Health and Education Needs of Ethnic Minorities in the Greater Mekong Subregion

Asian Development Bank ii

The photographs on the cover and title page were taken by study team members during field survey work in the highland areas of Cambodia, Lao PDR, Thailand, and Viet Nam. The cover photographs are images of highland, ethnic minority people. Starting from the top and moving clockwise around the diamond collage, the photographs are from: Ratanakiri Province, Cambodia (top, photo by Hean Sokhom); Vientiane Province, Lao PDR (right, photo by Myles Elledge); Chiang Mai Province, Thailand (bottom, photo by Preecha Upayokin); Phongsali Province, Lao PDR (left, photo by Inthasone Phetsiriseng). The pictures on the title page are views of the landscape of selected areas of the study team’s field work and are representative of the topography of the highland regions in the four countries. Starting from the top and moving clockwise around the diamond, the images are from: Son La Province, Viet Nam (top, photo by Vuong Xuan Tinh); Vientiane Province, Lao PDR (right, photo by Myles Elledge); Lampang Province, Thailand (bottom, photo by Myles Elledge); and Ratanakiri Province, Cambodia (left, photo by Hean Sokhom). The pictures on page xviii are some of the faces of ethnic minority villagers in the provinces where the study team completed field surveys. Starting from the top and moving clockwise around the diamond, the images are: Children playing in Ratanakiri Province, Cambodia (top, photo by Hean Sokhom); young girl caring for infant in Vientiane Province, Lao PDR (right, photo by Myles Elledge); village elementary school teacher and her family in Dak Lak Province, Viet Nam, near the border with Cambodia (bottom center, photo by Myles Elledge); village elder in Lampang Province, Thailand (left, photo by Myles Elledge).

©2001 by Asian Development Bank All rights reserved. Published 2001 Printed in Manila, Philippines Maps and photos: ©2000 by Asian Development Bank All rights reserved. iii

TABLE OF CONTENTS

ACKNOWLEDGMENTS iv 3 CROSSCUTTING THEMES 17 3.1 Constraints to Access 17 FOREWORD v 3.2 Country-Based Observations on Constraints 30 ABBREVIATIONS vi 3.3 Finding Solutions 30 MAPS vii 4 RECOMMENDATIONS 33 Ethnic Minority Populations by Province: 4.1 Replicate Good Practices in the Greater Mekong Subregion vii Social Sector 33 Percent Ethnic Minority Populations in 4.2 Strengthen Policies and Programs 35 Cambodia: Selected Provinces viii Percent Ethnic Minority Populations in BIBLIOGRAPHY 39 Lao PDR ix APPENDICES Percent Ethnic Minority Populations in Thailand: Selected Provinces x A Country Summaries A-1 Percent Ethnic Minority Populations in B Potential Health and Education Viet Nam: Selected Provinces xi Programming to Assist Ethnic Minorities in the Greater Mekong Subregion B-1 Ethnic Minority Populations and 1998 Literacy Rates: Cambodia Provinces xii TABLES Ethnic Minority Populations and Infant Table 2.1: Public Expenditure on Education Mortality Rates: Lao PDR Provinces xiii as a Percentage of GNP (1995) 7 Ethnic Minority Populations and Literacy Rates: Table 2.2: Literacy Rate for Ethnic Minorities Lao PDR Provinces xiv and Total Population (percent) 9 Ethnic Minority Populations and Lower Secondary Table 2.3: Comparison of National and Education Enrollment in Viet Nam xv Highland Infant Mortality Rates (IMR) 13 Ethnic Minority Populations and Infant Table 2.4: Comparison of National Maternal Mortality Rates in Viet Nam xvi Mortality Rates (MMRs) 13 1 INTRODUCTION 1 Table 2.5: Comparison of Highland Immunization Rates 15 1.1 Study Goal and Objectives 1 Table 3.1: Constraints to Access and 1.2 Study Methodology and Key Definitions 3 Use of Social Services by Ethnic Minorities 18 1.3 Report Content 4 Table 3.2: Summary of Constraints and Country Observations 31 2 THE STATUS OF ETHNIC MINORITIES 5 Table 4.1: Programs of Good Practice 34 2.1 Ethnic Minorities in the GMS 5 FIGURES 2.2 Ethnic Minorities and the Social Sector 6 Figure 3.1: Percentage of Births in Modern 2.3 The Education Status of Ethnic Minorities 8 Health Facilities 27 2.4 The Health Status of Ethnic Minorities 12 2.5 Environment and Ethnic Minorities 16 iv

