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Tackling challenges a step at a time

Health Matters
Dr Nick Walsh

I often sit back and wonder why things are so in Cambodia in contrast to the region. Yes, there are many similarities, but also stark differences. This is often explained away by the Pol Pot/Khmer Rouge years, but I can’t help thinking that it surely is more complicated than that. If the Pol Pot years had not happened, would Cambodia be like Singapore? Would Phnom Penh resemble Jakarta? Likely not.

The preeminent medical journal The Lancet recently published a health series focusing on the ASEAN nations, of which Cambodia is one. It was a fascinating series of papers, so much so that rather than posting a ‘like’ on my FB page, I thought I would devote this column to it.

“It’s the economy, stupid” so the immortalised words go. But in many ways it all boils down to economics. This is not Cambodia’s strong hand. On a purchasing power parity measure, Cambodia has the lowest per capita income of the ASEAN region and the highest proportion of population living in poverty. Nevertheless, economic growth is robust, and one would expect these figures to change in the coming years.
But there’s much more to health than economics.

Starting with the basic facts, life expectancy in Cambodia is 61 years – a little less for men, a little more for women. This has increased by around 10 years in the past 15 – significant progress. Cambodia has a largely young population with 50 percent younger than16. It’s also largely rural country (85 percent) compared to its neighbours, impeding economic growth and the provision of health care.

Cambodia has the highest infant mortality and death rate within ASEAN

It turns out that Southeast Asia is somewhat of a ‘hot spot’ for emerging infectious diseases. Take SARS and H5N1 as two recent examples, as well as the recent emergence in Cambodia of malaria resistant to new antimalarials. What is less known is that the first reported cases of dengue hemorrhagic fever occurred in Southeast Asia and have contributed greatly to the global spread of dengue fever. The SARS outbreak alone cost $18 billion with a significant impact on tourism – a key industry for Cambodia and neighbouring economies.
How is it possible that we live in an area which is a crucible to human infectious disease? The most important factors are rapid population growth (from high birth rates) and rapid urbanisation. The latter is responsible for dengue spread in particular. Interestingly, farming practices do explain some diseases. For example Japanese encephalitis requires water birds and mosquitoes to propagate itself – though pigs can also harbour the disease. In Cambodia, rice paddy fields next to farmed pigs in combination with no vaccination programme mean that it is likely the prevalence will increase.

Cambodia experiences the highest burden of communicable disease in ASEAN, even surpassing Myanmar and Laos. This, combined with a lack of health infrastructure and trained health professionals, means that the challenges for Cambodia are great. Despite this, there is no doubt that the SARS, H5N1 and H1N1 outbreak focused minds on the tasks at hand, and better surveillance of infectious disease, including border screening, ensued.

Turning to child and maternal mortality, the news is also worrying. Within ASEAN, Cambodia has the highest infant mortality and deaths under 5 (mostly from infectious diseases like diarrhoea and pneumonia) and the second- highest maternal mortality rate. Despite this, the figures have improved by about 20 percent in the past 20 years – so progress is certainly being made.

Other ASEAN countries provide an example of how it is possible to reduce maternal and child mortality. Indonesia and Thailand were both able to do this over an extended period, a combination of economic development, gender equity, mandatory rural placements for health trainees, and a number of public policy programs resulting in better health financing.

Interestingly, early infant mortality improved with maternal mortality, meaning that what’s good for the mum helps the baby too. In terms of evidence, emergency obstetric care, safe water and the availability and use of appropriate oral antibiotics in early childhood are the key interventions which reduce deaths in these groups.

Lifestyle diseases have become part of the developed world over the past 20 years. Diabesity is the latest word to describe the epidemic, with fast food and lack of exercise to blame. However, Cambodia does very well when it comes to lifestyle disease with diabetes and obesity being near lowest in the region. Little data is available about tobacco use, but the risk of developing complications from obesity and hypertension are two to four times higher in Asian populations when compared with world populations. With increasing wealth, Cambodia will be vulnerable to an upturn in these lifestyle diseases.

Cambodia spends around 6 percent of its GDP on health, which is higher than neighbouring countries, but unfortunately 60 percent of health expenses are out-of-pocket, one of the highest in the region, meaning that the burden falls on families rather than the tax payer. The major reason for this is that 70 percent of health care expenditure occurs in the private sector (the highest in the region), and as most health economists know, private health systems are more costly than public ones. Cambodia’s health system is supported by donors to a large extent and with dependency comes the question of sustainability. But transferring the burden of health finance to the tax payer means a structured and effective tax system – and necessitates a middle class to pay the bills.

In fact, it’s a vicious cycle. Cambodia introduced a user fee for health facilities in 1996  as an incentive to health workers. Unfortunately for the poor, this was a barrier, and the health equity fund (donor backed) was introduced in 2000 to compensate health centres and providers. It now covers almost 70 percent of the poor in Cambodia and about a quarter of the total population. The  final stage is then transferring this burden again to the taxpayer (in the form of a social insurance scheme).

This has already happened in the Philippines, Laos, Vietnam and Thailand where social insurance schemes covering health in the formally employed sectors have been introduced to varying degrees, Cambodia is not yet in a position to consider this option.

Lessons from neighbouring countries show that consistent economic growth is needed to establish the tax base necessary to fund health insurance schemes. Cambodia is challenged by a largely rural population so health financing will be more difficult than urbanised neighbours.

But it’s not just about the burden of infectious disease and health financing. Doctors, nurses and other frontline health workers are needed to provide care and develop public health care systems. Cambodia currently has 0.2 doctors and 0.9 nurses (stats not people!!) per 1000 population, leaving it with a deficit of 44,000 health workers in order to meet World Health Organisation standards, only surpassed in absolute numbers by Vietnam and Indonesia (both sporting  much larger populations).

Whereas Vietnam and Indonesia have 14 and 52 medical schools respectively (though have larger populations), Cambodia has only one or two, markedly restricting the country’s capacity to produce new doctors. Cambodia fairs better when it comes to nurses, producing around 900 a year in the public system, though this is still low compared to our neighbours.

The mind boggles at the complexity of this kaleidoscope of issues. In many ways it does come down to economics, but it is a long and complex journey from basic health services to a sector with universal health coverage. Cambodia has had a more difficult journey than most. Decoupling health from dependence on aid is another additional challenge with no easy solution. Where the heck do we start? One step at a time.

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