The vast majority of Cambodians turn to travelling doctors, pharmacies or traditional healers when they get sick. Are they doing more harm than good?
When Cambodians fall sick, the vast majority seek medical care from the private sector. Some take their wounds, aches and illnesses to unlicensed clinics. Others seek out travelling medics wielding serum injections or pharmacies with a ready-made bags of pills. Then there are Kru Khmer, traditional healers who grind tree roots into balms and teas.
Private healthcare has overshadowed the public system for decades, and remains beyond the regulatory grasp of the government. But since an HIV/AIDs outbreak was discovered in December in Battambang’s Rokha commune, unlicensed medics have come under increased scrutiny. The outbreak, which affected more than 200 people, was blamed on an unofficial medic’s reused needles.
“It’s a very sad situation and a crisis that’s providing new momentum and opportunity to re-evaluate the Cambodian health system,” said Marie-Odile Emond, UNAIDS country coordinator. “It is a wake-up for all of us to look at the health provisions and increase regulation and access to services.”
For more than two out of every three patients, healthcare is synonymous with the private sector, according to the government’s 2010 Demographic Health Survey. Most look to private clinics or hospitals, while another 20 per cent head directly to pharmacies.
Patients say they are driven to the largely unregulated private providers because the facilities are closer, operate during more convenient hours, provide more open access to medicines, have shorter waiting times and offer one-on-one consultations with medical personnel. Such luxuries are not typically available at the understaffed and underfunded public centres.
“Sometimes it’s the same doctor from the public hospital working in the private sector to make more money. But in the public hospital, we respect the guidelines. For the private provider, more prescriptions means more income,” said Sok Srun, director of hospital services at the Ministry of Health.
According to the last government count, only about 500 registered private facilities operate in Cambodia.
But even those rubber-stamped operations, which are supposed to report regularly to the Ministry of Health’s Hospital Department, routinely fly under the radar.
And, officially, there are no unlicensed clinics in Cambodia. After crackdowns shuttered 908 illegal practices in 2009, the Ministry of Health’s annual count has not noted a single unlicensed provider.
But Rokha’s outbreak has forced the government to acknowledge an endemic problem in the country’s health structure.
“Currently, we don’t know how many there are, but very soon we will conduct an inventory,” said Srun. “We cannot allow them to run illegally and spread contaminants and contagious diseases as we’ve seen with Rokha commune.”
But the ministry’s vow to root out the perceived blight includes no promise to replace unofficial treatment services that in some cases provide the only medical care accessible to poor, rural villagers.
An expensive journey
Far outside Siem Reap town, along Chi Kreng district’s cavity-stricken dirt road, the options for medical care are drastically reduced: baggies of indeterminate drugs sold at corner shops alongside vegetables and shampoos, or calling a travelling “doctor”.
For Khvav village residents, simply getting to the nearest government-run health post is a struggle that can easily eat away two days’ wages in transport costs alone.
Almost 60 per cent of household medical costs, according to the demographic survey, are incurred while obtaining transport to a facility, a process that can put a family in debt, force them to sell land or evaporate savings.
Thon Thol, 55, doesn’t own a moto, a phone or even a house after it burned down while she was cooking rice. She ekes out just over $1 a day chopping cassava. So when her one-year-old granddaughter Lyly fell ill in the middle in the night with dengue fever last November, she asked her brother to call a doctor known to come to villagers’ homes and deliver injections on a pay-back later credit scheme.
Early the next morning, Dr Sat as he’s known to the villagers came and gave the baby a shot of serum. Twenty minutes later, the little girl was dead.
“We don’t blame the doctor, he is very good to always help us and kind to give us money to get to the provincial hospital,” said Thol.
Thol said her family goes to the government-run health post when they can afford it, but otherwise heads to the village store to buy medicine packets that she can pay for later.
Dr Sat wasn’t at his house and couldn’t be reached by phone, but his wife confirmed that government officials had told him not to offer medical treatment anymore after another “doctor” reported the dengue death.
But even if Thol had found some form of transport to undergo a witching-hour trek to the closest health centre when Lyly fell ill, they would’ve arrived to find the grey, dust-swamped outpost empty. The centre’s official opening hours – which working villagers referred to as prohibitive – are 7:30am to 5pm. It can stay open no later due to severe understaffing.
On a good day, the post – which lacks running water and weighs children using a jerry-rigged laundry basket affixed by ropes to a vegetable scale – has two nurses, two midwives and a medical director. There is not a single doctor on staff.
“All government health centres in remote areas don’t have doctors on staff,” said Oeur Meng, the director. Health Ministry officials confirmed the statement.
When Post Weekend visited the Khvav Health Centre during business hours on a Thursday afternoon, it was crowded with young mothers rocking sick, listless infants while waiting on the fanless porch.
