Faxno:26284
PO Box 176, Phnom Penh

47,

UNDP (United Nations Development Fund) 53, Street 51, Boeng Keng K*9, Phnom Penh Tel no : 26257 126167 1277 18/2688 I

Faxno:26429 PO Box 877, Phnom Penh

48. 49. 50.

UCC (United Cambodian Community)


Wat Than Rehabilitation Center Norodom Blvd., Phnom Penh

WHO (World Health Organization) 120, Street 511228, Boeng Keng K*g, Chamcar Mon Phnom Penh Tel no :26610126942 Faxno 26211

51.

WVI (World Vision International)


34, Street 360, Boeng Ken Kang, Chamcar Mon, Phnom Penh Tel no :26052127923

Faxno:26220
PO Box 479

56

ANNEX: B
Source: Lai Heng Foong, National Task Force for Disabled Persons, "The Situation of Disabled Persons in Cambodia", pp.63 -72.

v.l

MEDICAL REHABILITATION
V.1.1 Provision of Assistive Devices

Wheelchairs The main organizations which produce wheelchairs are JRS/\4EKONG,, HI, AFSC, VL Initially, HI and AAR.CC were the main producers of wheelchairs to meet the need of disabled Cambodians, based on HI design. Their wheelchair is made of wood, and was developed some years ago as a solution to meet the immediate need. 1992, MOTIVATION collaborated with CT to develop wheelchair production in Cambodia. Eventually due to funding problems, they ended up working at the JRS vocational training site with funding from JRS, AFSC, and ODA. They had originally planned to produce wheelchairs made of metal, but decided that it would be more appropriate to use wood instead. They improved on the design and mobility of wheelchairs. After they set up operations for the production of the Mekong wheelchair, the best technology available in Cambodia, they left it to JRS to continue with the program.

In

At about the same time, VI also began producing wheelchairs, based on their assessment of unmet need for wheelchairs. Production figures vary according to the availability of funds, demand, and staff capacity. VI produces wheelchairs of three sizes, to suit different age groups, and they also adapt the design according to individualized need. However, they are difficult to repair and expensive to produce. An associated problem is the lack of monitoring of wheelchairs that are given out to patients. Attempts need to be made to
address the problem of the inadequacy of

follow-up with the provision of services.

Prostheses and Othoses

This sub-group seems to be the most well organized group in the medical rehabilitation sector. Careful planning goes on to ensure that there is no overlap of service provision and distribution in the country . As shown in section IV 2, there are currently 9 orthopedic centers all over the country. Covering all provinces except Preah Vihear, Mondul Kiri, Rattanak Kiri. The latter two provinces are covered through the outreach program of VI, while Preah Vihear could access the facility in Kompong Thom.

Most organizations providing prostheses have standardized, their technology, using the ICRC polypropylene technology and the HI foot. Only ICRC is producing component parts for prostheses, which avoids the problem of overlap of services.

JI

acknowledged that there is a real need to increase the production of orthoses and ensuring
the necessary follow-up.

Physical Therapy Since 1987, Wat Than, the National Center of Rehabilitation in Phnom Penh has served disabled persons people with club foot, cerebral palsy, disabilities resulting from polio, and other disabilities. This center was established by MSALVA, and is the operational center for a few organizations, namely Maryknoll and HI.

of physical therapists within the Phnom Penh Ecole Central des Cadres Sanitaires (para-medical school). Currently there are graduates from this program in 8 Phnom Penh centers and hospitals and 7 provinces other than Phnom Penh. In addition to staffing physiotherapists in their P& O centers, HI also have 3 physiotherapists in the center for Spinal cord Injuries in Battambang. FFAC

HI

operates a school for the training

will

have one expatriate physical therapist

to take care of the Kien

Kleang

orphanage in the Phnom Penh area.

The ICRC prostheses workshop in Battambang hires an expatriate physical therapist for training amputees, and also handles other forms of disabilities e.g. club foot on a case by case basis. She is assisted by a few local physiotherapists trained in the HI School of Physiotherapy. Other P & O workshops such as VVAF, AFSC, ALIMCO, also have their own physiotherapists as part of the medical rehabilitation of patients. SERVANTS have one expatriate occupational therapist for their children with disabilities progftrm, who is in charge of rehabilitation for a whole range of disabilities, from cerebral palsy, epilepsy, polio to visual impairment.

V.2 VOCATIONAL REHABILITATION


Vocational rehabilitation is a process of preparation for work and providing suitable employment for disabled persons, taking into consideration their residual work capacity and acquired skills. It involves vocational guidance based on vocational assessment, vocational training, placement in suitable employment and follow-up. Vocational guidance is the first and very important phase of vocational rehabilitation. It is defined as a process of assessing a person's physical and mental abilities and aptitudes and his/her personal preferences and then outlining a range of occupations to determine the line of funher education and training that he/she is particularly suited to. Vocational training is aimed at acquisition of vocational knowledge and vocational skills as well as development of necessary attitudes and patterns of behavior in a work situation.

58

After a disabled person has received the necessary training that he/she felt was appropriate and desirable, the next step is to ensure that he/she is able to find employment so that heishe can start earning an income and be self-supportive. Since may disabled persons in Cambodia come from the poorest and most disadvantaged groups, this element of vocational rehabilitation is even more important for their reintegration into society.
The final step is the follow-up, to ensure that disabled persons person who have found suitable employment continue to improve his/her situation and to address any problems that might arise.

Current Programs MSALVA, in accordance with one part of the previous National Rehabilitation Plan from 1987 - l99l6e and in collaboration with NGOs and Ios working in rehabilitation for disabled persons, has established four provincial vocational training centers in Battambang, Siem Reap, Phnom Penh and Sveng Trey. The Ministry envisages that there would be one vocational training center set up in each of the 20 province in Cambodia in the future, pending the availability of funds and other resources. There are plans to set up 5 Regional Center of Excellence around the country to provide the needed administrative support for the provincial. Vocational Training Centers (VTCs), and also provide a few
vocational skills training.

At present, the Ministry have identified broadly the needs for vocational training, which are based on opinions of disabled people attending VTCs, recommendations from NGOs and IOs currently involved in vocational training, and current needs assessment. These are

I' Machinery repairs-small

and glasses repair (because people usually sell watches and glasses. This kind of business people can own, instead of working under someone) 5. Agricultural training-animal husbandry (with focus on chicken raising) 6. Electrical circuit and electronic equipment repair 7. Sewing for Disabled Women

2. Welding 3. Radio/tape recorder/TV 4. Electrical and manual watch repair

machines, water pump, motorbike, small generator

organizations active in this field are APHEDA, coERR, CWDA, FSUN, HI, JRS, JSRC, Krousar Thmey, Maryknoll, SKIP, UCC, and World Vision.

World Vision runs a VTC in Battambang province, which oflers training in radio repair, engine repair, sewing, typing, silk screening, food processing, and welding. Its counterpart agencies are the Department of Social Affairs, Ministry of Education, and the Secretarial of state for Women's Affairs. They have an Extension Program that look after students who have graduated from the center, for example looking for job placements from graduates, sending field workers to follow-up on students with management of workshop

59

and financial accountability. They also offer loans to graduates to set up their own workshop. The approach of the extension pro$am is based on a participatory system, where students are in charge of coming up with their own workplan, and WVI will provide the necessary materials and advice after an assessment of their workplan for feasibility and sustainability. One potential stumbling block for disabled persons is that WVI has very specific criteria that potential students must meet before being considered for a place at the training center. A minimum of three years of education is required for consideration. This might be a diffrcult criteria to meet, for many of disabled persons are not educated, or have receive minimum education 70. Another difficulty is that the students have to leave their family for an extended amount of time. In the meantime who will provide for their
families?

WVI also runs a VTC in Mong Russey district, which provides training in textiles and design, and hairdressing. Its counterpart is the Secretariat of State for Women's Affairs. This center also has dormitory facilities for students.
HI organizes a Sports for disabled persons and an Educator's Training Program in Phnom Penh and Battambang. This program trains educators to be able to train disabled people in Sports. The coordinator of the program has also recently set up an Association for
Disabled Sports. JRS nrns the Banteay Priep Vocational Training Center for the Handicapped, which is based in Kandal province, with follow-up services in Siem Reap, Banteay Meanchey, and Pursat provinces. It provides a one-year training course in welding, electricity, motorcycle

repair, sculpture, and carpentry, and MSALVA.

a dormitory for students. It

collaborates with

JSRC also has a vocational training center that provides training in printing, carpentry, sewing and embroidery in Phnom Penh. collaborates with the Phnom Penh Municipality of education Service and Ministry of Education. It has an age limit of l8 for students and does not offer dormitory facilities.

