Reseach on the Needs of Community Based Rehabilitation (CBR) for Disabled Persons in Cambodia

8/6/2019 Reseach on the Needs of Community Based Rehabilitation (CBR) for Disabled Persons in Cambodia

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Research on the Needs of Communlty BasedRehabilitation (CBR) for Disabled Persons

in Cambodia

Som-arch Wongkhomthong, M.DSomboon Kietinun, M.DChongkolnee Chutimatavin, IVIAYasuhide Nakamura, M.D

ASEAI{ bestitute for Health DevelopmentMahidol University1998

Funded by National Rehabtlttation Center forDisabled Persons JaPan


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Research on the Needs of Community BasedRehabilitation (CBR) for Disabled Persons

in Cambodia

Som-arch Wongkhomthong, M.DSomboon Kietinun, M.DChongkolnee Chutimatavin, MAYasuhide Nakamura, M.D

ASEAI{ Institute for Health DevelopmentMahidol Universitv1998

Funded by National Rehabilitation Center forDisabled Persons Japan


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

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

First Edition 1998Printed by : Printing DivisionASEAN Institute for Health DevelopmentMahidol University, SalayaNakornpathom 7 3170, Thailand

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


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Acknowledgement

We are grateful to the Embassy of Cambodia in Thailand and all these peoplewho 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 EngMony, Dr. seng Rattana, Dr. Phok chansorphea and Mr. Vong samnang who hadbeen kindly arranging and accompanying us to conduct our interviews.

Som-arch WongkhomthongSomboon KietinunChongkolnee ChutimatavinYasuhide Nakamura

September 1998.


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Executive Summarv

A cross-sectional descriptive study to identi$' the situation and needs ofcommunity-based rehabilitation (C.B.R) for disabled persons in Cambodia wascarried out during August - September 1998. The research has specific objectives inidentiffing the general situation of disabilities and impairments, the situation andneeds of community-based rehabilitation and possible af,eas for internationalcooperation for C.B.R. in Cambodia. The research methodologies consist of fourmethods: literature review of published and non-published documents of relatedorganizations, data collection from structured questionnaires given to Cambodianhealth authorities, visits to eleven institutions in Cambodia as well as personalinterviews of eighteen Cambodian authorities using unstructured questionnaires. Theresults were summarized under six topics: basic statistics, C.B.R. services, the needsof 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 healthconditions among Asian countries. The government's health budget is very low,resulting in poor health services, in prevention and promotion, and poor accessibilityand availability This is even more so for services directed to the disabled. Thesituation concerning disabilities is severe and may become more so due to theexistence of a lot of land mines in many places and the increasing number of trafficaccidents. People experience malnutrition, deficiencies resulting in blindness,poliomyelitis and encephalitis. Presently, immunizations are not sufficiently coveringthe population. Due to the Pol Pot Regime and long history of internal fighting, thereis an increasing number of disabled persons and an increasing shortage of manpowerin all medical fields, especially for handicapped, as well as in the social fields andspecial educational fields. So the needs for Cambodia are not only community-basedrehabilitation but also a general need to assist in all medical fields, social fields, andeducational {ields in order to improve the entire health, social and educational system.


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iii

ContentsAcknowledgementsExecutive sunmaryContentsList of figwesList of tablesIntroductionResearch objectivesResearch methodologyOperational definitionModels for CBRResearch results

I. Basic information1.1 Health situation1.2 Competent authorities on the health services:

principle organization collaboration1.3 Health policy and Planning 20-221.4 Actual conditions of people with disabilities 22-261.5 Administrative Division on the Rehabilitation services 26-281.6 Specialists in the rehabilitation fields 321.7 Main organizations of C.B.R. 32

II. The actual condition of medical rehabilitation 36III. The needs of C.B.R. 46IV. Foreign assistance for C.B.R. 46Conclusion 48Recommendation 48

ANNEX A: List of Organizations in the Field of Disabilities in Cambodia 49-55ANNEX B: Medical Rehabilitation 56-64ANNEX C: List of Interviewees & List of Institutional Visits 65-68ANNEX D: Community-Based Rehabilitation 69-78ANNEX E Summary of Recommendations 79-96References 96

iiiiiiivvIaJJ3-67-9999-18

19-20


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iv

List of Figures

PageFig. 1. Main health problems of out-patient consultations by age group I I

at health centers, Cambodia 1996Fig.2. Main health problems of out-patient consultations by age group 13

in hospitals, Cambodia 1996Fig. 3. Main causes of hospitalizationby age group in Cambodia, 1996 15Fig.4. Organizational structure of the General Directorate of the Ministry of 29

Veterans Affairs and Social AffairsFig. 5. Organizational structure of the Rehabilitation Deparftnent 30Fig.6. organizational structure of the Disability Action council (DAc) 3l


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V

List of TablesPage

Table 1.Main health problems of out-patient consultations by age r0group at health centers, Cambodia 1996

Table 2.Main health problems of out-patient consultations by age 12group in hospitals, Cambodia 1996

Table 3.Frequency and age distribution of main health problems 14seen at in-patient hospitals.

Table 4.Main health problems among in-patient hospital in 1996 16Table S.Number of cases, causes of dealths, and case fatality rates 17at the I.P.D.Table 6.National hospitals: main causes of hospitalization and 1g

death in 1996Table T.Total number of disabled persons in Cambodia 23Table 8.Final classification of confirmed polio cases by district 25

ofresidenceTable 9.Mine and road accidents in 1996 26Table l0.Services for disabled persons by province 35Table l l.Statistics of disabled persons who have received training 44


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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 disabledand can still be provide potential man power. Even though they have lost someability, either temporarily or pennanently, many still have other abilities whichmay 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 orsevere disability . If the world population were 276 millions there would be 93million disabled persons (or one in three) living in developing countries.In Thailand, the Health Research institute had done a survey of the health situationof those above five year of age in the population and found that 8.1 percent of thepopulation was disabled out of the total population of 4,614,650 persons, excludingpsychological disorders.

United Nations has given guidelines for the disables as follows:1. The disabled have the equal human's right as others so they shouldbe supported, protected and given the opportunity of rehabilitation.2. Due to disability, these people already have psychological and mentaldistress; 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 developthemselves and be useful to the society.4. The disabled, after completing rehabilitation, will be responsible insociety and the country.5. The disabled prefer to live freely in the general community instead ofin special places provided for them.6. To rehabilitate successfully, it is important that all people concernedmust give good cooperation and give them opportunities.

From 1982-1992, there were ten years of focus upon issues of the disabled, includingprevention, rehabilitation, and equality. The Asian and Pacific region has joined toestablish the LIN-ESCAP committee and declared in 1992 in Beijing that the years 1992-2002 will mark ten years of focusing on the issues the disabled in the Asian and Pacificregion. The LIN-ESCAP is composed of 31 country leaders out of the 60 countries thatdeclared the Proclamation on the Full Participation and Equity of People with Disabilitiesin the Asian and Pacific Region. Organizations of disabled persons exist such as "Self-help organizations of disabled persons" and at the world level such as the "DisabledPeople'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 aresingle disability organizations. In Thailand there is a council for all disabilities called "TheCouncil of Disabled People of Thailand" (DPT) and in Cambodia there is an organizationcalled "The Disability Action Council" (DAC).