ACKNOWLEDGMENTS

This report was prepared as part of the project “Health Duangchak (Ministry of Foreign Affairs), Ms. and Education Needs of Ethnic Minorities in the Sathaphone Insixiengmai (Ministry of Health), Dr. Greater Mekong Subregion,” through Asian Somchanh Xaisida (Ministry of Health). Development Bank (ADB) TA 5794-REG, under Thailand: Dr. Songphan Singkaew (Ministry of Public contract to Research Triangle Institute (RTI), North Health), Mr. Chantharat Kotkam (Ministry of Carolina, USA. Education). The report was produced by study team members Mr. Viet Nam: Mr. Ho Minh Chien (Ministry of Planning Myles Elledge (team leader), and Dr. Erik Bloom and Investment), Mr. Mong Ky Slay (Ministry of (health and education economist), along with research Education and Training), Mr. Truong Viet Dung team members in each of the four focus countries: Mr. (Ministry of Health Care), Mr. Trinh Cong Khanh and Khieu Borin (health) and Dr. Hean Sokhom Mrs. Luon Thu Chau (Committee for Ethnic (education) based in Phnom Penh, Cambodia; Ms. Minorities and Mountainous Areas – CEMMA). Khamtanh Chanty (health) and Mr. Inthasone Phetsiriseng (education) based in Vientiane, Lao PDR; Furthermore, representatives from international Dr. Preecha Upayokin (health) and Dr. Chupinit organizations, local and international nongovernmental Kesmanee (education), based in Bangkok, Thailand; organizations, the public sector, and ethnic minority and Dr. Bui The Cuong (health) and Dr. Vuong Xuan communities assisted in reviewing the research findings Tinh (education) based in Hanoi, Viet Nam. and in formulating the report observations. In-country workshops held in July and August 2000 provided an Beyond the study team, a broad constituency of actors opportunity for candid and insightful dialogue. contributed to this effort. A series of Steering Committee meetings in 1999 and 2000 brought Close collaboration with and flexibility from Edward together key public sector actors from ethnic affairs, M. Haugh, Jr., Manager, Education, Health, and health, and education ministries during the course of Population (West) Division ADB and the ADB Project the project. The project study team is grateful for the Officer, Dr. Indu Bhushan (Senior Project Economist), support provided by the Steering Committee members have contributed greatly to the success of what is a in each country throughout the process. By country, challenging topic and research study. The thoughts and the Steering Committee members included: ideas offered by representatives of the UK Department for International Development (DFID) also have Cambodia: Mr. Seng Narong (Inter-Ministerial supported the project’s objectives. Committee for Highland Peoples’ Development – Ministry of Rural Development), Mr. So Chhunn Ms. Apiwan Pansook, Project Assistant in the project (Ministry of Education, Youth and Sports), Dr. Sok office in Chiang Mai, Thailand, coordinated all the Touch (Ministry of Health), Dr. Hong Rathmony administrative and logistics details for the reports and (Ministry of Health), Ms. Luon Chanmoly (Ministry meetings, without which the project would not have of Education, Youth and Sports), Ms. Chhay Kim been possible. The report has also benefited greatly Sotheavy (Ministry of Education, Youth and Sports). from the contributions of RTI editors Ms. Erin Newton and Ms. Anna Weaver. Lao PDR: Mr. Pheng Lasoukanh (Lao Front for National Construction), Mr. Ouam Sengchandavong Reports, maps, and general information prepared by (Ministry of Education), Mr. Meckham Silykhoune RTI under this project are available at http:// (Ministry of Foreign Affairs), Mr. Bovonethat www.rti.org/mekong. All photographs used in the reports were taken by members of the project team. v