It

JSRC nrns a pottery center in Battambang, working with provincial authorities. They have facilities for production of bricks, coal from rice husks, pottery, and ceramics. It is not set up exclusively for disabled persons, but they do recruit students who are disabled. There are dormitory facilities, where students can stay for the duration of their one-year training

program.

Maryknoll helps run the Wat Than Rehabilitation Center. It provides skills training in tailoring, carpentry, Khmer and English typing. Students at Wat Than spend six months in a classroom setting, and the next six months in a production workshol, which produces handicrafts to be sold at the showroom in Wat Than on a profit sharing basis for students. The students purchase the material themselves, and the profit is kept by students to set up their own business in the future. The latter six months is also spent leaming basic

60

management

skills. They have recently started a silk weaving workshop in collaboration

with MSALVA and UNESCO Mary knoll's Rehabilitation of Blind Cambodians program offers vocational training in crochet, kniuing, Braille, and it recently started a blind massage service called "Seeing Hands," all based in Wat Saravoan. This center is open only to the blind and the severely visually impaired. Generally, it does not offer dormitory facilities, but they are flexible in certain circumstances. Both programs work with their counterpart, MSALVA. What Saravoan is the center for Maryknoll's CBR program, which has 5 outreach workers going out to the community to seek out disabled people who might not know that services are available for them. Records of patients are kept for follow-up purposes. The trained workers then work out a realistic program for disabled persons, whether it be provision of vocational training or starter loans for them to start up small rural enterprise like pig rearing. They are planning to start another program in Takeo. SKIP is based in Pursat. They have set up four VTCs in Pursat for teenagers, with deliberate effort to recruit 20o/o staff trytth disabilities. These are.
Bakan Center: goldsmithing, electrical repair Kandieng Center: Carpentry, tailoring Krakor Center: typing and electrical work, tinsmithing Kravanh Center: Stone carving, motorbike mechanics
a

Children with disabilities are given priority considerations. They have dormitory facilities during the weekdays. Students must go home during the weekend.
Krousar Thmey in April 1994 opened a School for the Blind which offers the equivalent to the national education cuniculum in Braille, and teaches mobility education, orientation and music.

AARCC has a vocational training center in Kien Kleang and a literacy project for disabled persons. Its counterpart ministry is MSALVA. All students take a course in literacy before receiving training in wheelchair repair and production leatherwork, iron sheeting, small business training and rattan work (including rattan wheelchair). The program provides housing for students for the duration of their study. COERR is active in Phnom Penh, Sisophon and Siem Reap. It works closely with the following ministries: Ministry of Foreign Affairs and International Cooperation, Ministry of Education, Youth and Sports, MSALVA and MOH. In Phnom Penh, training coqrses are offered in tailoring, computers, beautification, and typing. Their target group is government offrcials for their typing and computer courses. In its VTC in Siem Reap, it offers courses in motorcycle repair, welding, electricity, shop mechanics, auto mechanics, construction and tailoring. In Sisophon COERR offers courses in auto mechanics, welding, electricity and electronics, tailoring, construction and typewriting. The Sisophon center is the only one equipped with dormitory facilities.

6l

CWDA is a Cambodian NGO with funding assistance from the Australian People for Health, Education and Development Abroad (APHEDA). It offers classes in typing (English and Khmer) and office skills. It does not have dormitory facilities.
UCC has a VTC in Kampot. Its VTC offers skill training in motorbike and small engine repair, and commercial poultry production. They are also planning to include training in commercial vegetable production, fish farming and radio repair in future. Follow-up and starter loans are integral parts of the program.
FSTIN runs a tailoring course at their center in Phnom Penh. At the end 1995, the center has finished two sessions, each lasting six months. FSTIN provides dormitory facilities for students for the duration of the course.

of

TEHO runs

program for disabled persons in Phnom Penh. The beneficiaries of its program are amputees and polio victims. They offer courses in jewelry making, silk screen painting, computer use and repair. Jewelry made by students at TEHO is sold on TEHO premises. In addition, a tradition, a traditional music school for handicapped and orphaned children opened in Kampot in July 1994. Its aims are to combine the restoration of traditional culture as vocational therapy, with practical provision of basic care for disadvantaged children in extremely impoverished circumstances. Wat Than Rehabilitation Center
The National Rehabilitation Center or Wat Than Rehabilitation Center was set up in 1991, originally consisting of a Physiotherapy Department, an Artificial Limb Workshop, and a Vocational Training Center. It acts as a refenal center for disabled persons. Wat Than is

a skills training

currently the only real physiotherapy outpatient f'acility in Phnom Penh. The center now houses seven facilities : A Skills Training school offering courses in tailoring, typing and carpentry, a tailoring workshop, a carpentry workshop, a physiotherapy center for landmine and polio disabled persons, a traditional silk weaving workshop, a tailoring workshop, a carpentry workshop, a physiotherapy center for landmine and polio disabled persons, a traditional silk weaving workshop, and a literacy program. Since it opened, 350 students have been trained. The center at Wat Than has been implementing an integrated rehabilitation program for mine victims and polio victims. However, an issue that has recently arisen is the location of the National Rehabilitation center.

*d

Wat Than, the present location, belongs to the Ministry of Religious Affairs (MRA). An agreement signed between MSALVA and MRA has set December 1997 asthe deadline for the transfer of buildings to take place. The issue now is to find a new location for the National Rehabilitation Center. Discussions are presently taking place to find a suitable relocation, which would ideally not involve substantial expense for the MSALVA.

62

V.3 COMMUNITY BASED REHABILITATION PROGRAMMES


The main thrust of this philosophy for rehabilitation of disabled persons is that the reintegration of disabled persons has priority over the creation of a special environment and special services for disabled people. According to the WHO definition, Community Based Programs (CBR) uses resources within the community to achieve social integration of people with disabilities. The resources include disabled persons themselves, their families and members of the community. A comprehensive CBR program has rehabilitation workers at the community level, rehabilitation supervisors at provincial and district levels, and technical experts (prosthetists, physiotherapists etc.) national, provincial and possibly district levels, with strong referral between levels of services.
In the Cambodian context, such extensiv'e linkages are beginning to be developed CBR in Cambodia favor provision of services and follow-up visits in disabled people's homes, and attempts to reach people of all ages and all types of disabilities.
The overall philosophy of community based programs is that disabled persons themselves are the ones best equipped to decide what is best for them, and how best for people to help them. On a more practical level, CBR has also evolved from a recognition of the increasing costs of institution-based health/rehabilitation services, and the growing appreciation for sustainable benefits of providing rehabilitation services within the community.

Current Programs
More organizations are using this approach in rehabilitation of disabled persons. The PRES program of Handicap International is one of the active players in the field of community-based interventions. The Khmer Buddhist Society through its REACH program in Kompong Speu also provides community based rehabilitation. Other organizations are ADD, AFSC, CT, Khemara, Maryknoll, Servants, WAF, and Francais Amities are also active in this field.

HI's Program de Rehabilitation Economique et Sociale (PRES) has outreach services in


eight most populated provinces in Cambodia: Battambang Banteay Meanchey, Kamot, Kompong Cham, Kompong Thom, Pursat, Siem Reap and Takeo. PRES was designed to assist severely disabled people and economic independence and social integration. It works from the premise that disabled people themselves know their own priorities, and it is from these that any assistance should beginTr. It is complementary to other programs in Cambodia which focus on medical rehabilitation, vocational haining and the production of assistive devices. Its approach takes three general forms, namely counseling, referrals to other services and direct assistance for therapeutic needs or for income generation.
has just begun its program of formal and informal training of development workers to collect information of the situation of disabled persons in their communities to determine the social contexts in

ADD has a CBR program in Samrong Tong district in Kompong Speu. It

63

which disabled people are living, and aspects of disability awareness. Based on a Training Needs Analysis visit by the International Training Unit of ADD, India, the team will travel to India for 7 weeks to receive intensive training on disability issues, causes, prevention and early intervention for disability, counseling, orientation and mobility and personal growth.

AFSC had an outreach program in Kompong Som, to find people who might need prostheses, and to refer disabled persons to other services such as vocational training, reeducation or other support services. Their outreach program has just begun, and employs only one expatriate with an assistant for the time being.
Kandal provinces, and Calmette hospital in Phnom Penh funded by LINICEF that specifically target women and children amputees. The rationale for this program is because women and children do not have knowledge of the availability of services. Women and children also do not usually travel on their own and waiting for a male member of the family would mean loss of working days. There are four aspects of this program : 1) educating the relevant MSALVA from provincial to commune level to ensure that the target group is reached, 2) finding women and children amputees to be assessed and set up appointments, 3) patient education and 4) coordinating patients reviews.