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L

In Cambodia the health status of the people is amongst the lowest in Asia. Reliablemortality and morbidity data rarely is available in Cambodia - most are hospitalbased and most of the surveys conducted in the past were small in scale.ooo

Pregnant women receiving 1 ANC visitMaternal Mortality RatePopulation with access to health servicesRuralUrbanSource: Health Policy and Strategies 1996-2000

44%4731100000 live births25%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 healthservices.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 ofmalnutrition.The influx of vehicles is a major cause for concem of road accidents. Monthly hospitaldata show that there are 500 to 600 traffic accident admissions with the case mortalitv rateof 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 - thehighest 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 earinfection, causing hearing loss. For those with disabilities under 15 years of age, 43Yo arecaused by polio, ll.6% by mental disorders and 2lohby amputations.Due to the highly traumatizing events, such as prolonged war, the constant fear of mineinjury, the dislocation of families, and the loss of relatives, have resulted in considerablepsychiatric morbidity confirmed by studies among displaced Cambodians in the bordercamps. Large numbers are in need of psychiatric and counseling services for mentaldisorders.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 tohealth care services, and the absolute poverty of the majority of its citizens all contributeto the fact that Cambodia is a country with a high number of disabled people. In 1994


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3

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

2. Resdearch ObjectivesGeneral Objective: To identify the situation of the disabled and the needs of community

based rehabilitation (C.B.R.) programs in CambodiaSpecific Objectives

2.1 To identify basic statistics2.2 To identify community-based rehabilitation (C.B.R.) services2.3 To identif the needs of Community-based rehabilitation2.4 To identiff foreign assistance for C.B.R.2.5 To identify the possibility and the limitations of C.B.R. models.3. Research Methodology

Cross-sectional descriptive study including:3.1 Review of literature and documents3.2 Structured questionnaires targeting concerned persons.3.3 Institutional visits to observe certain activities as well as to gather someunpublished information: a total of 11 institutes3.4 Personal interviews: A total of l8 persons were purposively selected andinterviewed by using unstructured questionnaires concerning their directinvolvement in disabilities and rehabilitation.4, Research Period

August-September 1 998.5. OperationalDefinitions:Community-based Rehabilitation in CambodiaIncludes either the government or NGOs

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


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Rehabilitationr Restoration of form and function following an illness or injury.o Restoration of an individual's capability to achieve the fullest possible lifecompatible with his abilities and disabilities.o The development of a person to the fullest physical, psychological, social,vocational, and educational potential consistent with his or her physiological oranatomical impairment and environmental limitations.

ICIDH definitions (WHO 1980)o Impairment in the context of health experience is any restriction or lack (resultingfrom impairment) of ability to perform an activity in the manner or within therange considered normal for a human being.o Disability, in the context of health experience is any restriction or lack (resultingfrom impairment) of ability to perform an activity in the manner or within therange considered normal for a human being.o Handicap in the context of health experience, is a disadvantage for a givenindividual resulting from an impairment of disability, that limits or preventsthe fulfillment of a role that is normal (depending on age, sex, social andcultural factors) for that individual.

Disabilities can be divided in 5 groups as follows1. Visual Disability2. Hearing Disability3. Physical or Locomotive Disability4. Psychological or behavioral Disability5. Mental or Leaming disability- Visual Disability : visual acuity of any eye or both after using ordinarymagnifying lens is equal or worse than 6/18 (20/70) to cannot see even light or visual fieldis narrower than 30 degrees.- Hearing Disability : those hearing frequencies at 500 Hz, 1000 Hz or 2000 Hzaverage

5.1 Children under 7 year > 40 Decibel cannot hear5.2 Others >55 Decibels so that they cannot hear or those who have abnormalimpairment to understand or use speech language to communicate with theothers.- Physical or Locomotive disability : those who have abnormal or physicalimpairment so that they can not do their own daily living or loss of limbs, upper or/andlower, or/and part of the body from amputation, paralysis, weakness, diseases of the jointsor chronic pain, including chronic diseases of other organs, until they can not live in theirnormal daily lives as others do.- Psychological or behavioral disability : those who have abnormal orpsychological or brain impairments that create difficulties in emotion learning or thinking


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5

so that they are not able to control necessary behavior to take care themselves or live withthe others.- Mental learning disability = those who have abnormal or mental impairment orintellectual impairment so that they can not leam by usual methods.Causes of disability (WHO expert committee)1) Congenitall.l Genetic e.g. mental retardation1.2 Acquired e.g. wrong medication, intrauterine infection and during labor2) Infection e.g. Poliomyelitis, Syphilis3) 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.4) Psychosis e.g. depression, obsessive-compulsive neurosis

5) Alcoholism and other drugs addictions6) Environmental and accidents e.g. water, air and land transportation, warfare7) Malnutrition during pregnancy and extra uterine period e.g. congenital iodinedeficiency8) Others e.g. toxic substances such as Mercury poisoning, lead poisoning,o Rehabilitation within health care services has traditionally been thought to involve theprovision of therapy - physical, occupational, and speech - as well as specialequipment. Traditional rehabilitation services are provided in various settings, forexample, special institutions, hospitals, and out-patient clinics. In some countries,these services a.re delivered in people's homes. They are generally not provided incoordination with other services. Community based rehabilitation (CBR) enlarges theconcept of rehabilitation to include all of the services that assist disabled people todevelop their abilities.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.

o Occupational therapy (OT) - A system of medically prescribed activities, typicallyinvolving the use of objects to increase coordination, range of motion, power, andfunction, or for diagnostic, psychiatric, or other therapeutic purposes.. Speech therapy (ST) - Treatment of speech disorders such as aphasia due to cerebrallesions, dysarthria due to local organic lesions, speech defects after laryngectomy andother disorders of communication.o Prosthesis (plural prostheses) - From the Greek, freely translated as "placed instead"Artificial part of the body: tooth, eye, joint, digit,limb, breast, etc.


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o Orthosis (Plural, orthoses) - General term for a device applied to a patient, usuallywith a deficiency of the locomotor system, for a supportive, assistive, adaptive,preventive or corrective purpose. This excludes prostheses, which replace missingparts, but includes objects that may be known as braces, splints, collars, corsets,supports, bandages, or callpers.. Major strategies for rehabilitationl) Institution-basedrehabilitationservices2) Outreachrehabilitationservices3) Community-basedrehabilitation(CBR)

o Service delivery system for CBR.4) Community5) District6) Provincial7) National

o Rehabilitationin as social issuesl) Traditional approach CBRIndividual issues - Disability- Social issuesMalfunction Barrier in SocietyDirect services - Approach - Social changeCurative PromotiveChange PWDs Change communitySpecialized -services- GeneralBy professionals By the communityFunctional recovery - rehabilitation - Break the social barriersSpecialists in this study apart from medical staff in special fields also include1) The pychiatrist is the doctor who will assess the physical ability of thehandicap as well as prepare him or her for rehabilitation.2) The physical therapist rehabilitates according to the physician's order3) The vocational guidance officer gives information for occupationalrehabilitation and make the handicapped person understand their training choices4) The social worker takes care of individual social, family andcommunity problems and refer cases5) The vocational training officer gives information and skill training, increasesthe physical ability and experiences of the handicapped to be able to work6) The job exploration or job placement officer coordinates with otheragencies to find the jobs for the handicapped.7) Etc.


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

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

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

Model 2. Mobile rehabilitation unitSupplementation of C.B.R. Indonesia

Sub-center of VRC Sub-center of VRC

Community rehabilitation center atevery district3 month services

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

Activities of volunteers, community workenhome visits, vocational training.

Independence of the handicappedIncluding economical independence


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Model 3. Community volunteer system(Local supervisor system) The Philippines

Instruction, management,psychological support

Families traininghandicapped peoplewho are chosen by the village

Education

Specialists

Specialists give one-week training to the local supervisorspeople

Model4. Volunteer systems with health care centers ThailandVillage health communicator, VHC, role of information givingVillage health volunteer, VHV; provision of basic medical services(two-week training and ongoing training)VHCs and VHVs are chosen among the village people

VHV, VHCEarly detection and intervention to theDisabilitv

Local supervisor (LS)

Handicapped people families


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VHV, VHC will detect disabilities and report them to the health center. The health centerwill bring the handicapped people, their families and volunteers together to collectinformation.6. Research Results

The results are presenting under the following topics:6.1 Basic statistics6.2 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. models6.6 Requests to National Rehabilitation Center for the Disabled, Tokorozama,Japan

L Basic Information1.1 Health situation (1995)* Total population- age >15- Size of the household* Women headed householdt GDP growth* GDP* Life expectancy at birth* Infant Mortality Rate* Under 5 Mortality Rate* Infant low birth weight* Under weight (under 5 )(weight by age)+ Immunization of children, age one year, againstMeaslesPolioDPTBCG* Pregnant women immunized

against tetanus (T2 +1Source: Ministry of Health.

