The following is a concept paper that I wrote for a new rural health initiative during my final year in Cambodia. It is based on research of similar health initiatives, interactions with local shareholders, and discussions with provincial experts.
1. Basic Information
- Country, Plan Title & Partner: Cambodia, Sangha Health Equity Fund, Rural Pagodas.
- Brief Description of project: To develop and implement a holistic approach by which existing institutions in rural communities can provide economic support for and improve the quality of public healthcare for the rural poor.
- Anticipated start and end dates: 3 years
- Anticipated Budget: $7,000 USD over three years
- Funding source: Dedicated Funds
2. Context & Rationale
Asked what was the single most serious health problem facing the countryside, Dr. Ngoa Hour, Vice Director of the Prey Veng Health Department, surprisingly and wisely replied, “Economics.” By international poverty guidelines set by the World Bank, 42% of Cambodians live in extreme poverty. The International Food Policy Research Institute 2008 Global Hunger Index ranks Cambodia among the 33 countries having an “alarming or extremely alarming” level of hunger. In 2008, the World Food Programme identified Prey Veng as one of ten provinces in Cambodia facing critical food scarcity. Rice farming is the primary livelihood of 92% (Prey Veng Department of Planning, 2006) of Prey Veng’s total population. Food production shortfalls impact the mostly agrarian population not only through lack of sustenance but also economically. The Prey Veng Department of Water Resources and Meteorology has identified seven of the province’s twelve districts as experiencing annual food shortages due to drought and flooding; these are Kampong Leav, Pea Reang, Peam Ro, Sithor Kandal, Peam Chor, Preah Sdach and Kompong Trabek. Annual food shortages are enough to force many poor rice farmers into high-risk situations such as working abroad (primarily in Thailand).
Due to poor diets and heavy workloads, impoverished rice farmers are not only more susceptible to disease and injury but they also have fewer resources to expend when health problems arise. With poor families already living “rork see” (literally: searching for each meal like an animal), injury or illness often forces families over the edge into extreme debt and/or high-risk situations. MCC Service Workers participating in the Prey Veng Health Program in early 1990s were direct witnesses to this, as is evidenced by their reports from that era. The resources that poor families lack are not limited to economics but also include medical information and education that would protect them from ineffective and often dangerous medical practices.
In 1993, MCC Service Worker Dr. John Martens reported on the “inappropriate use of Western medicine” at the Prey Veng provincial hospitals. He relayed that “indiscriminate use of powerful and potentially dangerous medicines is common both among trained and untrained health care providers. Antibiotics are the most prominent group and because of their expense many people end up with large bills for medicines that are often prescribed in inappropriate diagnoses.” He recommended that MCC “facilitate educational initiatives directed at raising awareness of appropriate use of medicines-primarily antibiotics” and “encourage appropriate and safe use of traditional medicine as a lower cost alternative to expensive western medicine.”
Pharmaceutical drugs are widely available, and virtually unregulated, in Cambodia. Counterfeit drugs are commonplace; annually since 2000 the Cambodian Ministry of Health has maintained that 13% of drugs on the market are counterfeit, however an independent study published in 2007 by the French-Cambodian Chamber of Commerce estimated that 30% to 40% of drugs are counterfeit. As a guideline, the World Health Organization estimates that as much as 30% of all drugs in developing nations are counterfeit. To become licensed in Cambodia, a Pharmacy needs to publicly display the certificate of a qualified Chemist but no other restrictions are made on shop operation and many shops function illegally without displaying certification. In licensed shops untrained family members often staff the counter and disperse drugs. Even if a qualified Chemist is present there are effectively no official regulations governing sales and clients can either describe their symptoms trusting the clerk to choose the proper medication or request a specific drug in stock. The drugs are sold alongside herbal remedies coming in a mismatched assortment of languages, primarily Thai, Vietnamese, Chinese, Hindu, French, English, and Korean. Practically none of the drugs sold in this manner have labels in Khmer, leaving the correct dosages and side-effects incomprehensible to most Cambodians. Verbal instructions are often given with drugs as they are sold but these are rarely in line with the written instructions.
Mineral and vitamin deficiencies related to malnutrition are often misdiagnosed and mistreated as diseases. The World Health Program has identified Vitamin A Deficiency, Iodine Deficiency Disorder, and Iron Deficiency Anemia as the three most prevalent and severe nutritional deficiencies facing Cambodia. These deficiencies cause a wide range of negative effects including migraines, night blindness, fatigue, depression, cretinism, goiter, blindness, and mental retardation. In Cambodia malnutrition most seriously affects children and women though adult men are also affected, especially those who consume excessive amounts of alcohol that prevents the absorption of essential micronutrients.
In 1997 the Cambodian government implemented a user fees policy for public healthcare as a means of generating resources for public healthcare institutions and supplementing the salaries of staff. Unfortunately, the introduction of user fees has effectively barred the poorest segments of society from making use of the public healthcare system.
Officially, Government Health Centers have been established throughout the countryside in order to provide accessible healthcare for all rural Cambodians. Unfortunately, in reality staff salaries below living wage and a general lack of accountability encourages Health Center staff to open their own private healthcare practices that are often operated at the neglect of public services using public supplies. The quality of and cost of service varies widely from private practice to private practice. Due to personal connections, bribes, or oversight, the majority of these private practices are unregulated.