CT has community outreach programs in Kompong Som-Koh Kong and

Mary knoll is active in Phnom Penh, and Takeo provinces, but focuses their services on the blind. Their community health workers go out to the community to find cases of disabled people and refer them to the relevant organizations and support services. They keep a record of all patients for follow-up and referral. SERVANTS has a CBR program based in Phnom Penh. It does outreach services to locate children with disabilities in the community, and trains children with disabilities and their families about carrying out rehabilitation at home, such as activities of daily living, mobility and participating in family and community life. It also provides the necessary medical rehabilitation to disabled children.
JRS has outreach programs related to their skills training graduates for the handicapped in Sisophon and Siem Reap.

Khemara was the first local NGO that was set up in Cambodia, with funding assistance from ECHO, Redd Barna, oxfam uK a uS and Diakona, a Swedish NGo. It is an NGo for women, dedicated to the empowerment of women and the improvement of their living conditions. Its CBR program began 1991, but from 1991-92, no direct services were rendered yet, and efforts were focused on survey research. In 1993, they employed and expatriate physiotherapist specializingin community-based interventions to begin training volunteers selected from two village where the program will be based, consisting of community leaders, family members of disabled persons and staff from NGOs. To supplement the income of these volunteers, a paper making business was started, which is sold through the Khemara House. This would provide the needed incentive for the

in

64

volunteers to continue with their work. However out of the initial they are now reduced to five volunteer workers.

group of 12 people,

CARE-BIRCH used to run community based programs for disabled persons in Bakan district, Pursat province, but this project had been discontinued due to cutback in funding.
V.4 HANDICRAFT PRODUCTION

The organizations active in this field are Khemara, Rehab Craft, a program run by an individual in Siem Reap, UNESCO, TEHO, JRSC, and in the future, the National Center for Disabled Persons. Kfiemara nrns an integrated program of community based rehabilitation, handicraft production and income generation. It also provides skills training on small business management, and provides loans for women to manage small businesses.
NCDP, once it is renovated and open to the public will have a retail outlet for the sale of handiuafts. It will sell handicrafts from different organizations, women's groups, disabled persons' groups and other self-help groups. The income generated from the sale of the handicrafts will be put back into the center, and hopefully in a few years time the center will be self sufficient in funding. UNESCO is rejuvenating some traditional crafts in a few provinces, such as silk weaving in Takeo province. They helped establish a silk weaving center at Wat Than, in collaboration with MSALVA and Maryknoll. The products are sold at the showroom at Wat Than, and at other handicraft stores and fairs. Organizations like TEHO and JRSC have a showroom within their premises where handicrafts such as jewelry and pottery could be sold on a profit sharing basis.

65

ANNEX: C
List of Interviewees

Ministry of Health

l.

Name Position Address

Dr.Eng Huat Director General for Health Ministry of Health 151 - 153 Kampuchea Krom Rd. Phnom Penh, Cambodia Tel. (855) 023-366-334, Fax (855) 023-362-516 Dr.Mao Tan Eng Head, Health Information Unit Planning and Health Information Department Street Ministry of Health, Cambodia 15l Kampuchea Krom Street, Phnom Penh, Cambodia Tel (855) 023-366-337 Dr.Prok Piseth Raingsey Deputy Director, Preventive Medicine Department Ministry of Health, Phnom Penh, Cambodia Tel. (8s5) 023-366-202 Dr.Khuon Eng Mony Chief, Health Emergency Bureau Management & Environmental Health, Preventive Medicine Department Ministry of Health, Cambodia Tel. (885) 023-366-202,Fax (8S5) 023-426-g4l
Dr.Seng Rattana Staff, Department of Preventive Medicine Ministry of Health, Phnom Penh Cambodia.

2. Name
Position Address

3. Name
Position Address

4. Name
Position Address

5. Name
Position Address

6. Name

Dr.Phok Chansorphea

Position Address

Stafl
Department of Preventive Medicine. Phnom penh Ministry of Health, Cambodia.

66

7.

Name : Position : Address :

Mr.Vong Samnang Deputy Chief, ASEANI Bureau International Relations Office Ministry of Health Russey Keo District, Phnom Penh, Cambodia Tel. (855) 023-366-186

Ministry of Social Affairs, Labour and Veterans Affairs.


8. Name

Position Address

H.E., Dr.Hong Them Under Secretary of State, Ministry of Social Affairs, Labor and Veterans Affairs Phnom Penh, Cambodia.

9. Name

Position Address

Mr.Keo Kim Thon Deputy Director, Fehabi litation Department Ministry of Social Affairs, Labor and Veterans Affairs Phnom Penh, Cambodia. Tel. (855) 023-2ls-34t Mr.Mao Sovadei Deputy Director, Ch ild Welfare Department Ministry of Social Affairs, Labor and Veterans Affairs
Phnom Penh, Cambodia Tel. (855) 021-808-644

10. Name

Position Address

Specialists
11. Name

Position Address

Dr.To Chhun Seng Vice Director (Ophtalmologist) Preah Ang Doung Hospital C2, Street 84, Sangkat Sreash Chak Phnom Penh, Cambodia. Tel. (855) 023-723-774

12. Name

Position Address

Dr.Vch Yutho National Eye Health Coordinator Ang Duong Hospital P.O. Box 2027, Phnom Penh
Cambodia Tel. (855) 023-366-207

67

13. Name

Position
Address

Mr.Ung - Nak Rehabilitation Worker, Kien Khleang Rehabilitation Center Kien Khleang District, Phnom Penh, Cambosia

Specialist
14. Name

Position Address

Dr.Ka Sunbaunat Chairmn, Mental Helath Sub - Committee, Preah Bath Norodom Sihaknuk Hospital 73, Monivong Blvd.
Phnom penh, Cambodia Tel. (855) 023-212-859

NGOs
15. Name

Position Address

Ms.Helen Pitt Executive Director Disability Action Council (DAC) 28 Street 184, Chey Chum Nas Quarter, Khan Paun Penh, Cambodia Tel. (85s) 023-215-34r

16. Name

Position Address

Mr.Dudluy Tumer Manager (Chief ProsthetisVOrthotist) The Cambodia Trust Limb Project P.O.Box I22, Preah Monivong Boulevard Phnom Penh, Cambodia Tel. (855) 023-427-067
Mr.Sovanna Ley Fam

17. Name

Position Address

Staff
School for the Blind Children Doem Sleng Village, Chbar Ampoen Cammune, Mean Chey District Phnom Penh. Cambodia

Ministry of Education
18.

Name : Position : Address :

Mr.Ung Say Chief, Bureau of External Relations, Ministry of Education, Youth and sport
Phnom Penh, Cambodia. Tel. (85s) 023-360-234

68

Institutional Visits 1. Ministry of Health, Phnom Penh, Cambodia 2. Ministry of Social Affairs, Labor and Veterans Affairs 3. Rehabilitation Department, Ministry of Social Affairs, Labor and Veterans Affaris 4. Child Welfare Defartment, Ministry of Social Affairs, Labor and Veterans Affairs 5. Disability Action comcil, 28 street 184, chey chum Nas euarter, phnom penh 6. Preah Ang Doung Hospital, c2, Street 84, sangkat sreash chak, phnom penh 7. The cambodia Trust Limb Project, Preah Monivong Boulevard, phnom penh 8. Kien Khleang Rehabilitation center, Kien Khleang District, cambodia 9. National centre of Disabled Persons (NCDP), Norodom Blvd, phnom penh l0.Preah Bath Norodom sihaknuk Hospital, Monivong Blvd, cambodia l l.Ministry of Education, Youth and Sports, phnom penh

69

ANNEX: D
Source: Lai Heng Foong, National Task Force for Disabled Persons, "The Situation of Disabled Persons in Cambodia", pp.91-93.

III.

Community Based Rehabilitation

Since 85%

of the

Cambodian population lives

in rural areas, corlmunity based

interventions seem to be the most appropriate level to provide services for disabled

persons. This would improve accessibility to services, heighten community


participation, and improve local capacity. Village Health Volunteers could be
recruited and trained in simple management of disability such as physical therapy for

polio victims, vocational training, and income generating activities. Local traditional
healers could also be a cost-effective strategy

to implement services for

disabled

persons. This would be a cost-effective strategy to implement services for disabled

persons. Incentives could be given as deemed necessary to encourage continued


participation. Pilot projects could be inhoduced and the success of these programmed could gain the confidence of the community and provide the impetus for further
programming.

Handicraft Production and Income Generation

This is an important avenue for generating income for disabled persons, and also to
generate revenue

to maintain some existing services for disabled persons. More

efforts should be focused on ensuring good quality products for increased customer

satisfaction. With the opening of the NCDP, there will be a permanent place for the
sale of handicrafts produced by disabled persons. The government should ensure that

prices are monitored and standardized.