FOREWORD

The mighty Mekong river flows through six and education status and needs of highland countries—Cambodia, Lao People’s ethnic minorities. The study also identifies the Democratic Republic, Myanmar, Thailand, constraints that prevent ethnic minority Viet Nam, and Yunnan Province of China— groups from improving their health and linking them not only geographically but also education levels. It reviews policies and economically and culturally. This area, called programs and highlights examples of good the Greater Mekong Subregion (GMS), is practices. We hope the report will provoke in- characterized by ethnic diversity. About 21 depth discussion on options available for million people from ethnic minorities live improving the human capital of ethnic among the 240 million people in the GMS, minorities and assist the respective many of them in remote mountainous terrain, governments and their development partners, with relatively poor social and physical including ADB, to fine-tune their policies, infrastructure. programs, and social investments to obtain the People from the ethnic minority groups in the greatest possible benefits for these groups. GMS experience more than their fair share of This study was initiated by ADB in response socioeconomic deprivation. Handicapped by to a request by the Greater Mekong Subregion lower-than-average levels of health and Working Group on Human Resource education, and lacking access to capital and Development, which identified the poor economic infrastructure, people from these health and education status of ethnic ethnic minority groups have not benefited minorities as a key priority. The government from expanding economic opportunities or of Japan and the Department for International been able to contribute actively to economic Development (DFID) of the United Kingdom development. Meeting the basic education and funded the study. health needs of ethnic minorities will be an ADB expresses its sincere appreciation to the important priority as the GMS countries and governments of Cambodia, Lao PDR, the Asian Development Bank (ADB) push Thailand, and Viet Nam for their ahead with their mandate of reducing poverty commitment to these issues and their active and improving people’s quality of life. involvement in producing the report. ADB This study is a synthesis of four country also thanks the government of Japan and studies undertaken in Cambodia, Lao PDR, DFID for their financial support. Thailand, and Viet Nam to analyze the health

Akira Seki Director, Agriculture and Social Sectors Department (West) Asian Development Bank 30 June 2001 vi

ABBREVIATIONS

ACF Action Contre la Faim LFNC Lao Front for National Reconstruction

ADB Asian Development Bank MDM Médecin du Monde (French NGO)

ARI acute respiratory infection MMR maternal mortality rate

AusAID Australian Aid Agency MOE Ministry of Education

CEMMA Committee for Ethnic Minorities and MOH Ministry of Health Mountainous Areas (Viet Nam)

CIDSE Cooperation Internationale pour le MOPH Ministry of Public Health (Thailand) Développement et Solidarité (Cambodia)

CWS Church World Service (international NTFP Non-Timber Forest Products (Program, NGO) Cambodia)

DETC Department of Economic and Technical NTUP Network Teacher Upgrading Program Cooperation (Thailand)

DFID Department for International NGO nongovernmental organization Development (UK)

DNFE Department of Nonformal Education ODA Overseas Development Assistance (UK) (Thailand)

PHC primary health care; also Primary Health DPW Department of Public Welfare (Thailand) Care (Program, Viet Nam)

GMS Greater Mekong Subregion RETA regional technical assistance

HAE Hill Areas Education (Program, Thailand) SCA Save the Children Australia

HHDC Highland Health Development Center TA technical assistance (Thailand)

HRD human resource development TB tuberculosis

HU Health Unlimited (UK NGO) UK United Kingdom

information, education, and UNDP IEC United Nations Development Programme communication

ILO International Labour Organisation UNFPA United Nations Population Fund

IMC Inter-Ministerial Committee for Highland UNICEF United Nations Children's Fund Peoples' Development (Cambodia)

IMPECT (Association of) Inter-Mountain Peoples USAID United States Agency for International for Education and Culture in Thailand Development

IMR infant mortality rate VLSS Viet Nam Living Standards Survey

JSRC Japan Sotoshu Relief Committee WB World Bank (Japanese NGO)

Lao PDR Lao People's Democratic Republic WHO World Health Organization vii

MAPS

The maps that follow show some findings of data (see map source notes) as part of ADB TA interest regarding ethnic minority status in No. 5794-REG, Health and Education Needs Cambodia, Lao PDR, Thailand, Viet Nam, of Ethnic Minorities in the Greater Mekong and the Greater Mekong Subregion as a whole. Subregion. RTI generated them using census and other