10.2 millions.56.3%5.621.2%7.6%US$ 289 millions

56 years.115/1000 live births181/1000live birth17%39.8%

75%80%79%9s%33%


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Table L. Main health problems of out-patient consultations by age group atHealth Centers, Carnbodia, 1996Health

Problems0-4 s-14 >15 Total

N , N V" N oSuspectedMalaria 18,807 19.95% 27,508 28.60 47,967 53.40 94,282Other Fevers 213,529 32.8t% t82,726 27.60 254,591 39.20 650,846Diarrhea I 15,554 31.72% l12,20l 29.80 t36,541 37.r0 364,296ARI r43,633 31.30% 148,858 32.20 166,394 35.00 459,885Coueh >2ld 3,253 t3.st% 5,381 22.70 15,453 63.40 24,087Polio 55 22.82% IJ 23.50 113 4.40 24rMeasles 1,102 42.90% 1,124 37.00 343 I 1.80 2,569NeonatalTetanus 0 0.00% 0 0.00 0 0.00 0Others 125,389 23.14% 143,578 26.20 272,853 49.70 541,820Total 621,322 29.07% 621,449 29.08 894,255 41.85 2,137,026

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


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ilFig.I Main Health Problems of Out-patient Consultations by Age group at Health CentresCambodia, 1996

a. Children under 5

b. Children 5 to 14OtheF

t2%Suspwted Malaria

B%

c. Adults >15 vearsSusp@ted Malari&t8,/e

Oths FeveBt3vo

ARIt2o/o

Source: August 1997 MOH


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l2

Table 2 Main Health Problems of Out-patient Consultations by age group inHospitalsn Cambodia,1996

Health Problems 0-4 5-14 >15 TotalN % N % N % Out-patients

Malaria 10,606 12.2 17,062 19.69 58,967 68.06 86,635Other Fevers 44,910 21.5 48,1 13 23.02 I16,018 55.50 209,041Dianhea 35,602 27.1 29,405 22.38 66,409 50.s3 l3l,416ARI 76,746 24.1 69,837 21.91 172,104 54.00 318,687Cough >21 day 1,922 8.6 2,712 12.13 17,730 79.28 22,364Measles 632 aa a)). t 462 24.67 779 4t.59 1,873Malnutrition 3,905 3,905Skin Infection 7,218 21.6 8,322 24.70 18,094 53.70 33,697GYN Infection 53,461 r00.00 53,461STD (Males) 9,939 100.00 9,939Others 57,109 t2.2 73,184 15.57 339,630 72.27 469,923Total 238,713 t7.8 249,097 18.58 853,1 3 1 63.622 1,340,941For Inpatient Hospitals, the possible health problems which may result in disabilitiesare meningitis poliomyelitis, measles, mine accidents and road accidents which areprevalent in all age groups. Meningitis is prevalent in almost every province. (Table 5-7)


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t3Fig IIMain Health Problems of Out-patient Consultations by Age Group in Hospitals, 1996

Othen24%

Children under 5Malaris40/r

Other Fcverslf/o

Cough >2ldayP/.

Malnutrition2%

Skin infwtion40/o

DimhalSYo

I

Other Fwrct9%

Cough >2ldrylloSkin Infwtion

3yo

Other FeveRt4vo

I

I

t_ lo/o cyn lnfection cough>2tfiy skin Infection6% 2%, 2%


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t4Table 3 :

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

Health Problems 0-4 5to 14 >15Totrl

InpatientsN o/o N o/o N o/o

MalariaDianheaDysenteryARIDengue/DHFMeningitisPolioMeaslesNeonatal tetanusTetanusTBGyn-obMine accidentsRoad AccidentsOthersToal

3,0134,077

9417,204

777408

555

24l3

22t99

6,49423,237

13.8443.7330.523t.6754.2247.5521.43s6.t2

100.00t5.290.09

0.912.76

r 0.0013.88

4,0121,742

7023,918

603233

739

2979

237I,0539,444

2l,0gg

18.4218.68)) 1117.2342.0827.1650.0039.80

18.470.55

9.8014.5813.00t2.60

14,7513,505r,440

11,62353

2t744

10414,15819,1072,1595,970

50,012r23,107

67.7437.5946.715r.10

3.7025.2928.574.08

66.2499.35

100.0089.2982.6677.00

73.522

21,7769,3243,083

22,7451,433

858t498

t5714,25019,r072,4197,222

64,950167,442


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III

Fig III Main Causes of Hospitalisation by Age Group, Cambodia, 1996

a. Children Under 5Malaria

136/o

t- b. Children 5 to 14

Road Accidenhsyo

Mcningitis Dengue/DIIFtvr lVrMinc accidcnts

l'/o

ARJ't%

TBtgyo

Road A@idot!4vo

Minc rccidenh2'/. Gynobl5o/o

l5


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Provine 0ther Sholera DHF dvsent., cyn-ob ARI mslarir meningitir AFP TB TotalSvay Rieng 2,648 t4 218 51 I,1 50 |,t62 5t2 63 1,t39 6,968Prey Veng 4,0t 0 t5 469 lr4 1,349 1,356 381 )J I 1,002 E,750Kandal 5,161 ll9 612 120 886 1,199 144 23 1,099 9,363Phnom Penh'

Kampong Cham

8,142? tot

4

100

405

6l470

1,060

zt430

209

2,320

437

3,052195

1 a)7 145203

1,129

10,086

r 7,0t 5Kampong Chhnang 2,039 30 297 t04 I,163 560 166 l4 388 4,761Kampong Speu t,965 f) 458 t79 929 824 630 25 404 5,469Takeo 4,820 23 466 92 745 |,4',13 544 74 I,l6l 9,398Kampot 3,684 106 746 t75 I,1 26 |,287 I,416 JJ 778 9,35lSihanouk Ville I,891 38 277 6l 358 360 2l I zt) 3,219KohKong 324 I ll5 9l l5l t63 903 2l t,113PurSat 2,684 324 52 215 lt9 1.245 |,t76 |,447 30 577 7,869Battambang 6,813 JJ 798 256 3,7 s7 2,4't2 t,728 152 899 16,908Bantey Meanchey 4,81 I 49 222 554 221 |,002 I,503 382 t20 978 9,E42Siem Reap 4,787 115 69 364 208 683 1,608 3,069 42 t,w2 t2,u7Kmpong Thom 3,418 98 29 379 r36 913 |,244 655 l6 877 7,765Preah Viher 1,126 11 432 80 229 564 993 20 102 3.563Kratie 3,283 52 401 lll 633 869 2,40s IJ tt2 7,880ltung Treng 9?7 l0t t93 62 6 203 883 t 4 2,432v{ondulkiri 120 2t0 100 251 t20 661 29 1,491tattanakkiri 822 t0l 7l 7l l8l 829 J 66 2,t44(ep lt6 39 l 5 7l 273Rubber Plantation |,254 450 270 245 89'l I ^875 4 2 4,997Iotal 72,087 764 t,433 9,324 3,083 19,t01 22.745 21,776 858 3 t3,045 t64,225

t6Table 4 : Main Health Problems among In-patients at Hospitals in 1996

* Not including data from the National HospitalTuberculosis : Data from National Commitee of Tuberculosis (lnctuding PT, Extra pT and TB with BK-)KEP is including in Kompot for tuberculosis dataPlantation is including in Kampong Cham for tuberculosis data


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l1Table 5 : Number of Cases, Causes of Death and Case Fatility Rates at the IPD

Health Problems Cases Deaths CFR%Malaria 2177C 764 3.5Dianhoea 9324 86 0.9Dysentery 3083 42 1.4ARI 22745 554 z..lDengue/DHF 1433 73 5.1Meningitis 858 t47 t7.lPolio t4 c cMeasles 98 2

az

Neonatal tetanus 2 28.6TB |42sA 232 t.6Suspected Acute Severe Diarrhoea 764 l8 2.4GYN-OB t9107 68 0.4Mine Accidents 2418 lt4 4.7Road Accidents 7222 143Cthers 64343 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%ofollowed with DHF 5.lolo, mine aecidents 4.?%o,malaria3.So/o,others and suspected acute severediarrhoea and AN 2.4o/o meules and road accidents 2o/o (Table y)