With no X-ray machine or doctor, diagnosis is “symptom-based”, with cases that can’t be triaged referred to the district hospital more than 70 kilometres away.
“The people living here are very poor, and the district office is very far; many of them have trouble getting there,” said Meng, adding that he needs written approval from the provincial health department to drive patients to the hospital and that sometimes his centre runs out of tuberculosis medication.
That afternoon, the nearly empty medicine cupboard contained just a few cardboard boxes of antimalarials, antibiotics and betadine.
A 2012 study from the World Health Organization found that health centres, the primary gateway into the public system, tasked with providing everything from initial consultations to deliveries to chronic disease management, are unable to provide their full array of services about 60 per cent of the time.
Yet the majority of public sector cases are treated at these rural outposts, which handle eight times the number of patients per year than hospitals despite the lack of physicians, medicine and equipment.
The nearest hospital to Khvav village lies over an hour down a dirt track made almost impassable by trucks lugging in concrete cylinders and shifting mounds of earth in order to bring villagers piped water.
When Post Weekend visited the 24-hour Sot Nikum Referral Hospital, the medical doctor was away and the two on-call physicians were engaged in surgery.
Patients wrapped in bloody head gauze wandered the hallways. The single bathroom facility was splattered in a layer of blood and urine. The sole hand-washing facility was under a collection of trash. The rusted metal beds of the gynaecological ward were so close together patients laid less than a hand’s width apart.
Next to the hospital horrors, the white-washed walls, fluorescent lights and scrubs of larger private and possibly unofficial providers down the road allowed for at least a veneer of hygiene.
Apart from the Rokha commune outbreak, many observers note it’s hard to assess, given the scarcity of oversight or information, whether unregulated private providers pose more of a risk than the public system.
“It depends on what they’re doing,” said Emond at UNAIDS. “Some provide basic health services, while others delve into more advanced services they may not have the skills to be equipped to do.”
In a 2014 evaluation of the quality of care in the private sector, the World Bank found only 54 per cent of private health providers had any formal training.
In a series of diagnostic scenarios, only one out of three trained physicians were able to correctly identify all the illnesses; of the untrained providers, only 17 per cent were able to ascribe the right diagnosis and medication to each case.
A deadly ‘quick fix’
In Siem Reap’s Rolous commune, the Phe family believes their daughter would still be alive if she had not been treated by an unlicensed provider.
Last August, Phe Sopheap, 23, felt an itching on her scalp late in the evening, long after the public facility had closed, according to her mother and older sister. Because she had to work the next day, as a waitress in a tourist restaurant near Angkor Park, she wanted a quick-fix injection to relieve the symptoms. She and her sister went down the road to the bright green, wood-lined Hong Meng Thai Clinic.
Dr Hong Yeung has been treating villagers in Rolous since before there were any other available medical options, according to the villagers. He admits his clinic doesn’t have a licence and that his medical training originates in the army.
“After the Pol Pot regime, I came back to Siem Reap. People came to see me because they heard I had some medical experience and wanted to know if I could help them,” he said.
When Sopheap came to see him, he diagnosed her as having an allergic reaction to whitening creams she had been using to prepare for her upcoming wedding. He had his niece, a midwife, administer two shots, one of chlorpheniramine, an antihistamine, and one of triamcinolone, a cortisone-like steroid.
What happened next and how long it took Sopheap to get sicker is disputed by her family and the doctor, but both agree that by the time she came back to the clinic a couple of days later, she was unable to walk.
“If we had given her the injection wrong, maybe she would be sick or vomiting, but it wouldn’t have done this,” said Yeung.
A trip to another, licensed clinic and then to the provincial hospital led to doctors who said they could do nothing but suggest treatment in Thailand, or, if that was out of the family’s means, maybe at Phnom Penh’s Calmette Hospital.
After 21 days of a catheter, and then a feeding tube and then windpipe intubation, Sopheap’s lungs collapsed and she died.
“No one ever told us what she was sick with,” said Sopheap’s mother.
Officially, according to the Siem Reap Provincial Health Department, Sopheap died due to a rare autoimmune disease called Gullian-Barre syndrome that causes paralysis. But the Phe family said no one told them about a disease, and they hold Yeung responsible.
After having to borrow more than $8,000 to pay the Calmette bills, they’re suing the Hong Meng Thai clinic in a bid for compensation and to shut it down.
“In Battambang, [the HIV outbreak] happened because the doctor didn’t get proper medical training and gave injections carelessly,” said Phan Samphous, Sopheap’s sister.
“The two cases are very similar, but the Battambang doctor confessed what he had done. Here, the Hong Meng Thai Clinic denies anything is their fault.”
“I think most people don’t know the difference if a clinic is licensed or unlicensed, if it is good or bad,” she said.
“But something has to be done: I don’t want more people to die like my sister.”