If the sales of handicrafts

are encouraging, there could also be expansion of the scope

of production to include exports. Staff at NCDP, and the people who produce
handicrafts themselves should be given training in proper marketing strategies and
qualrty control.

70

IX

RECOMMENDATIONS

There are two general approaches to the management of development activities in a

less developed country like Cambodia. The first focuses on the development

of

managerial capabilities and institutions, while the second emphasizes the management

of concrete development activities, with a concentration on the delivering of


meeting the needs, and providing tangible benefits to the people.

goods,

Developmental planning
these two approaches,

in Cambodia has been ehanctefized by the dichotomy of

without an apparent attempt to reconcile the two. For example,

certain bilateral donors prefer

to

support projects that would build institutional

capacity of the government, while other would rather fund community-based projects.

However,

it is important to look at these two perspectives not as irreconcilable


in
Cambodia, there

entities, but rather as complimentary processes that are interdependent on one another.

is a lack of confidence in the capacity and capabilities of government agencies to implement projects successfully, and an
unwillingness to take calculated risks

Unfortunately

in

supporting them

in project planning

and

implementation. This perception must change if true institutional capacity building is


to take place.

Another symptom

of the development

impasse

in Cambodia is the tendency of


of

projects and programs to focus on outputs rather than process. This is due in part

the framework from which donor agencies operate, and the legacy of the euick Impact Project (QIPs) days left over from the large scale IIN Repatriation program in
Cambodia

in 1992-1993. Donors work under the model of evaluating project impact


in the

based on certain outputs at the end of the project cycle, which had been defined

initial project proposal. Many projects are thus "forced" to look at project implementation from the perspective of its ability to produce these outputs, which must be quantified. However, many aspects of community participation and
empowerment are not easily quantifiable. Thus there is a philosophical and also a practical gap between theory and practice in this approach.

7l
There has always been

a long-standing debate between agencies and programs

involved

in meeting the initial relief and assistance phase with longer-term

development and reconstruction processes. The same contested issues continue to


pervade the development scene in Cambodia. This dichotomy exists not only in large agencies like the UN agencies working in Cambodia, but also smaller scale NGOs.

A UNHCR report in March

1992 alluded

to "how (the) repatriation

(process) can

jump-start reconstruction without sucking UNHCR into a development role." On


January 14, 1994, LINHCR signed a memorandum

of understanding with the I.lN

Development Program (I-INDP) under which LINHCR agreed

to

concentrate on

meeting the immediate reintegration needs of retumees while LINDP would work to

"bridge the initial integration phase with longer term regional integrated rural development." Together LINHCR and IJNDP established
mimagement

a joint technical

unit (JTMU) in Phnom Penh to review QIPs and ensure continuity


to projects that do little to

between shorter and longer-term reintegration efforts. The tendency to view these two processes as separate and irreconcilable entities has led

promote sustainable community development and self-sufficiency. Among NGOs,

there is also traces

of the relief-mode of providing

services; again output rather

process oriented. Very often, since relief-mode is grounded on "quick impact' effects

of programs, there is very little time to do a proper needs assessment before going into
project planning and implementation.

In the context of service provision for disabled persons, which is often a life-long
process for disabled persons, this "quick impact" approach has tended

to be countera

productive. Before implementing projects for disabled persons, there must be


comprehensive needs assessment to look at the extent of the problem and levels

of

intervention given all the constraints that are operating within the environment that
service providers and disabled persons themselves are working under. There should

also be continuous monitoring

to ensure that services are working well, and

to

ascertain that certain services are not over-subscribed or over-emphasized.

72

IX.l
1.

GENERAL

Structural constraints

of the Ministry must to be addressed to

ensure

sustainability of programs, especially the issue of low government salaries and


lack of resources to maintain services for disable people in Cambodia.
2.

Better coordination between provincial, district and central government (i.e. Ministries) needs to be forged to ensure that existing programs are running
smoothly and can reach the most vulnerable, and to avoid overlap of services
and activities.

3.

An Information System or

database must

be kept at all levels and by


coordination,

government, NGOs and IOs working

in disability for better

monitoring, and evaluation of programs for disabled persons. While awaiting the computeization of the database, proper records must be kept of disabled
persons and programs and services so ease of transfer when a computerized
database becomes available.
4.

Training should be provided to government staff in management and other

skills lacking within the Ministry after a Human Resource Development


assessment

by an expert. It is important for attitudes of Ministry staff to

be

changed as to how they view the purpose of training programs, that

it is for

improving job performance. They have to have the right predisposition for training to have any impact at all.
5.

Better collaboration with other ministries, institutions, agencies


community groups
causes

and

in Public-Awareness

campaigns

in the prevention of

of disability, as stated in the roles of responsibilities of the Department

of Rehabilitation.
6.

After all financing mechanisms have been considered, there should be clear
plan outlined as to how the Ministry

will finance services for disabled

persons.

This is a critical factor in ensuring that existing services are maintained, and

new services that are implemented


Ministry.
7.

will

be within the capabilities of the

Greater collaboration of MSALBVA with UNDp should be forged, especially since the target groups for both are the sarne, namely the poorest and most

73

vulnerable. Coordination of planning and programming needs to be enhanced between these

two institutions, so that the most vulnerable groups in

Cambodia can truly benefit.


8.

More process analysis should be done to look at community development in the context of disabled persons in order to come up with programs that are
consistent with the needs of disabled persons themselves. Self-Help groups should be involved in developing programs for disabled persons.

9.

Income generation activities should be a priority because it can help facilitate the reintegration of disabled persons into society and allow them to be selfsuffrcient.

IX.2

BY DISABILITY SECTOR

Blind
1.

Since the process is already far advanced in the formulation

of a National off

Prevention of Blindness Plan, effons should be focused on getting the Plan

the ground, with proper logistical support, technical assistance, support from

the Central government and provincial and district inspectorate, existing eye

units and cornmunity participation. This would include strengthening the


Human Resource capacity for catering to the needs of the blind. This would include training of eye doctors, specialist eye nurses (new and upgrade), and
supporting services such as incorporating primary eye care training in the pHC

worker training.
2.

Existing eye units need to be maintained, and more eye units should be set up,

ideally by strengthening already existing structure, i.e. provincial/district


hospitals so that additional expense is not incurred to build more buildings and
structures.
3.

Given resource and infrastructure constraints

of the Royal

government,

emphasis should be placed on cost effective interventions such as Vitamin. A supplementation for the prevention of Vitamin deficiency and complications

arising from it, such as Xeropthalmia. This will be done for the first time through the National Immunization Day
should be continued.

in 1996.

Supplementation efforts

74

Amputees
1.

Based

on current rate of
amputees, except

amputation and production figures


seem

of

these

workshops, existing P
needs

& O workshops

to be adequately meeting the


resources,

of

for conflict areas. Given the limited

more attention should be focused on maintaining existing services, and to continue repair services and follow-up

of patients. In other words, new

workshops should not be set up unless a needs assessment study shows that

they are absolutely necessary. Production in existing workshops could be


increased
2.

if the rate of amputation

increases.

Outreach services to areas that are difficult to access due to geographic and

security problems need to be emphasized, to increase accessibility of services to amputees.


3.

De-mining activities should continue to give priorities to resettlement of


internally displaced persons, and clearing of land for agriculture. Funding for de-mining operations should continue due to the extensive land area ajfected
by mines.

4.

International pressure for a Ban on the use Landmines

in conflicts

should

continue, as it is the only viable way to stop the proliferation of these insidious
weapons.

Polio

l.

Coverage of immunization with OPV in collaboration with increased, as a primary preventive measure

MOII

needs to be

for childhood disability due to

polio. Immunization for polio is a cost effective way to address the problem
of paralysis due to complications from polio and should be an option that is
pursued by the Royal govemment, especially since financial resources are

limited. Existing mechanisms (Expanded Program on Immunization) could

be

unutilized, and support is already present from organizations like the World Health Organization through the National Immunization Days. As long
as

funds are forthcoming, this effort should continue, with the end goal of
eliminating polio in Cambodia in five years time.

75

2.

Physical therapy can be carried out by family members at home, but proper

training should be given

to family members through

community-based

interventions and proper follow-up. Counseling should also be provided to

make sure that the family understands that physical therapy should
continued on a long-tenn process for proper outcome.
3.

be

More emphasis should be given to orthoses production in existing P workshops. Only

&

organizations are producing orthoses, even though the

potential is there for production. This is because production

of

orthoses

requires more follow-up (which is time and resource consuming), and is not as

high profile as providing prostheses to amputees are. Nevertheless,

it is an
be

important rehabilitation process


advocated.

for

disabled children, and should

Deaf

l.

proper needs assessment should be done

to look at the extent of

the

problem, needs identified by deaf people themselves, md how appropriate


programs could be implemented given the financial constrains.