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l8Table 6 : Main Causes of Hopitalizationn Number of Cases and Death in National Hospitals i

MCH : Matemal and Child Health HospitalNPH : National Paediatric Hospital

Causes MCH NPH CALMETTE KOSAMAK NORODOMCases Death Cases Death Cases Death Cases Death Cases Death

Malaria 394 ll \) 27 2 l9l 28ARI 3,31 I 240 1,728 99 76 15 4 74Diarrhea 934 1,622 6 I l8 4 61 I 89 tICholera 2t 2 2Iyphoid Fever 687 z 984 2 14l 2 39 134Dysentery t9l 89 t2 l3Dengue Fever 402 24 343 9 ) t9 IMeningitis ll0 t7 76 tt 54 t2 ll 2Acute Flaccid Para, I9 2 87 4l 2AIDS 30 5 217 30 t4ItTraffic Accidents 545 1,194 7l t23Mine Accidents 5t 140 5 T2Others I1,619 3,552 9,068 2,660 4,714Iotal 17,688 299 8,476 r39 r0,396 I l8 4,t08 77 5,412 49Note:


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t9

1.2 Competent authorities on health services of principle organizationsand collaborations.Health Care is the responsibility of the Ministry of Health, except for the care ofthe physically handicapped which is under the responsibility of the Ministry of SocialAction 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 andfarmers are under the Ministry of Agriculture.The national health system is organized into four levels: central, provincial, districtand commune levels.The Ministry of Health funds and directly administers the following central institutesand 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 Healtho The Center for Venereology (STD) Training Instituteso The Faculty of Medicine, Dentistry and Pharmacy.o The Ecoles des Cadres Sanitaires Secondaires (ECCS)o Four Regional Training CentersHospitals:Calmette Hospital, Preah Naredom Sihanouk Hospital, National Paediatric Hospital,Preah Kosomak Hospital (17 April) - surgical, December 2 Hospital -ENT andNational Blood Transfusion Centre (CNTS), January 7 Hospital - women, KunthaBopha Hospital - children.There are 19 provinces, 2 municipalities and 176 districts. The administrativeorganization of the provincial and district health system follows the centraladministrative system. In each province and district there is health service. It isheaded by the provincial director. The Department of the Health Services at thislevel are similar to those in the MoH which include pharmacy, a hygiene andepidemiology station, planning and statistics, finance and budget, and administration.At the district level, there is a District Health Officer, responsible for both curativeservices at the district hospital and health services in the communes and villages ofthe 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 thecriteria for the location of health facilities together with a definition of a basicminimum services package to be offered at each level organizedby the Ministry ofHealth. This Plan entitled the health coverage plan to be based upon equitablegeographical access to basic health and referral services for the population in order tooptimize the allocation of scarie health resources. At the prouinriul level, this will


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20

result in two levels. The first level is a provincial level and the second level is areferral 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 avoidor to manage health problems. In addition, the absence of reliable information toassess public health problems stands in the way of effective action to address them.Human resource situationIn 1975-79 the Pol Pot regime devastated the Cambodian professional classes,including health professionals. Only 50 medical doctors remained after the fall of thePol 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 poorquality of this training partly explains the inadequate technical capacity of the publichealth services today. There are currently 23,270 health workers at all levels who areemployed by the MOH (17,964) as well as other government agencies. Two thousandof these workers were trained at the border camps. The various categories of healthworkers include 1,201 medical doctors, 1988 medical assistants, 47 dentists, 321pharmacists,3,l06 secondary nurses and 1,316 secondary midwives.Expanded programs on immunization, pharmacy, etc. to provide staff for health carein the hospital were put into place. The number of staff at this level range from 15persons to more than 30 in larger districtsAt the commune level, there is a cornmune committee in which one member is givenresponsibility for health matters. This committee is responsible for appointing threehealth workers: a primary nurse, a primary midwife and a tradiiional healer.Traditional birth attendants exist within communities and additional training has beentaken on by non-governmental organizations. However, there is no formal strucrurefor their integration into the regular health system. Now, the Ministry of Health isundertaking a process of rationing health services resources in the district/ communelevels, basing this on population size rather than strictly administrative boundaries.

1.3 Health Policies and planning: the present policies by central andlocal governments -The Royal Govemment of Cambodia (RGC) affirms its mission to improve the healthand 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 curativehealth cares for people living in the rural areas by organizing healthcenters and maternity services;3) Reducing infant and maternal mortality rates through mother and childhealth care;4) controlling communicable diseases, especially malaria, tuberculosis,

dengue haemorrhagic fever and acute respiratory infections;5) controlling the spread of sexually transmitted diseases, especiallyHIV/AIDS;6) Improving the supply and distribution of drugs for people, if possible, by


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2l

organizing local drug production using local raw materials; otherwise bybetter management of international tendering, procurement, importationand distribution.

After developing the health policy and strategy, the Ministry of Health had a long-term perspective in developing the health services in the country. Significantinvestrnent by the govemment and its partners has been made in the development ofboth policy as well as the management and planning capacity within the MOH. At theend of 1995, the new health coverage plan for the provincial and district levels wasalso formulated. Additional investment has been made in a number of priority healthprograms, with varying degrees of success. In the implementation of the NationalPrograms for Rehabilitation and Development, the Royal Government chose theMinistry of Health to be a pilot ministry in the reform and the development of thehealth 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 staffmanagement,- 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 andchildren, especially through immunization, birth spacing, antenatalcare, safe delivery, essential obstetrical care and essential clinicalservices.Reduce the burden of communicable diseases, especially malaria,tuberculosis, STD/HIV, dianhoeal diseases, acute respiratoryinfection and dengue haemorrhagic fever.Monitor, coordinate and distribute equitably the resourcesfrom international and non-governmental organizations. Ensuresustainable development with considering ways to generaterevenues at the communitv level.

Health policies and strategies are designed to develop an affordable and rationalhealth service that will meet priority health needs as well as to ensure access to theseservices by the majority of the people of Cambodia, particularly those living in ruralareas. They are:o Extend basic health care services based upon a cost-effective, but essentialminimum package of curative and preventive health services covering allcommunes in the country; a system that will be based on the "District HealthSystem Approach" which is successful with community participation;

aJ.

4.


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22

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

OVERALL OBJECTIVE OF'THE RGC IN SOCIAL DEVELOPMENT1. Reduce maternal mortality rateby 40Yo2. Reduce child mortality rate by 30%3. Reduce prevalence of malnutrition by 50%

TARGET FOR THE YEAR 2OOODespite the immense health problems, some progress of strategic value has beenmade in recent years. Immunization services are now increasingly available.Although inadequate to meet the need, a basic supply of essential drugs reacheseven the remote commune health centers. District and commune level healthservices are already operational in some areas. The first steps are now beingtaken towards reviewing how basic health services, e.g. Minimum Package ofActivities (MPAs) for Health Centers can be accessible and available at thecommunity level.

1.4 Actual Conditions of people with disabilitiesAs 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 verypoor. No nation-wide statistics have been collected. Data is primarily obtainedfrom the hospitals, institutes and health centers. For disabled persons, datamostly comes from only those who come for services with the govemment orNGOs' Thertefore, it should be recognized that the statistics come fromestimations which may result in under-estimations. In 1994, the American RedCross, the National Rehabilitation Seminar, the Ministry of Social Affairs, andthe Labor and Veterans Affairs reported that there out of a population of8,830,176, there were 21,192 amputees, 7,947 paraplegics or tetraplegics,17,66apersons 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 vnthother disabilities totaling 122,739 disabled persons.Four principle surveys have been done using the ICRC survey instrument: PhnomPenh, Bantear Meanchey, Kompong spen and Kampong Som. These wereconducted by ICRC/MLSA (first two), Am RCA4LSA and CT. Comparisons willonly be considered for the results from the first three surveys because coveragedata is available. The Phnom Penh needs assessment was known to include IOO%


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of all known groups, sub-districts, and districts surveyed in the Phnom Penhurban area. The Kompong Speu needs assessment surveyed 99J% of knownvillages at the end of 1992. The Banteay Meanchey needs assessment wasconducted in only 82% of the known sub-districts (Khums); 18% wereinaccessible due to logistic and security problems.From the analysis of the various surveys, the results of numbers of disabledpeople in Cambodia are as follow:Table 7 : Total number of Disabled People in Cambodia