ETHNIC MINORITY POPULATIONS BY PROVINCE: GREATER MEKONG SUBREGION

Boundaries are not necessarily authoritative. viii

PERCENT ETHNIC MINORITY POPULATIONS IN CAMBODIA: SELECTED PROVINCES

Boundaries are not necessarily authoritative. ix

PERCENT ETHNIC MINORITY POPULATIONS IN LAO PDR

Boundaries are not necessarily authoritative. x

PERCENT ETHNIC MINORITY POPULATIONS IN THAILAND: SELECTED PROVINCES

Boundaries are not necessarily authoritative. xi

PERCENT ETHNIC MINORITY POPULATIONS IN VIET NAM: SELECTED PROVINCES

Boundaries are not necessarily authoritative. xii

ETHNIC MINORITY POPULATIONS AND 1998 LITERACY RATES: CAMBODIA PROVINCES

Boundaries are not necessarily authoritative. xiii

ETHNIC MINORITY POPULATIONS AND INFANT MORTALITY RATES: LAO PDR PROVINCES

Boundaries are not necessarily authoritative. xiv

ETHNIC MINORITY POPULATIONS AND LITERACY RATES: LAO PDR PROVINCES

Boundaries are not necessarily authoritative. xv

ETHNIC MINORITY POPULATIONS AND LOWER SECONDARY EDUCATION ENROLLMENT IN VIET NAM

Boundaries are not necessarily authoritative. xvi

ETHNIC MINORITY POPULATIONS AND INFANT MORTALITY RATES IN VIET NAM

Boundaries are not necessarily authoritative. INTRODUCTION 1

INTRODUCTION

This Integrated Report is one of the products of still substantial and impressive. Maintaining the Asian Development Bank’s Technical and distributing these gains fairly is a major Assistance Contract No. 5794-REG, entitled challenge for all countries in the region. “Health and Education Needs of Ethnic One common characteristic is the ethnic Minorities in the Greater Mekong Subregion” minority peoples (see Section 1.2 below for (GMS). This study focuses on an analysis of definitions) among their populations. Among the health and education status, needs, the nearly 240 million people living in the constraints, and opportunities of highland GMS, roughly 21 million are of ethnic ethnic minorities in Cambodia, Lao PDR, minority heritage. Many of these groups span Thailand, and Viet Nam, and reviews relevant the political borders of the region. In addition, policies and programs intended to address many are socially marginalized, leading to these factors in the four countries. As a part of poorer health, lower educational attainment, this project, individual country reports were fragile means of livelihood, and, therefore, a prepared for those countries (see Appendix A compromised ability to attain a decent for summaries). standard of living or to contribute to the The report introduces many of the common economic development of the region. themes that were found in the country studies. Another shared characteristic in the GMS is a It also seeks to synthesize individual country large proportion of upland and mountainous research reports and the discussions held terrain that lacks the level of infrastructure during in-country workshops, in order to available in the rest of the country, and in highlight crosscutting themes and to offer which many of the ethnic minority peoples regional recommendations. live and work. Upland, mountainous areas are These four countries are distinct from one regarded by planners and developers as an another in many ways. They differ in terms of opportunity for relieving population and land history, political and governmental structures, pressure in the lowlands, whereas economic base, and level of production and environmentalists want to preserve the forest development; however, these areas are and other fragile ecosystems. Thus, the very nonetheless linked in numerous ways beyond livelihood of the people resident in these areas their shared borders. Common characteristics is besieged from both directions. of these countries include recent economic growth and crisis, large ethnic minority populations, and upland and mountainous 1.1 Study Goal and Objectives terrain. In 1992, the Third Ministerial Conference under ADB’s Greater Mekong Subregion The past decade has seen enormous economic Initiative identified the poor human growth, often with significant reduction of development of ethnic minorities as one of poverty, in most of the countries in the region. seven priority issues. Health and education are Although the Asian economic crisis of 1997 basic elements of this development. This study and 1998 tempered this growth, the gains are 2 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