2'

Immunization efforts for measles should continue to be improved, especially

in

hard+o-access

areas. More social mobilization campaigns should

be

introduced to educate mothers of the importance of immunization.

Paralysis

t.

The Spinal Cord Injuries center in Battambang should be maintained to meet


the needs of this group of disabled people.

2.

Training of nurses and medical staff at health facilities in the three provinces, Battambang, Pursat and Banteay Meanchey (and gradually extended to the whole country) should continue to be emphasized.

3.

Depending on availability of funds, more regional centers should be set up to meet the needs of victims of paralysis, or alternatively, a facility could be set up in existing provincial hospitals.

76

Mental Illness

l.

Medical residency for psychiatry should continue


psychiatrists who could provide medical treatment

to
to

produce qualified
patients who have

mental illness. The first batch of medical residents trained by IOM could then
be trained to train other residents, with the end goal of self-suffrciency.
2.

Diagnosis

of patients with

developmental disabilities should be improved

(early detection), and Special Education programs should be set up for


children with developmental disabilities.
integrated into the regular school system.

If

possible, these children could be

Psycho-s ocial Comp laints

More ethnographic studies should be conducted to get at the heart of the


matter

of the psychological trauma that

Cambodians have been subjected

through many years of genocide, conflict and civil unrest. The nature of
psychosocial problems is such that only with a more in-depth and long term study could the root of the problem be addressed.
2.

As psychosocial problems are more difficult to diagnose and interventions are

not so clear-cut, community-based workers should be trained well to know


how to distinguish mental illness from psychosocial problems, so that proper
referrals could be made.

Other

1.

Clubfoot--Orthoses production should be increased for children with club foot


because with proper orthoses

fitting and follow-up, more disabling sequelae of

clubfoot could be prevented.

2.

Tuberculosis--The National Center

for

Tuberculosis Control should be

strengthened, as TB continue to be a major disease among adults. This has

implications for the productive workforce of Cambodia. With HIV infection


and AIDS on the rise, more people

will develop TB,

and more of them

will

have atypical TB and multi-resistant

TB.

Public Health Workers should be

trained on proper management of TB patients, and education programs for the prevention of TB

77

IX.3
1.

BY REHABILITATION SECTOR:
Re h

Medical

abilitation

Existing services, such as P &

workshops, physical therapy and follow-up

care should be maintained, but more linkages should be forged at district and

village levels through community based rehabilitation programs.


2.

capacity building

of Ministry should

progress beyond consultations and

discussions, and short-term consultancy and training programs. Ministry staff

must be trained to actually absorb the responsibility for the running of these
services, i.e. from administration, management training to running the direct operations of service.
3.

A centralized

database should be kept, which could be updated on a monthly

basis by provincial and district authorities. Information that could be included

in this database are: demographic characteristics of disabled persons, type of


disability, and by cause of disability. This would facilitate the monitoring and
evaluation ofdisabled persons and services.

Vocational Re habilitation
1.

More feasibility studies to be done to look at the appropriateness of the


vocational training offered according to local conditions and availability of financial and human resources.

2.

More emphasis should be given to the follow-up of graduates of vocational


training programs, and how the skills that they gained could be channeled into
something productive and income generating.

C omm un ity B as e d Re h a b ilit at io n

l.

More community-based programs should be implemented


community participation, and improve local capacity.

to

rehabilitate

disabled Cambodians. This would improve accessibility to services, heighten

2.

Village Health Volunteers could be recruited and trained in simple management of disability such as physical therapy for polio victims,
vocational training, and income generating activities. Collaboration with

78

ministries and agencies that are already using village health volunteers could
avoid the problem of reinventing the wheel, and save on resources.
J.

Look into to possibility

of

involving local traditional healers

in the

rehabilitation of disabled persons. This would be a cost-effective strategy to implement services for disabled person.
4.

In-kind incentives could be given to village health volunteers and traditional


healers as deemed necessary

to

encourage continued participation. Pilot

projects could be introduced where the suitability of these projects could be


tested, and the impact evaluated.

Handicraft Production and Income Generation

l.

with the opening of the NCDP, there will be a permanent place for the sale of
handicrafts produced by disabled persons. The government should ensure that prices and quality of goods are monitored and standardized.

2.

If the sales of handicrafts


scope

are encouraging, there could also be expansion of the

of production to include exports. However, such an expansion will


control. Staff at NCDP, and the people who produce

necessitate good quality

handicrafts themselves should be given training in quality control and proper marketing strategies.

79

ANNEX: E
Source: Summary Report pp.VII-XIX.

- MSALVA Task Force on Disability Issues, October 1996,


Summary of Recommendations

Section

: CHILDREN WITH DISABILITIES

PREVENTION

1.

Prevention of disability should be a priority of the MSALVA Disabled Children's Bureau, and of the sub-committee.

INTEGRATION 1. The MSALVA should


2.

encourage a community-based approach in the development

of new programs for disabled children. Both center-based and community-based services should strive for the integration of disabled children into normal society as their main goal.

ECONOMIC SUPPORT

1.

There should be free access for disabled children to education. health care. and rehabilitation services.

PARENT EDUCATION l. Parents of disabled children should have access to informational and receive instruction on their child's disability, on the available resources, and on the available resources, and on the right of their disabled child to education in public
schools.

ADVOCACY 1. The Children with Disabilities sub-committee should continue to advocate for better and more services for disabled children and for the promotion protection of
disabled children rights.

ABANDONED CHILDREN 1. Efforts to trace the families of abandoned disabled children, and to assist the families to be able to care for those children should be instituted from each

2.

orphanage.

MSALVA, with the assistance of NGO's should arrange for shelter, ongoing care and resources for all children, including disabled children. Who have been
abandoned.

COVERAGE 1. Currently undeserved groups should be targeted, although within the existing general programs. It is not recommended to begin parallel programs for each type

80

SUSTAINABILITY

1.

The technical and managerial sustainability of programs should continue to be improved. Financial sustainability will only be possible if the govemment decides to make this a priority.

SUB-SECTORAL ISSUES l. The Children with Disabilities sub-committee should merge with the CWD subsector, keeping open the possibility of meeting in a smaller working group when
necessary.

Source: Summary Report MSALVA Task Force on Disability Issues Oct. 1996.
Section 2: COMMUNITY BASED WORK

WITH DISABLED PEOPLE

GUIDING PRINCIPLES

l.

2.

The CWD sub-sectoral group should continue as before, by sharing information on program changes, but should also work proactively for the transformation of the Task Force's Guiding Principles into actions, both within the CWD group and in other sub-sectors, to begin with the Children with Disability sub-committee, which would like to merge with the CWD group. All CWD programs need to develop strategies on how to facilitate the inclusion of disabled people as a whole, not only in a case-by-case approach, into mainstream activities and programs. For example. CWD workers need to know better the other activities going on in the places where they work, and to enter into relationships with them (schools. health facilities. wats, associations, local authorities, and mainstream development programs) in order to be effective advocates for the inclusion of disabled people into them. * The CWD sub-sector should link with the Community Development Sector * Access to education for all disabled people should be addressed through the impending teacher training programs being planned now. * Special schools should be encouraged and assisted to mainstream their students. + CWD programs, when counseling or referring someone for vocational training, should attempt to use mainstream or integrated vocational training facilities, normal apprenticeship systems, and should aim for employment in the open labor market.

4.

5.

women and disabled people should be recruited as rehab workers. Plans should be formulated with the aim of raising public awareness about the causes and prevention of disability, the rights of disabled people. The abilities and potential of disabled people if given opportunities. Public awareness activities should target the general population rehab workers, and government bodies with the support of experts in this field and strategies such as mass media campaigns, and grassroots approaches such as travelling exhibits, theatre and puppetry. Awareness activities should also target disabled people themselves, using different strategies, such as developing leadership and the ability of disabled people to come together and tackle the issue of negative attitudes themselves.

8l

6.

7.

8.

Whether in the community or through their link with centers, disabled people should be given the opportunity and the skills to associate together. This is so that they can develop their own understanding of their problems and needs, and their own position on appropriate solutions. This should also provide a forum in which they can develop the confidence and the ability to participate in initiatives which affect them, and to develop self-help projects. Disabled people should be represented on all national, regional and local committees and sub-committees in which policies and decisions concerning disability issues are discussed. Guidelines should be developed for the participation of disabled people as consumers of rehabilitation services.

COVERAGE
I

'

2. 3.

4.