Source: AmRC Rehabilitation Survey, American Red Cross and World VisionThe ADD report cited the following comparative statistics concerning each of theidentified disability groupings: amputees, blind, polio, mental health, deaf, paralysis,leprosy and "other," using statistics from ICRC/IV{LSA, AmRC, and cr.2' From thefigures of ICRC/Ir4LSA and AmRC, a projection of the number of disabled peoplehave been made (see Table 4) using the average of l.39Yoof the total population beingdisabled. From this percentage, and using the most recent population figures fromNIS, it was estimated that there are approximately 136,000 disabled people inCambodia.BlindThere are currently 90,000 blind people in Cambodia,60Yo caused by cataracts. Othercauses are glaucoma(10%o), corneal scar (10%), and others (20%o).22 There are alsomany people with refractive errors that are not corrected by reading glasses due tolack of funds.AmputeesStatistics given of the prevalence of amputees in Cambodia differs according to thecriteria for inclusion, and the sources of data used for the estimation. A report byPhysicians for Human Rights and Asia Watch23 reported at the end of l99l that theprevalence of amputees is at 36,000 with 120 new amputees arriving every month toP & O centers to seek treatment.Recently, ICRC reported that there are approximately 20,000 to 25,000 amputees inCambodia now, with 100 new amputees each month.to This projection is tased onrecords that were available at the Mongol Borei Hospital, Banteay Meanchey

Area PhnomPenh BanteayMeanchy KompongSpen KompongSom Pursat (onedistrictonly)Population 612,315 350,000 465,73r 40,000 86,000No. ofdisabledpeople

7,191 4,273 8,252 1,000 1,320


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24

Province from 1 January, t994 to September 30, 1995 (a 2l-month period). Totalmine injtrriesAJXO victims for that period (soldier and civilian) were 567 (or 27victims 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% inSeptember 1995; upper limb amputation was l6Yo and 20% for 1994 and 1995respectively. The ICRC statistics is only based on the number of hospitalizations dueto mine injuries. The breakdown of military and civilian for this period was about 2to 1.25According 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 inBanteay Meanchey, 98 in Kompong Thom giving a cumulative number of 383 for thatperiod. As a comparison, ICRC showed that for the same period, there were 30 minevictims requiring amputations admitted at the Mongol Borei Hospital in BanteayMeanchey.ATnRCA{LSA estimates that there are 21,194 amputees, excluding retumees, by usingthe average percentage of amputees found in the Phnom Penh, Banteay Meanchey,and Kompong Speu surveys, with an additional minimum of 200 new amputees permonth nation-wide, especially during the heavy conflict periods.26Mental IllnessFrom extrapolation of figures from three surveys, it was found that 0.13% of thepopulation was mentally ill. As the surveys did not include psycho-social problems asa criteria formentally illness, it is difficult to assess the prevalence of psycho-socialtrauma brought about by years of civil unrest, the genocide of the Pol Pot regime, andthe uprooting of massive numbers of people during times of conflict that has plaguedCambodia for the past three to four decades.PolioThere are approximately 20,000 people with polio in Cambodia, with varying degreesof disability severity. Statistics from a report by Redd Barna showed thatbetween24-54% of disabled children in Cambodia are suffering from this condition.2t The AmRCsurvey cites a figure of 77,660 people with polio based on their projections.DeafDeafness is one of the main causes of childhood disability. In surveys that have beenconducted in a few provinces, 0.19% of the population were found to be deaf, Amongthose disabled in Cambodia, between 10-19% are due to deafness. The main causesof deafness are untreated ear infections, complications from measles, and congenitaldeformities.ParalysisUsing data from three provinces, it is estimated that 0.09% of the population arepara/tetraplegics, and0.04Yo are hemiplegics. Between 6 - 13.2% of disabled personshave paralysis. The causes for paralysis varies; among them are spinal cord injuries


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classification of confirmed oolio cases bv district of residenceProvince District witdVirus

ResidualPar

Death Lost toF-up

TotalSvay Rieng Ramduol

Svay Reang (PT)Romeas Hek

000

II2

000

000

II2Pray Veng Kg. Leav

Komchay MearKanh ChreachMesangPeam RoPreah SdechSithor Kandal

I0I0000

II1I020

0000I00

000000I

21I)1I2I

Kandal Khsach KandalMuk KampoulPonhea LeuSaang

00I2

210I

0000

00I0

212JPhnom Penh Chamkar MonDon PenhToulKork

Rusey Keo

0002

120I

0000

00I0

I2IJKampong Cham Batheay

Kg.SiemKang MeasMemotKrek

000I0

22II00

0000I

00000

22IIIKampong Chhang 0Kampong Speu Baset

Phnom SruochOudongI00

II0

00I

000Takeo BatiAngkor Borey I0 01 00 00Kampot Angkor Chey 0 I 0 0Sihanouk Ville Mittapheap

Prey Nup II 00 00 00Koh Kong 0Pursat KrakorBakan I0 I2 00 00 22Battambang Battambang (DC) 0 2 0 0 2Banteay Meanchey Smach Meanchev 0 0 0Siem Reap Thmar PuorkChi kreng 0I 00 00 I0 IIKampong Thom Barey

Brasat SamboStoung

000

Iz0

00I

000

I2lPreah Vihear 0Kratie Chhloung

KratieI0

0I

00

00

IIStung Treng Thala Bariwatt 0 I 0 0 IMondulkiri 0Total l5 37 4 5 6l

25

due to bullet wounds, falls and stroke, congenital deformities and other types ofinjwies.Table 8 Fina

Source: EPI


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No. Province Mine Accidents Road AccidentsCas Deces Cas Deces

I Svay Rieng 9 0 n5 22. Pray Veng 60 aJ 355 53. Kandal 6 0 652 44. Phnom Penh 0 0 23 05. Kampong Cham t34 10 996 246. Kampong Chhnan 84 0 393 u7. Kampong Speu 92 I 511 t48. Takeo 22 0 580 aJ9. Kampot tt2 aJ 721 1010. Sihanouk Ville 34 0 330 27n Koh Kong 42 2 85 2t2. Pursat 84 J 260 )13. Battambang 608 3l 564 l414. Banteav Meanche 405 19 351 I215. Siem Reap 408 34 526 I16. Kampong Thom 155 6 394 4t7. Preah Vihear 115 54 018. Kratie 2l 0 178 219. Stung Treng 5 0 29 I20. Mondulkiri 9 I J 02t. Rattanakiri 0 0 38 222. Kep 0 0 5 023. Plantation 13 0 59 0Total 2,418 tt4 71222 r43

26

Table 9 : Mine and Road Accidents in 1996

Source: Planning and Statistics Unit1.5 The Administrative Division of the Rehabilitation Services: relationshipamong administrative organizations and work responsibilities schedulesThe Ministry of Health's role is primarily concerned with curative and preventiveservices in regards to disabilities. The Ministry of Social Affairs, Labor, and VeteranAffairs (MSALVA) has responsibilities concerning rehabilitation also but due tobudget constraints, most of the work is done and paid for by 35 NGOs (see annex inSept. 1995 of the Directorate). The Social Affairs section of MSALVA initiated ajoint minishy-NGO process to develop a common strategy for the continuation,development and coordination of appropriate programs, services and support fordisabled people. There were six essential steps as follow:1. Formation of Task Force2. Assessment of the current situation of the sector3, Generation of Guiding Principles4. Analysis of information and identification of main issues5. Prioritization of the main issues6. Development of recommendations and action plans