Traditionally illness in rural Cambodia was considered primarily a spiritual matter and a wide array of spiritual forces was evoked simultaneously in hopes of appeasing the spiritual cause of the physical ailment. This approach of attempting many different treatments at once without care for their interaction is often dangerous when applied to Western medicine.
With the neediest unable to pay the user fees necessary to receive public healthcare, International Agencies have responded since 1997 by attempting to create institutions that pay healthcare bills on behalf of the poor. These Health Equity Funds are generally designed to be independent from the public healthcare system and accountable to external authorities. Most HEFs use household assessments to identify who qualifies for economic healthcare support and the selection process is generally standardized.
In 2007, the London School of Hygiene and Tropical Medicine published a study comparing four of the Health Equity Funds that have been established in Cambodia. While all four of the HEF models presented had positive aspects, the model implemented in Kirivong was the only one which utilized existing local institutions (Pagodas), which did not rely on external donors for continued funding, and which operated independently on a health center by health center level. The study verified that the four HEFs studied have helped the poor gain access to public healthcare in an accountable and accurate manner.
Traditionally, the Sangha (the community of Monks) has been the second most important institution in rural Cambodian life, second only to family. The pagodas were traditionally the center of rural village life. Monks were educators, mediators, healers, and councilors. The Sangha was shattered during the Khmer Rogue years when religion was outlawed and the majority of Cambodia’s Monks were brutally killed. The Sangha in Cambodia today retains significant social capital and fund raising capacity as evidenced by its extensive construction projects.
3. Goal & Plan Synopsis
The goal of this plan is: to develop and implement a holistic approach by which existing institutions in rural communities can provide economic support for and improve the quality of public healthcare for the rural poor. The Sangha (community of Monks) is envisioned as the most appropriate institutional target of these efforts given its unique position in Cambodian society.
- To empower a local self-sustaining institution that would serve to provide economic support for the healthcare of the rural poor.
- To empower local authorities to act as healthcare councilors who promote healthy low-cost treatments.
- To motivate and educate local authorities to act as voices for the poor in matters related to healthcare.
- To promote interfaith action by encouraging Christian Churches, Buddhist Pagodas, and Moslem Mosques to all contribute to support the healthcare needs of the rural poor.*
*This objective presumes that the Sangha is selected as the primary actor.
Describe the activities that will accomplish this goal:
Year 1 (50-70% Time): The principal MCC service worker will…
- use existing MCC connections within the Health Department to select potential target districts for implementation. Note: HealthNet International is operating in Pearang and Preah Sdach districts.
- make contact with existing Health Equity Funds in Cambodia and study their implementations. Of particular interest is the self-sufficient Kirivong HEF located in Takeo and Kampong Speu Provinces. The two HealthNet International projects located in Prey Veng Province (Pearang and Preah Sdach district) and the UNICEF project in Svay Rieng are close enough for regular visitation and direct observation. Note: Toch Amara worked for a Health Equity Fund in Kratie province before being hired by MCC.
- develop relationships with local stakeholders in target districts, including district chief monks, district governors, and public healthcare staff.
- select a target district for implementation and collaborate with local shareholders to develop a model that works there.
- work with the MCC health worker to develop simplified reference materials and educational materials in Khmer to help HEF representatives to act as healthcare councilors to the poor under their care. Primarily, reference materials on dangerous treatments and drug interactions, common drug side-effects, simple low-cost treatments for common ailments, dietary guidance for malnutrition, and similar guidelines. Additionally, HEF representatives should be offered training to identify counterfeit drugs and possibly language training to enable them to read medication instructions.
Year 2-3 (40-50% Time): The principal MCC service worker will…
- assist local shareholders to implement the model designed.
- continue to work with the MCC health worker to train local HEF representatives.
- manage initial MCC support for the provision of health reference materials, donation collection boxes, and other startup costs for the HEF.
- monitor and evaluate the effectiveness of the HEF.
One health operational district; comprised of 200,000+ individuals. Specifically, families of rural rice farmers who experience extreme poverty in conjunction with illness, especially women and children.
5. Resources and Summary Budget
The MCC Service Worker should be trained and/or have experience in Social Work, Public Health, Community Development, Business Organization, or a similar field.
GRANT PROPOSAL FOR INITIAL FUNDS AND MATERIALS
GRANT PROPOSAL FOR INITIAL FUNDS AND MATERIALS Summary Budget Breakdown DESCRIPTION AMOUNT GRANT REQUEST Initial Materials (Collection Boxes, Printed Vouchers, etc.)* $2,500.00 $2,500.00 Healthcare Reference Materials (Approximate Printing Cost) $1000.00 $1000.00 Startup Grant* $3500 $3500 TOTAL COSTS $7,000.00 $7,000.00
*Estimates based on Kirivong HEF Budget.
6. Monitoring & Evaluation
After Year 1, the MCC Partner Adviser would be responsible for updating, monitoring, evaluating, and managing this Plan.