Where only one type of program exists, outreach workers and rehab workers workers ought to be trained to know and be competent in each other's domains. Where more that one type of program exists already, collaboration should be extremely well coordinated. The expansion of CWD programs should happen in a logical, coordinated. Planned way expanding geographic coverage and avoiding overlapping and duplication. Under-represented groups - people with Hansen's Disease (leprosy). Disabled women. Deaf people disabled children, disabled adults needing intense and longterm care - should be targeted with specific plans to ensure their representation in all programs and activities. Prevention of disabilities should become a stronger focus of CWD programs.

TRAINING

l.

The training of Rehab Workers should be shared among all existing programs, in a systematic way, using the strengths of each program. In the future, a standard curriculum could be developed. Topics to be included: * Technical skills, with a strong emphasis onoodo no-harm', + General rehabilitation knowledge: types of disabilities, causes, and physical effects. Etc. * The social model of disability / understanding the context in which disabled people live Social skills of rehab workers: interviewing, empathy, listening * Manageriall or ganizational skills Self-help groups: why and how to encourage their formation * How to do income generation work in an empowering way

82

SUSTAINABILITY
1.

2.

a J.

Funding for income generation activities and for the CWD progftlms in general should be sought locally, through the government and/or from businesses, intemal funds, etc. True sustainability for CWD programs in Cambodia will depend on a commitment from the government. The grounds for such a commitment should begin to be built now. The formation of self-help group and parents associations, and the targeting of community associations, local NGO's and other permanent structures to receive information and training about CWD, and the use of volunteers are all possible means of supporting local sustainability.

A NATIONAL STRATEGY

l.
2.
a J.

A national strategy for CWD must include discussions with disabled people,
existing progftlms, and the government. MSALVA should create a bureau for CWD, and begin to build its own capacity to monitor and evaluate CWD programs. Evidence of the effectiveness and cost effectiveness of CWD programs should be gathered. Guidelines for new CWD programs and targets for improving existing ones should be set. For the creation of a broad-based and integrated CWD progftrm, local and national structure outside MSALVA, as well as other ministries. Health, Education, and

4.

).

6.

Rural Development for example, should participate in the development of a national strategy for CWD. A permanent national level forum for disabled people, service providers, other interested organizations, and the government to coordinate and regulate initiatives related to disability: this should extend to province level also, and include in its mandate the implementation of the recommendations of the Task Force which do not fall under a single sub-sector.

SECTION 3: PROSTHETICS AND ORTHOTICS


STAF'F'ING l. There should be minimum standards for P/O staff, and clear personnel policies, for all staff ministry or otherwise, in both technical and administrative poritionr. 2. Staffing problems would be alleviated to some degree by the establishment of grades and conesponding pay scales. 3. All staff needs to be selected on their qualifications for the jobs, according to written job descriptions: regular evaluations should be instituted and staff showing definite and unchanging incompetence should be removed from their positions. 4. The MSALVA should create a commission to study and act on the problem of nom-ministry personnel, with the very concrete example of lCRC-Battambang as the first case to be rectified

83

5.

Measures to improve attitudes of workshop personnel towards disabled people should be implemented.

QUALITY OF SERVICES

l. 2. 3.

All P/O workshops in the country should provide a minimum


service.

standard of quality

Mechanisms to provide systematic feedback from the users of prosthetics from all the workshops should be developed, as an important measure of the quality of services. It should not be tolerated that a workshop provides devices, which are physically harmful to the people coming for assistance.

SUSTAINABILITY

1. 2' 3. 4.

MSALVA's present and future role in the P&O area must be discussed and redefined. NGO and MSALVA personnel's management capacities should be targeted for improvement. MSALVA's financial input should be re-defined, standardized, and guaranteed from the central level. NGO salary scales should be reasonably appropriate to Cambodia, and more or less equal across the sub-sector according to the qualifications of the person and the demands of the job.

COVERAGE

l. 2. 3. 4. 5.
l.

A variety of ways to get information to remote areas about the existence of services should be developed. For example, cwD programs could easily spread information about the P&O services if relevant materials were developed. Mass media could be used. District level MSALVA could be used. One database on disability should be created. Existing data, including MSALVA information on veteran amputees should be used to extrapolate and crosscheck current estimates of the number of amputees in
Cambodia. NGO practices should enhance the use of all services: practices (other than the pursuit of quality) which undercut another NGo should be stopped. The expansion oforthotics services should be encourased.

COOPERATION WITHIN THE SUB.SECTOR A national system of identification cards, patient records, and user feedback would facilitate the coordination of current services and the development of future services as well as reducing the number of cases of workshop-hopping Participation in sub-sectoral activities should be mandatory for all agencies.

2.

84

SECTION 4: PEOPLE WHO ARE BLIND OR HAVE VISUAL IMPAIRMENTS

TRAINING

All

rehab workers should be trained in skills necessary to help blind people, these being: * Identification of eye problems and knowledge of which problems may be arrested or reversed with medical or surgical intervention, * Knowledge of and regular connections to the existing services for prevention and remediation, * Orientation and mobility training. * Daily living skills for people with blindness and low vision. * Methods to assist blind people to earn an income.

PUBLIC AWARENESS
I

'

The general public, blind people themselves, and especially rehab workers who are most likely to be in contact with blind people should learn what the potentials of blind people are and should work to overcome harmful misconceptions about blindness.

EDUCATION
I

'

2. 3.

Schools for blind children should see their role in the long-term future as preparing the children for normal schools, when the school system has developed the capacity to receive blind children. Until then, the efforts to maintain the children's ties to their families and communities should be continued. The special schools should continue to develop as resource centers. producing materials, and as places where regular teachers can come for training More blind people should be trained to be trainers of other blind people, and some blind people should be assisted to go all the way through the education ryrt"-, ,o that they will be ready to assume leadership roles in the future.

LOW USION

1.

The question of low vision verses total blindness should be addressed in all training and intervention programs related to blindness.

EMPOWERMENT THROUGH ASSOCIATION

l.

The next general assemble could be used as a forum for blind people to meet together to discuss issues specific to their situation.

85

LINKS WITH OTHER MINISTRIES

l.

In the efforts to implement the recommendations of the Task Force on Disability Issues. MOEYS and MOH should be included in discussions and activities related to people with blindness and low vision.

SECTION 5 : VOCATIONAL AND SKILLS TRAINING

PRE.TRAINING ACTIVITIES

1.

2. 3. 4.

The existing procedures for helping students select the most appropriate course should be reviewed and considered for adoption by all the vocational programs. Pre-training counseling should help disabled people decide if skill training will benefit them in the long term. If so, which skill is most appropriate, if not, where there are other means or options to achieve the same goal. Information about opportunities in vocational and skill training and other income generation and employment creation programs should be made available at the local level, perhaps through district level MSALVA staff, so that potential trainees have more than one option to choose from. Vocational training curricula for illiterate students should be sought out, so that low educational levels will not otherwise deserve people from applying for entrance. People who could benefit from training but can not leave home for an extended period should have other options to choose from, such as apprenticeship style training, or satellite training possibilities.

TRAINING

1. 2. 3.

The selection of skills to be taught should be driven by demand by the local market. The number/types of skills taught need to be shifted, at least in part, to skills useful in rural areas If some marketable skills are inappropriate to incorporate into training in institutional settings, then other forms of training should be investigated and developed.

POST.TRAINING FOLLOW-UP
1.

It is recommended that all vocational training progr.rms have at least a minimum


level of post-training follow-up. MSALVA staff should be trained to assist with post-training follow-up. NGO and government staffs who are active in post-training follow-upshould be trained in community level advocacy work.

2.

86

THE ET'FECTIVENESS OF' EXISTING INSTITUTION-BASED VOCATIONAL TRAINING PROGRAMS IN LEADING DISABLED PEOPLE INTO THE
WORKFORCE
1.

All programs should keep clear, verifiable records of their graduates' employment rate this should be measured soon after graduation, 6 months after graduation and
18 months after graduation. The reason graduates do not find employment must be examined and addressed. Make financial assistance available for post-training business start-up Evaluate skill trainers regularly and re-train them as necessary. Sensitize community leaders and develop incentives, such as good publicity, for commurities to facilitate the graduates' success. The involvement of MSALVA should be increased in identifying employment opportunities for graduates, researching and advising programs on which skills should be trained, approaching businesses to encourage them to hire disabled people, securing govemment contracts for vocational training schools. The role of an Employment Bureau and its potential link with vocational training programs should be investigated. For skill areas in which certification exists in the formal Technical Vocational Education and Training (TVET) system, certification should also be possible for NGO-run schools. Other methods to attain the affective objectives without the huge financial and time costs of institutional vocational training should be considered. Programs which are parricularly good in helping disabled people build selfconfidence and self-esteem should share their ideas and methods so that students of all the schools benefit. New vocational training programs should be clearly informed of the limits of the institutional-based approach, and methods other than institution-based (school) skill training should be explored and implemented.

2.
3.