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27

Five sub-committees met regularly, following the guidelines developed by the TaskForce coordinators. Once a month, one representative of each sub-committee,representatives of the four largest NGO's, the executive director of the CambodianDisabled People's Organization, several other resource persons, and MSALVArepresentatives from several departments (approximately 25 people) met to review theprogress of each group, bring up topics for discussion, and keep everyone mutuallyinformed.Development of the Guiding Principles was a crucial step for the Task Force. The 14statements are meant to guide the sector, so that all programs and activities moveforward in the same direction, rather than working at counter-purposes, as is possiblewhen 35 agencies have the same target group.The main issues identified by the sub-sectors are:Children with Disabilitieso Prevention of primary and secondary disabilitieso Integration of disabled children into mainstream education and societyo Parent and caretaker education on disability issueso Advocacy for disabled children's rightso Services for orphaned and abandoned disabled childreno Coverage, sustainability, and sub-sectoral participationCommunity Based Work with Disabled People (CWD)o Adherence of programs to the Guiding principleso Expanding geographic coverage and all ages and types of disabled peopleo Training Rehabilitation Workers to be generalistsr Sustainability of the programso Development of a national CWD strategyProsthetics and Ortheticso Staffing issues: improving the skills of technicians in hiring and salaries based onmerito Quality of services: establishing minimum standards and bringing each workshopup to that levelo Sustainability of the serviceso Coverage and avoidance of overlapping, duplication, and competition for clientso Participation and cooperation within the sub-sectorBlindness and Visual Impairmentso Training of Rehabilitation Workers in skills necessary for helping rural blindpeopleo Increasing public awareness of the capacities of blind peopleo Education of blind children and their eventual integration into normal schooiso Low vision verses blindness and the different interventions requiredo Empowerment of blind people through associationo creating links with other ministries for comprehensive services


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28

Vocational and Skill Trainingr Evaluating and developing appropriate pre-training activitieso Improving the quality and range of skills taughto Sharing successful methods in post-training follow-up among NGO'so Effectiveness of the programs in leading disabled people into the work forceo Integrated verses segregated training for disabled peopleSub-sectoral issues: projected needs, cost effectiveness. Coverage, MSAVAresponsibility and capacityThe Ministry of Industry and the Ministry of Education also have responsibilities inrehabilitation. MSALVA, in collaboration with NGOs, has established the DisabilityAction Council (DAC) as a coordinating body to enhance the effectiveness and thesustainability of the programs for disabled people among the many involved NGOsand ministries. Agencies need to contact MSALVA and DAC before starting orcanying out new services for disabled people. Ms. Helen Pitt has been appointed theExecutive Director.At the MSALVA, the Department of Rehabilitation has responsibilities inadministering, implementing, managing and following-up the policies and programsof the Royal Government conceming the rehabilitation sector and vocationalrehabilitation. 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 andcultural benefits.


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!gc)5.!o.i6=a.AFEa0)Ud

ctlq)

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cl()Lmq)q0c!cg


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oE.g bA r- .aJ.85 Fcg Gl ,:z6utv.H-.d.gg =r)6t=&9FiE-Y6l\Jfn EcBgood)0-e .vELaoP>Fr e).P c)o.trtrF3ofr

Loar)9oLa o*)cqra-E9:=Era&

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F{FYE3EE EEb 3.8aT esas

FrzrdFrtY.A,-cA-zol-(FrtrFlf-ltrFIf{rdN.f.lfrll+{t-(FtrAFi&JFU;)tV-tF0FlzAFFN-zr^\Jrt.Avtab-


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\.E .?6vLo)Frtrcr5FEl9o).Otr*()

r-

LFe)q/)6t,{g'.atlU.x

(Dtv.Ira>t

.F

?r

-lof,8c4x\nx;c\,1 ql6c.) r\NV dv_ -6^o--r F(aii'ivqVEA A-E'ncg#Q*rXo? hFa6 o:-i*av.E tralitr Y0AH(/')F d.rAALX H'd\r/ ,HbtHhnqr(l)=.IAHdH.d --Ed3=(|)(strF n.r{' E!.H eo;i \lxr-Hvg .6 d*.iig 9JtslL.L dg xd= &rm.: vs/\JaQ cdA9 'zE, 4.1N aJ.- H .dHd6t 5:.-dCts o6,* hR* i-i c-'lvo\t,ogoo c.rgili9-aEoo .O$>

HHHHUA()oc,)o.H|I:cnv)AEQ)*)llo0)L

'ar,Ifra6lNc!boliAq0-

roOr r-1*F-.EoH-!v olr .C,)

Q.=OrH()ogF-5


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32

1.6 Specialists in rehabilitation fields : kinds of specialties.Specialists in rehabilitation fields* Orthopedic Surgeon* Eye specialist* Physiotherapistt Psychiatrist* Social worker* Educators* Nurses1.7 Main organizations of C.B.R.MSALVA is the main organization responsible for C.B.R. but because of its very limitedbudget, MSALVA can only coordinate with the NGOs that are doing the community-based 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 fororthotics and prosthetics. This is followed by eye disabilities and deafness as there is aschool for the blind and vocational training. The mentally disabled and the elderly appearto receive less serives and are just beginning to be established. There programs are listedas follows:ADD Community-Based Rehabilitation (K. Speu)AFSC National School for Prosthetics and Orthotics. NSPO(Phnom Penh)

Community-based program in Kompong SomALIMCO Prosthetics and Orthotics Workshop (K. Thom (planned))AMDA Mental Health Project (Phnom penh)AmRC P&O workshop (Kompong Speu)APHEDA Vocational TrainingAAR.CC Vocational Training Center (Kien Kleang)Wheelchair Manufacture and Distribution (Kien Kleang)cDPo self-Help Group of disabled people in cambodia, Advocacy fordisabled persons (Phnom Penh)CFDS Social work for vulnerable familiesCMAC Mine Clearance and Mine,A.wareness Programs (Battambangand Kompong Thom)CT Calmette Limb CenterSihanoukvillage Limb Center NSPO (Phnom Penh)Community-Based Rehabilitation (Kompong Som)CIOMAL National Leprosy Control Program (Phnom penh)


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JJ

COERR Skills Training ProjectsProsthesis Proj ect (Sisophon)COFRAS Demining Operations (Siem Reap)CWDA Vocational TrainingDPI Support for CDPO, advocacy for Disabled Persons (PhnomPenh)ECCS School of Physiotherapy (Phnom Penh)FFAC Handicapped Children Program (Phnom Penh)FSUN Prosthetics Workshop (Phnom Penh)HT De-mining Activities (Siem Reap, Banteay Meanchey, Pursat)HI Prosthetics (Six Provinces), wheelchair production anddistribution, and Foot Factory Center for Spinal Cord Injuries(Battambang)PRES social and economic rehabilitation (8 provinces)National School of PhysiotherapySports for disabled personsSupport for CMACHKI Primary Eye Care programVitamin A Nutrition Programs (integrated with NID 1996)HELPAGE CambodiaOpthalmicProgram(Battambang)IPA/VAF P & O & Feet Workshop (Kien Kleang)Wheelchair Production (Kien Kleang)Outreach Program (Prey Veng, Kandal, Stung Treng,Rattanak Kiri)ICRC P&OWorkshop(Battambang)P & O Component Factory (Phnom penh)IOM Medical residency in Psychiatry @hnom penh)IPSER Community-Based Mental Health program (K. Speu)JSRC Vocational Training Center (Battambang)JRS Handicapped Training/Outreach program (Kandal)Wheelchair Production, distribution and follow-upKBS community-Based Mental Health project, REACH (ResourceEducation and Community Healing)KCDI Cultural programsKhanta Bopha Disabled children's medical services (phnom penh)Hospital

Krousa Thmey School for the BlindMaryknoll Community-BasedRehabilitation(phnompenh,Takeo)Blindness Program (CBR) (Phnom penh)Wat Than Skills Training (Phnom penh)MLI Mental health program (Phnom penh)

MDM Surgical assistance-plastic surgery (phnom penh)MED Support to Eye Units and Eye CampsMAG Mine Clearance and Mine Awareness programmesMine Victims Surveillance System (Battambang)


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34

NCDP Resource Center and Handicraft Retail Outlet (Phnom Penh)Rehab Craft Handicraft Production and Sales (Phnom Penh)SER VANTS Vocational Training (Phnom Penh)SAO SCOPE Eye Care Program (Phnom Penh)SKIP Vocational Training (Pursat)TEHO Vocational Training (Phnom Penh)UNDP Trust Fund for De-miningTechnical assistanceUNICEF Education, Children and Women Services supportFunding for capacity building projects

Expanded Program on ImmunizationVocational TrainingWat Than Rehab Handicraft productionCenter Skills trainingPhysiotherapyLiteracy (Phnom Penh)Polio Eradication ProgramExpanded Program on Immuni zation (country-wide)Vocational Training Center for Disabled PersonsExtension Program (Battambang)

UCC

wHoWVI


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35

Distribution of Services for Disabled Persons bv ProvinceTable 10 : SERVICES FOR DISABLED PERSONS BY PROVINCE

SELF-HELP GROUPS AND LOCAL NGOsThe importance of the participation of local groups in advocating for the rights andprovision of services for disabled people could not be over-emphasized. Closercollaboration of local self-help groups with the govenrment would allow for bettercoordination of programs and ensure that the needs of disabled persons are truly met at alllevels. Strengthening the capacity of local initiatives will also improve the sustainabilityof programs and services that are currently being provided to disabled persons inCambodia.