Overlook en route to Phongsaly Province, Lao PDR. The topography of the highland regions in the GMS countries poses many challenges to service delivery. Low population densities, few roads, and limited communications make it difficult to deliver health and education services. Many remote areas are accessible only by foot during the rainy season. (Photo by Inthasone Phetsiriseng)

grew out of the GMS working group on • Identify and document good practices of human resource development as an area responsive health and education services. requiring further attention and • Identify strategies, approaches, tools, and understanding. interventions that respect minorities’ chosen The goal of the present ADB study is to foster ways of living. the well-being of ethnic minorities living in • Organize and support efforts to disseminate the mountainous and border areas of and exchange research findings, case studies, Cambodia, Lao PDR, Thailand, and Viet and other experiences with ethnic minority Nam, and to increase their opportunities for organizations and the general public, as well good health and education. This study also as key personnel in health, education, and seeks to understand the capacity of providers related sectors. to design and deliver services responsive to The Asian Development Bank has increasingly ethnic minorities’ needs and to inform oriented its lending toward activities that decision making at all levels. directly benefit vulnerable populations; The specific objectives of the research project moreover, as noted above, indigenous peoples are to were identified as a key vulnerable population in the region. The Asian Development Bank’s • Identify constraints that impede access by Policy on Indigenous Peoples of April 1998, ethnic minorities to responsive health and which provides a foundation for this study, education services. says that • Identify local, national, and regional oppor- indigenous peoples may be regarded as one tunities that exist and can be fostered to of the largest vulnerable groups in society. address needs and to remove or reduce While differing significantly in terms of constraints. culture, identity, economic systems, and INTRODUCTION 3

social institutions, indigenous peoples as a The work has been led by local research staff, whole most often reflect specific working with representatives of key policy and disadvantages in terms of social indicators, implementing agencies in each of the four economic status, and quality of life. countries. Representative provinces in each Indigenous peoples often are not able to country were selected for field work, which participate equally in the development involved the completion of key informant processes or share in the benefits of interviews and observations at the provincial, development, and often are not adequately district, commune, and village level.1 represented in national social, economic, The policy analysis and qualitative field work and political processes that direct have focused on the that ethnic development. (ADB, 1998, Introduction) access minorities have to social services and the In 1999, the Asian Development Bank constraints that impede their effective access. adopted a new poverty reduction strategy, Social services are one of the most important, placing the objective of reducing poverty at although they are by no means the only factor the center of ADB’s mission, as its overarching that contributes to the health and education goal (ADB, 1999b). In the GMS, highland status of ethnic minorities. Better access ethnic minorities are among the poorest improves the opportunities that ethnic populations and need to be at the center of minorities have to raise their health and poverty-reduction strategies in the region. It is education status. By using supply and demand clear that ethnic minority highland of social services in health and education populations tend to be poorer and more sectors as lenses to focus on minority groups, vulnerable than the general population. These the study results identify related issues raised population groups have significant health and with respect to social exclusion, poverty, education needs. environment, and infrastructure, among others. 1.2 Study Methodology and Key A number of key terms require clarification to Definitions establish operational boundaries for this study. To address its objective, this project has “Ethnic minority.” The diversity of peoples applied several different methods: residing in the countries of the Greater Mekong Subregion is vast, and the factors • A review of the existing relevant research, affecting service provision in urban, rural policy, and program documents and statis- lowland, and rural upland and highland tics; settings are similarly diverse. The study • Informational interviews with officials and team adopted ADB’s working definition of technical personnel in key ministries, “indigenous peoples” (“those with a social government institutions, other government or cultural identity distinct from the offices, development agencies, and nongov- dominant or mainstream society, which ernmental organizations (NGOs), includ- makes them vulnerable to being ing field studies in the areas where ethnic disadvantaged in the processes of minorities reside and work; development” [ADB, 1998, para. 12]), • Brief structured field surveys; and and amended that definition to specify those living in highland and upland • Multiple evaluation methods to review project and program interventions and 1 In Cambodia, field activities covered the provinces of highlight noteworthy programs serving Ratanakiri and Mondolkiri; in Lao PDR, field work was completed in Phongsali, Sayaburi, and Khammouan areas with significant ethnic minority provinces; and in Thailand, field interviews were com- populations in Cambodia, Lao PDR, pleted in Lampang and Chiang Mai provinces. In Viet Thailand, and Viet Nam. Nam, field work was completed in the provinces of Dak Lak (Central Highlands) and Son La (Northern High- lands). 4 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