4.
5. 6.

7.
8.

9. 10.

l.

SEGREGATED VERSES INTEGRATED TRAINING OF DISABLED PEOPLE

l.
2. 3.

4.
5.

Sensitize all parties-existing programs, disabled people. MSALVA personnel-as to the advantages and disadvantages ofsegregated training. Continue the segregated approach in existing schools/programs, while actively pursuing an integrated approach in new programs. Advocate for the inclusion of disabled people in mainstream development initiatives: rice banks, credit schemes, training an employment progftrms, etc. Ensure that the general vocational training system does not block admission of disabled people If necessary, address the issue of confidence building in integrated programs.

87

SUSTAINABILITY OF PROGRAMS

l. 2. 3. 4. 5.

Every issue under sustainability needs to be clarified directly with MSALVA, since it seems that there are many expectations of MSALVA involvement, which may not be possible or desirable. MSALVA should make clear agreements, using very precise terms, with any new programs as to the eventual turnover of the program to the government. MSALVA should seek funding for the takeover of vocational training programs and absorption of non-govemment staff as agreed on in original Memo's of Understanding, or it should make known its intentions not to takeover programs and staff so that the NGO's can make other plans. MSALVA needs to build their capacity to plan, monitor, and evaluate services, to seek their own funding, and to determine the need for more services. Government staff working in vocational training programs should be chosen based on merit, and should adhere to the same regulations as non-government staff.

PLANNING FOR IMMEDIATE AND LONG TERM VOCATIONAL AND SKILL TRAINING NEEDS.

1. 2. 3. 4. 5. 6. 7. 8. 9.

Since institutional vocational training reaches only a small percentage of disabled people who need to increase their income, other approaches should be investigated and implemented. Data on the numbers of disabled people of productive age province by province, and with precise information on their proximity to population centers should be collected to make planning for the future more fact-based. The MSALVA Financial Management Technical Adviser and his counterparts should make analysis of the different approaches to income generation a priority. A number/photo identification card system could be instituted to keep people from collecting services. Discourage the opening of new vocational training programs in or near Phnom
Penh.

Explore the idea of making regional decisions on the skills to be taught as a means of improving the quality of training and avoiding duplication of services. The vocational training sub-sectoral group should adopt a goal-oriented agendato address many of the issues raised during the Task Force process. Consider a division of responsibilities of programs, with the Ministry of Education in change of the schools of vocational training, and MSALVA in charge of student selection, information dissemination in the villages, vocational assessment and guidance, job placement and follow-up Investigate further these specific organizations or programs: The Japanese pottery factory in Battambang, a self-help scheme in Battambang, which is reportedly having great success. ILO. ACLEDA, UNDP, Helen Keller, and other mainstream programs.

88

FURTHER QUESTIONS:

l. 2. 3. 4. 5.

Should the current practice of offering everything free to the students be continued? Should every program concentrate on institution building, or is it enough simply to train as many people as possible for the period of the NGO's stay in Cambodia and then close the program? Do schools with low or flexible student selection criteria have better or worse employment rates? In what capacity should MSALVA staff be seconded to vocational training programs? Can links be made between the so-called "informal" schools for disabled only and the "formal" schools for the general population?

SECTION 6 : DISABILITY ADVOC.A.CY AND EMPOWERMENT

1. 2. 3.

Whether in the community of through their link with centers, ensure that disabled people are enabled (given the opportunity and skills) to associate together if they so wish. Develop guidelines for the participation of disabled people as consumers of rehabilitation services. Ensure that disabled people are represented on all national, regional, and local committees and sub-committees in which policies and decisions concerning disability are discussed.

SECTION 7 : THE CAMBODIAN DISABLED PEOPLE'S FUND

l.

CDPF should be supported, as it is a concrete attempt to move toward financial sustainability for rehabilitation services, and the first time a local fund has been established on behalf of a vulnerable group of Cambodians.

SECTION 8 : THE CAMBODIAL DISABLED PEOPLE'S ORGANIZATION

1.

The Task Force recommends that this positive collaboration between the Rehab Sector NGO's MSALVA, and CDPO be continued in the future.

SECTION 9 : DEAFNESS

l. 2. 3. 4.

Open a school for deaf children (Krousar Thmey is planning to do this in 1997). Develop the school's capacity to do outreach to deaf children outside the school. Assist deaf adults in forming a Deaf Club for socialization and development of Sign Language. Conduct leadership courses, deaf awareness and organization building activities with deaf people, including study trips and participation in intemational congresses

ofdeafpeople.

89

5. 6. 7. 8. 9. 10. 11. 1. 2. 3. 4.

Arrange vocational training opportunities for deaf adults Further develop the Cambodian sign language through work with deaf Cambodians. Document the signs by compiling a dictionary. Ensure the cooperation of the Linguistics Department of Phnom Penh University in the development and acceptance of Sign Language as a language. Train deafand hearing persons to be teachers, trainers and interpreters in Cambodian Sign Language Conduct deaf awareness and sign language courses for hearing persons who are parents, relatives, friends and co-workers of deaf people. Organize hearing testing and treatment services, including medical services and the availability of hearing aids. Build links with the Cambodian government, NGO's and international groups.

SECTION IO: ELDERLY DISABLED


The premise that "No one should be denied access to services on the grounds of age" should be accepted by the rehabilitation sector/MSALVA. Services and programs available to disabled adults need to be made accessible to elderly disabled persons. The effects of aging, methods to prevent these effects from becoming disabling, and ways to lessen the impact of disabilities common among older people should be part of the training and the practices of all rehabilitation workers. The Rehabilitation Sector, including MSALVA department of Rehabilitation and the Directorate of Social Affairs, should continue to liaise with local and international orgarizations that provide support to older people to promote programs aimed at maintaining the well being of elderly people.

SECTION 12: INTEGRATION OF DISABLED PEOPLE

EDUCATION

1. 2. 3.

Study the plans of the Ministry of Education and examine other initiatives in the field of education in order to define how disabled people and their issues can best be integrate into such plans and initiatives. Where relevant, encourage organizations working with disabled people to enter into discussion with schools in their program areas concerning the integration of disabled children and young adults. Define and implement an appropriate training strategy for teachers in mainstream schools, which will facilitate the integration of disabled children and young adults into such schools.

90

4.

5.

Encourage the integration of disability issues into the cunicula of mainstream schools, in order to increase awareness amongst Cambodian young people of the causes and prevention of disability, the rights of disabled people, and the abilities and potential of disabled people if given opportunities Define the circumstances in which the provision of special educational facilities are appropriate and to determine a strategy for such provision.

VOCATIONAL TRAINING

l.

Define a strategy for the integration of disabled people, where possible, into vocational training initiatives intended for the wider population.

HEALTH

L 2.

Study the plans of the Ministry of Health and examine other initiatives in the field of health in order to define how disabled people and their issues can best be integrated in to such plans and initiatives. Define a strategy for the provision of an appropriate level of training in basic rehabilitation and/or awareness of disabilitv issue for health workers.

DEVELOPMENT

l. 2.

3.

Study the plans of the Ministry of Rural Development and to examine other initiatives in the field of rural and community development in order to define how disabled people and their issues can best be integrated into such plans and initiatives. Ensure greater collaboration between those governmental and non-governmental agencies working specifically with disabled people, and those agencies promoting mainstream community development work, with a view to responding to the basic needs of disabled people beyond the rehabilitation process. The involvement of disabled people should reflect the same criteria of consultation, participation and self-reliance as are applied to other disadvantaged and marginalised groups in the development Raise awareness of the rights and abilities of disabled people amongst mainstream development agencies.

process.

SECTION 13: INTELLECTUAL DISABILITY AND MENTAL ILLNESS

l.

Encourage multi-sectoral and inter-ministerial attention to the needs of intellectually disabled and mentally ill people. Train people who work for and with disabled people, especially those involved in home and community level interventions, to differentiate between and the effects

of intellectual disability and mental illness, ways to facilitate the rehabilitation and integration of people with intellectual disabilities, and the causes and ways to prevent some forms of intellectual disability.

9l

3.

Integrate, whenever possible, programs and services for persons with intellectual disabilities into existine cross-disabilitv and communitv based services.

SECTION 14:

LEGIST,auiN oN DISAB,",,'

1. 2.

3.

Encourage multi-sectoral and inter-ministerial attention to the needs of intellectually disabled and mentally ill people. Train people who work for and with disabled people, especially those involved in home and community level interventions, to differentiate between and the effects of intellectual disability and mental illness, ways to facilitate the rehabilitation and integration of people with intellectual disabilities, and the causes and ways to prevent some forms of intellectual disability. Integrate, whenever possible, programs and services for persons with intellectual disabilities into existing cross-disability and community based services.