Provinces/Municipality P&OWorkshop/FittingCenter

Comm. BasedRehabilitation VocationalTrainingCenters

EyeUniUVisualImpairedParalysisCenters

HandCrafUIncomeGenerationSvay RengPrey Veng I IKandal see P.P. 2 IPhnom Penh aJ J 5 J 4K. Cham I I IK. Chhnang IK. Speu tTakeo I 2 ISihanoukville I 2Pursat I I 2Battambang I I I I I 2BanteayMeanchey I 2 ISiem Reap I 2 IK. Thom 2 IPreah ViharKratie IStung Treng I 1IRattanak Kiri IMondul KiriKampot I I I IKoh Kong


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36

Policies for people with disabilitiesThe actual written policies are not available since the MSALVA and the partner NGOshave just finished the formation of their task force and recently appointed Ms. Helen Pittas 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 theMSALVA Task Force and DAC on Disability Issues. (See Annex A)The Ministry of Health focuses their policy on prevention, which include the eradicationof poliomyelitis, the reduction of vitamin A deficiency, the reduction of the severity of earinfections as well as out-reach to the community to provide both curative and preventiveservices. A more important policy issue concerns personnel development in all specializedfields dealing with preventive, curative and rehabilitation of disabilities, such asorthopedists, 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 rehabilitationAs mentioned earlier, the government has budget constraints as well as a lack of facilitiesand services. Thus, most of the medical rehabilitation is being done by the NGOs (seeAnnex B; names, position and address are in Annex C). The government has interviewedconcerned persons regarding policies and planning in the area of medical rehabilitation butlimitations 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 therehabilitation of the disabled and is focusing more on curative and preventive matters. Atpresent, the MOH is at the stage of reforming - the needs are emergency support healthcenters and for hospitals to improve their referral system. For community-basedrehabilitation, the needs are the training of first aid to volunteers, women's groups, and theRed Cross as well as the training of TBA on EPI and delivery. The most common causesof disabilities are mine accidents and road accidents; polio, Japanese encephalitis and birthtrauma also are cornmon problems. EPI coverage is at 70-8A% but for Encephalitis it isvery low - as low as only 2-3%. The Cambodian government's policy is to eradicate poliobut last year there was no budget for either this or for encephalitis. Thus, there are alsobudgeting needs for EPI.."


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Interviewees.Dr.Mao Tan Eng.Dr.Seng RattanaDr.Prak Piseth

"The Ministry of Health is concerned with the disability matters focusing on preventiveand curative services. The MOH is reforming to improve the quality of services by settingup and improving the referral system in the local communities, the health centers, and theprovincial hospitals. The most common causes of disabilities are mine accident, around300 - 400 cases/month along the border, and road accidents. For rehabilitation of mentaldisorders, visual disorders and elderly there are no actual statistics. There are sub-committees taking responsibilities on these matters under MSALVA and the NGOs. Basicstatistics 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 SurgerySurgeonsOrthopedistsPsychiatristsAnesthesiologistsImproving the entire referral systemSurgeons for each health facility

Eye C.B.R. SituationAt present in Cambodia, there is only one trained ophthalmologist, 22 eye doctors and 60nurses providing eye care, the majority of whom have undergone practical training inophthalmology in the country, where there has been no training program. A few havebeen trained for short periods in other countries such as Vietnam. Some eye doctors hadattended surgical training update courses. Also, nurses have been trained as ophthalmicnurse trainers in Thailand with the support of CBM. Eight optometrist technicians anddispensers have been trained by Southeast Asian Outreach 4 in Phnom Penh, 2 inBaffambang, and I each in Svay Rieng and Prey Veng provinces. Health Center staff havebeen trained on primary eye care.There are only 7 functional eye units in 5 provinces out of 22 provinces in the wholecountry.


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Cunent statistics showed that there are an estimated 25,000 outpatient consultations foreye cases in all of the eye units in the country (1996). The cataract surgical rate hasincreased 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 areage-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 byHelen Keller International in various provinces in Cambodia in 1993 showed that vitaminA deficiency is a problem. However, vitamin A distribution has been incorporated into thenational immunization days organized by the EPI program of the MOH. Helen KellerInternational 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 havebeen trained in Kandal and Battambang provinces. International Resources for theImprovement of Sight (IRIS) and the Mekong Eye Doctors in various provinces havesupported extended outreach eye care services by their guidance. These services will beimplemented by various NGOs.There are a number of private eye care clinics, including optometry clinics, which arelocated primarily in Phnom Penh and a few in the provinces. These clinics are run byeither local doctors/nurses or expatriates from neighboring countries. Only a few areequipped with the modern facilities.National Sub-Committee for Prevention of BlindnessThe National Sub-Committee for the Prevention of Blindness of the Ministry of Healthwas established in 1994 as part of the MOH coordinating committee. Its role andresponsibility is to develop a National Plan for PBL and to provide technical advice to theMinistry of Health in implementing the National Plan.In 1995, the National Sub-Committee for PBL launched a drive in its PBL activities. Withassistance and advice from expatriate ophthalmologists, who are working in Cambodia,and WHO PBL consultant from WHO regional office, the National Sub-Committee hasdeveloped a master plan and its first five years plan of action for PBL in Cambodia. All ofthe major actions in the plans are integrated into the Ministry of Health's national healthcoverage plan.The master plan of action and the national plan for eye care development in Cambodia aimto provide eye care services in each region of Cambodia and to reduce blindness to lessthan 0.5% prevalence by the year 2005. Human resource development is considered thetop priority in these plans. In addition, the plan also covers the development of facilities/materials, sourcing of financial resources, management and specific control of locallyendemic diseases for the different levels of eye care. The strategic approach toimplementation is based on an integration of primary eye care (PEC) into primary healthcare (PHC). The Ministry of Health, provincial and district health authorities and the


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National Sub-Committee for PBL, with assistance from Ios and INGOs would play animportant role in the implementation of the plans.To this end, various workshops has been organized in the prevention of blindness tostimulate interest among the policy makers and the population. It is hopeful that PBL isgaining increased priority and attention within the Ministry of Health.A national essential drug list as well as a standard list of equipment and supplies for thevarious eye units have been developed. A treatment guideline for eye diseases within thehealth centers and referral hospitals has also been developed. An eye care informationsystem for monitoring and supervision of PBL activities is cunently being developed. Thenational sub-committee has been in the forefront in these activities, especially in aidcoordination and is a model for other MOH sub-committees.In the past, WHO had sponsored the activities of the sub-committee. Currently, a "blindfund" had been set up by the various NGOs involved in eye care in the country to supportthe office of the national coordinator for PBL since there is limited funding of the nationalsub-committee for PBL's activities from the MOH. This fund has provided for theadministrative and other linancial costs incurred by the office in its work of coordinationand monitoring of eye care activities in the country.International Non-Governmental Organizations Involvement in Eye Care inCambodia.There are currently several INGOs involved in eye care in Cambodia. This includesChristoffel Blinden Mission, Help Age International, Maryknoll, Mekong Eye Doctors,Helen Keller International, and IRIS (International Resources for the Improvement ofSight). 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 hasbeen not only in rescue operations involving emergency surgery, but some organizationshave 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 sideunder mutual coordination of the national PBL coordinator and the MOH to implementtheir different programs. They have also been deeply committed to continue ro promoreand assist in the implementation of the major actions in the master plan for eye healthdevelopment in Cambodia.Most of the NGOs are involving in community eye care, prevention and training indifferent provinces. Supporting manpower development such as doctors and nurses to betrained in Thailand, India, Japan and other countries.


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The Needs of Eye C.B.R.Future Eye Care In CambodiaThe main objectives of the master plan and the first five year plan of action are to providebasic eye care for all Cambodians, to eliminate locally endemic blinding conditions and toreduce avoidable blindness to less than 0.5% by the year 2005. To achieve theseobjectives, the following priority action programs are planned provided that support isavailable:

Manpower development

o Training of Ophthalmologistso Training of basic eye doctorso Training of basic eye nurse. Training eye care personnel in refraction and orthopticso Training of health workers in primary eye careFacilities developmento Establishment of eye units in the provinces. Provision of standard equipment and instruments for eye careo Establishment of an optical workshopo Establishment of a national eye center for training and researchManagement and specific control of locally endemic diseaseso Cataract prevention programs. Eye health education programso Outreach eye care serviceso Community-based rehabilitation of the ineversibly blindo Information system developmentConstraintso Limited budget within the Ministry of Health's annual health budget for eye care

services.o Funds for training programs for eye care workers, for establishing eye care facilities,and equipment for implementing eye care services in the provinces.o Lack of training programs in the country for training of eye care personnel.o 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 theprovinces.o Poverty and difficult socio-economic conditions of the population.


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ConclusionCambodia, despite many years of turmoil is poised to improve the quality of life of itscitizens through reducing the number of blind people and preventing blindness in thecountry. However, there is a lack of eye care personnel and facilities to provide eye careservices in the provinces where 85% of the population lives. Support would be requiredfor training of eye care personnel, development of eye units in the provinces, control ofblinding eye diseases and rehabilitation of the blind.Interviewees:Dr. UCH YUTHONational Eye Health CoordinatorDT.CHHUN SENGVice-director Preah Ang Doung HospitalChairman of the Sub-Committee for Prevention of BlindnessDT.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..o cataract is the first priority as it accounts for 60-70Yo of all blindness.o Maryknoll / CBM is dealing with community-based rehabilitation, skill training for theblind adults, establishment of Takeo Eye unit and training of basic eye doctors andntrrses.o There are 60 blind children under the care of NGOs - New Family has 42 children inBattambang. The most common causes 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 lossEye health promotive and preventive activities- Case finding and referrals- Health promotion and education of target groups in the communityCooperate with NGO.


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Srihanhuk HospitalPsychiatric DepartmentInterviewee: Dr.Kasur BonatMental HealthBefore 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 thepatients were killed and the hospital was closed. In 1980, the hospital was reopened atSrihanhuk hospital with help from WHO, Vietnam, and Russia to develop/mental healthservices. ln 1992, the government tried to integrate mental health into its medicalcurriculum but was not successful. It was only successful in staffing outpatient serviceswith 2 psychiatrists. Others were receiving on the job training supported by Norway(IOM). Japan (AMDA). AMDA has ceased support for this program while IOM isexpanding its support. In March 1992, the Mental Health Sub-committee was establishedand Dr.Kasu Bonat has been appointed as the chairperson. Dr.Kasu Bonat himself has 2years of training in France and the U.S.A. In 1994, psychiatry was introduced to thefaculty of medicine. G.P. training on psychiatry consists of 92 hours of theory andpractical experience in primary care. The U.S.A. trained 2 doctors, 1 medical assistant, and6 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 clinicin the provincial hospital in Siam LeapLast year an Outpatient Department was opened at Battambang. There is one Koreanmedical doctor in the hospital who has trained 15 staff and I doctor.The education for handicapped childrenFor the education of handicapped children, the government still does not have much of arole. The interview of Mr.Ung Say Chief of Bureau of External Relation and MR.MAOSOVADEI Child Welfare Department MSALA follows.Ministry of Education, Youth and SportsInterviewee: Mr.Ung SayChief of Bureau of Extemal Relations"The Ministry of Education, Youth and Sports would like to be involved with specialtraining for various disabled groups as well as teaching these groups in primary andsecondary schools as well as integrating them into ordinary schools. Due to the lack ofmonies in the budget, there is no policy to implement this. Thus, the Ministry of Educationis not doing much in this area, only receiving reports from NGOs that run schools for theblind or the deaf. The Ministry of Education also collaborates with the Ministry of SocialAffairs, Labor and Veteran Affairs.


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Interviewee: MR.MAO SOVADEIChild Welfare DepartmentIn 1993 there was one NGO center called FFAC (Friend for All Children) whichconducted rehabilitation for disabled children. This NGO closed down, so the childrenwere transferred to the government. Due to budget constraints, the government could notdo much except provide food and shelter. There are currently 45 disabled children, aged8-15 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 ofSocial Action, which is caring for these children.The government's problern not only involve budget constraints, but also more than 100children being left in front of the center as well as the increasing number of street childrenThe needs include a budget for:- Children's shelter and food that include disabled childrenas well as street children- Training personnel- Training and education for disabled children- Support for'oNew Family"The conditions of employment and vocational training for handicappedThese are being done by NGOs in collaboration with MSALVA. The results of training areas follows:


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The current conditions of the supply the demand of prosthesis and orthosis are quiteenough but there are some problems with registration as follows:

Interviewee: MR. Dudley Turner, Manager Chief Prosthetist / Orthotist, CalmetteHospitalThe Cambodia Trust (CT) is a registered British charity established in 1989 to bringhumanitarian relief to Cambodia. Its major initiative has been to promote the well beingof Cambodian mine victims through the supply of artificial limbs. After 5 years ofdedicated service, the Cambodia Trust has delivered and fitted over 8000 prosthesis and1200 orthosis to Cambodian disabled persons.MISSION STATEMENTThe Cambodia Trust Limb Project works closely with the Ministry of Social, Labor andVeterans Affairs, the Ministry of Health and other prosthetic agencies to:o Provide free delivery of prostheses and orthoses to disabled persons in Cambodia.. Transfer Prosthetic Orthotic skills to Cambodian people through an ongoing trainingprocess.o Promote and encourage all appropriate activities which seek to raise the status ofdisabled people in Cambodia.The trust cooperates with the Ministry of Social Action and the Ministry of Health and hasstrong links with the military and other NGOs, including Japanese Handicap Intemationalwhich supports technical and equipment needs. The Nippon Foundation also supports thetrust.There are (in Phnom Penh, Sihanoukville, Kampong Chnang and Kean Svay) four Trustclinics have been established, all of which provide free artificial limbs and rehabilitation toamputees.The trust has also initiated and now co-nrns the Cambodian School of Prosthetics andOrthotics, based in Phnom Penh to train 60 Cambodians to be prosthetists. The school'sgraduates will ensure that the Trust's clinics and rehabilitation programs will be sustainedby Cambodians for Cambodians.CAMBODIA TRUST'S FIELD ACTIVITIES

l. 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 receivedfrom Hope (Humanitarian Orthotics Prosthetics Endeavor).


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Joint management and fiscal control of the CSPO (Cambodian School ofProsthetics and Orthotics).Provision and direct assistance for post-injury treatment to landmine casualtiesin Preah Ket Mealea hospital with appropriate follow-up in 317 centers (KienSvay).Foundation and technical support to CAAA (Cambodian Association ofAmputee Athletes).

Cambodia Trust does not do community-based rehabilitation itself but collaborates withUnicef and other NGOs for outreach programs that work closely with C.B.R. outreach incase finding of amputees and persons with polio as well as doing follow-up and teachstaff 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 reducedpreviously existing resources, Cambodia has a shortage in all areas, including personnel,facilities for services and health promotion and prevention activities. This is true evenmore 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 isperhaps better off than other areas as there are NGOs that are already trying to cover thisarea. For visual and mental disabilities, Cambodia already has a plan but it is not wellimpl

Documents

Reseach on the Needs of Community Based Rehabilitation (CBR) for Disabled Persons in Cambodia