SECTION 14: LEGISLATION ON DISABILITY

1.

It is recommended that the working group on legislation continue the process, through whatever structure is created with MSALVA to replace and implement the
recommendations of the Task Force.

SECTION 15: THE NATIONAL REHABILITATION CENTER AT KIENG

l.

KLANG
It is recommended that a steering committee is formed including representatives of MSALVA and the three NGO's working at the national rehabilitation center to ensure the coordination of all current and future activities of the center.

SECTION 16: THE NATIONAL CENTER OF DISABLED PEOPLE

l.

It has already been recommended that the information/resource branch of the NCDP consider the creation of an action-oriented research center on disabilitv.

SECTION 17: PHYSICAL THERAPY IN CAMBODIA PROJECTED NEEDS

L 2. 3.

Meet the need for hospital based physical therapists by graduating I0 Pt's in 1996. l0 in 1997, and 10 in 1998. Or 50 total, in a five year period. Develop outpatient physical therapy services Develop a strong and dynamic physical therapy clinic as part of the national rehabilitation center of Kieng Klang.

92

STRJ,NGTHENING THE PROFESSION

1. 2. 3. 1. 2.

Complete the definition of the roles and responsibilities of physical therapists with the MOH Develop information packets, and other means of promoting physical therapy among health professionals and high school students. Develop the AKC into an active organization
OF'

SUSTAINABILITY

THE PROGRAM

Understand the status of PT's working under MSALVA. Discuss and define the roles of the MOH and the AKS in the future of the profession.

INCREASING THE PROFESSION'S SCOPE

1. 2. 3. 4.

Develop a formal referral system between PT's and rehab workers (of CWD programs). Introduce the concept of CWD/CBR to Cambodian PT's Increase the knowiedge and skills of PT's in orthotics Develop a three-pronged plan for the effective provision of orthotics services

SECTION 18: PREVENTION OF PRIMARY AND SECONDARY DISABILITIES

PREVENTION OF PRIMARY DISABILITIES


National progftIms for prevention of disease should remain a priority of the Cambodian government Prevention of amputations by landmine accidents should be pursued in two ways by supporting de-mining efforts, and by supporring the Campaign to Ban Landmines. All rehab workers should understand, and be able to explain about the preventable causes of disability to people they encounter in their normal work Community awareness of the prevention of disabilities should be improved.

1.

2'

3.

4.

PREVENTION OF SECONDARY DISABILITIES

1. 2.

Midwives and traditional birth attendants need to know how to detect disabilities in newborn infants. A system for referring newborn with disabilities to rehab workers should be developed. The system should also link maternity wards and traditional birth attendants with physical therapists for cases of clubfoot, for example, and to provincial hospitals for cases of cleft palate or other conditions which surgery can
remediate.

93

3. 4. 5.

Rehab workers need more training in how to facilitate normal child development,

Prevention of secondary disability should be stressed in rehab worker training courses, as this is one of their main tasks. Parents of disabled children need to know how to prevent secondary disabilities.

PREVENTION OF HANDICAPS. OR DISCRIMINATION


Recommendations: see sections on advocacy empowerment, and public awareness.

SECTION 19: PUBLIC AWARENESS OF DISABILITY ISSUES

1.

Raise public awareness of the causes and prevention of disability the rights and obligations of disabled people, the abilities and potential of disabled people given opportunities Strategies for this could include : campaigns with the support of experts in this field, using mass media such as TV and radio, grassroots approaches such as traveling exhibits, theater and puppetry, developing leadership and the ability of disabled people to come together and tackle the issue of negative attitudes themselves.

if

SECTION 20: TRAINING OF STAFF IN DISABILITY-RELATED CONCEPTS AND PRACTICES l. Train all ministry staff working with people with disabilities to an acceptable level of competence (knowledge, skills, and attitudes) 2. Maximize the benefits of NGO and IO training by opening training to personnel beyond the scope of their own organization,particularly by opening to NGO and Ministry personnel working in the same sector or sub-sector. 3. Ensure that the Ministry HRD department is involved in the selection, evaluation, planning for methodology and content, and documenting training for purposes of credit and promotions when Ministry personnel are asked to participate in training programs of NGO's and IO's 4. Develop training about disability issues for people who come into contact with people with disabilities, e.g. teachers, medical personnel, and social workers 5. Ensure eventual local management of disability programs, by focusing on training and guided supervision in management. 6. Ensure that the content of training is in harmony with the key concepts found in the Guiding Principle of the Task Force including integration, t}re common experience of discrimination mainstreaming, community based services, and participation of disabled people in the programs affecting them. 7. Develop a system of registration of training courses and the classification of personnel according to the level of competence they have reached through training
and experience.

94

SECTION 21: THE CENTER FOR REHABILITATION OF SPINAL CORI) INJURED PERSONS

FINANCIAL SUSTAINABILITY

Develop a plan for the integration of the flaunt staff of the center into a government ministry.

COVERAGE OF' OTHER PROVINCES

1.

The specific knowledge and skills necessary for the care of spinal cord injured persons should be spread to cover the entire country.

LINK WITH THE MOH AND THE BATTAMBANG PROVINCIAL HOSPITAL

l.

Relations between the Center and the Ministry of Health should be strengthened

SECTION 22 : PRODUCTION AND DISTRIBUTION OF WHEELCHAIRS

SUSTAINABILITY

l.
2.
J.
1 t.

).

Sustainable of partially sustainable Cambodian production centers should be allowed to continue functioning and not undermined by gifts of free wheelchairs or y wheelchairs completely subsidized from exterior sources. Other means of increasing the sustainability should be developed and implemented A letter should go out to embassies and other similar groups to explain why gift wheelchairs are not desired. Methods of encouraging user participation in the cost of wheelchair production, distribution, and maintenance should be sought. For example, the responsibility for maintenance and repairs should be with the user, users who come from rich families should pay apart of the cost, politicians who insist on distributing wheelchairs to their constituents should pay for the chairs themselves Using the Cambodian Red Cross, or trains or a future public transportation system
to transport wheelchairs should be re-investigated.

COVERAGE
1.

Donors should be educated as to the only very slight usefulness of distributing wheelchairs with no other rehabilitation component available

2.

Production of wheelchairs should be planned for based on need and take into
account that

Wheelchairs break or wear out, sometimes irreparably, The needs of users change over time, especially children's needs. The needs of wheelchair users will change and expand with improvements in general health care.

95

QUALITY

1. 2. 3. 4.

Wheelchairs should be distributed only by people who have been trained to assess, prescribe, assemble, fit and modiff the chairs. Wheelchair users should be trained to use the chairs and should have adequate follow-up by persons trained to do this A protocol for the minimum follow-up should be agreed upon, and wheelchair staff trained to use it Information already gathered from the user survey should be entered into a computer and analyzed.

COOPERATION AMONG ALL CONCERNED PARTIES

1.

A wheelchair-working group should be formed to implement the recommendations and the plan for distribution developed by the group which met during the Task
Force period.

SECTION 23: IMPLEMENTATION OF THE TASK FORCE RECOMMENDATIONS l. A body (composed of 4 sub-sector representatives and 4 counterparts, one full-time coordinator adviser, two representatives of CDPO, two of CDPF, two from NCDP, and one from MSALVA at the Undersecretary of State level, one from the Department of Rehabilitation, and one from the Office of International Relations) should be formed to monitor and implement the approved recommendations with action plans of the Task Force on Disability Issues.

96

References

l.

Planning and Statistic Unit, Ministry of Health "National Health Statistics Report 1996'' August 1997.
and statistic Unit, Ministry of Health 1995" September 1996

2. Planning
3. Planning

"National Health Statistics Report "Health Policy

and Statistics Unit, Health Department Ministry of Health

and Strategies 1996-2000" Unofficial Translation April 1996.

4. Ministry of Social Affairs, Labor and Veteran Affairs "Future Directions X'or Social Affairs within The Ministry of Social Affairs, Labor and Veteran Affairs for the
year 1995 and the years 1996-2000" February 1995.

5. Summary Report MSALVA Task Force on Disability lssues ooA National Stratery for MSALVA and NGO's of the Rehabilitation Sector on Disability Issues and the
Rehabilitation and Integration of Disabled People in Cambodia" October 1996.

6. Enitan

Sogbesan (Help Age International) and Uch Yutho (National PBL Coordinator) "Prevention of Blindness in Cambodia" 1997 Embassy to Thailand Investment Handbook" 1 996.

7. Cambodian

"Country Background - Cambodian Business and

8. Lai Heng Foong "The Situation of Disabled Persons in Cambodia" National Task
Force for Disabled Persons.

9.

Pascale Laurent for American Red Cross Cambodia

Cambodia" December

"Rehabilitation Sector Costs

1997 .