settings. Special attention is given to the “Effective access.” Not all factors contributing particular circumstances of groups fitting to the health and education status of this description who live near ethnic minorities in the GMS can be international borders.2 The study addressed in the present study. We have explicitly excludes minority ethnic groups singled out factors related to effective access that live primarily in lowland areas, urban to services, whether public or private. We areas, and along the coast. For example, use the term “effective access” to connote a the Hoa in Viet Nam and Cham in state in which the populations of interest Cambodia are explicitly excluded from not only have physical access to services, but this study. also are using them, and in which the This study is grounded in the approach services are perceived by recipients as that it is important to focus on highland effectively addressing their needs. and upland ethnic minority populations as such, rather than to simply speak of rural 1.3 Report Content highland dwellers or underserved, poor populations. The highland and upland This Integrated Report presents a synthesis of ethnic minority groups of this study the health and education needs of the ethnic generally are poor, underserved minority populations in the highland provinces of the four focus countries. It is populations, but they are also the subject of specific policies and programs in most based on the results of the country studies that of the countries under study and they were conducted in each of the four countries present particular linguistic, sociocultural, by local teams. The regional summary and and, at times, political considerations that analysis emphasize constraints to service access do not generally apply to other poor or and effectiveness. underserved populations. The Integrated Report begins by describing the “Greater Mekong Subregion.” The term status of ethnic minorities in the target “Greater Mekong Subregion” encompasses countries. This portion draws heavily on the the five countries of Cambodia, Lao PDR, information presented in the four country Myanmar, Thailand, and Viet Nam, plus reports. This introduction is followed by a China’s Yunnan Province. Thus, the discussion of crosscutting themes—i.e., issues geographical range of this study extends affecting those in more than one study beyond those provinces or areas that country—that pertain to ethnic minorities physically touch the Mekong River or its and the social sector. They should be tributaries. As previously mentioned, this considered as the basis for policy by study focuses on ethnic minorities in governments, stakeholders, and donors, such Cambodia, Lao PDR, Thailand, and Viet as the Asian Development Bank. Nam. The report concludes with the presentation of a series of points as the recommendations 2 Note that the ADB definition does not speak of numeric coming from the study’s research. The “majorities” and “minorities,” but rather focuses on the dominant and nondominant groups at the national level. appendices provide additional information, Actual numerical “minority” status is not the salient including the summaries of the four Country feature. Indeed, at subnational levels, the term “minority” is technically incorrect. In numerous provinces, districts, Reports (Appendix A) and a proposed set of and communities across the countries of the GMS, “ethnic research and technical assistance projects that minority” groups represent the clear majority of the follow from the study’s recommendations population of the area in question. (Appendix B). THE STATUS OF ETHNIC MINORITIES 5

THE STATUS OF ETHNIC MINORITIES

largest group, the ethnic Lao, accounts for only 2.1 Ethnic Minorities in the GMS 52.5 percent of the total population. The Ethnic minority populations in the Greater ethnic Lao are the predominant group in Mekong Subregion are numerous and diverse lowland areas of the country, and in highland in and across the focus countries. Who are areas some of the larger ethnic groups include they, and where do they reside? Across the the Hmong, Khmu, Phutai, Kor, and Katu. In region, minority groups are concentrated in eight of 18 provinces, ethnic Lao are the largest the highland areas, and are mainly involved in ethnic group, while in seven provinces they uplands and subsistence agriculture. A brief account for less than 20 percent of the total sketch of the minority populations follows.3 population. In the provinces of Attapeu, Bokeo, Louang Namtha, Phongsali, Sayaburi, and Sekong, the three largest ethnic groups represent less than 70 percent of the total population of the province. CAMBODIA There are an estimated 36 minority groups in Cambodia, accounting for nearly 4 percent of the total population. An estimated 1 percent THAILAND of the total population is known as highland, Highland minority groups are known as hill or hill tribe, peoples. Hill-tribe groups in tribes in Thailand, and there are nine major Cambodia—which are heavily concentrated in groups: Karen, Hmong, Lahu, Lisu, Mien, the four northeastern provinces of Ratanakiri, Akha, Lua, Htin, and Khamu, as well as other Mondolkiri, Stung Treng, and Kratie— groups sharing similar characteristics. Hill represent about 66, 71.1, 6.6, and 8.3 percent, tribes are represented in 20 provinces in respectively, of the total population within Thailand, but are concentrated in the north these provinces. Hill tribes are also found in and northeast. Although they account for a Preah Vihear, Pursat, Kampong Thom, and small percentage of the total population (1.22 Sihanoukville. There are 15 major hill-tribe percent or approximately 753,000 people), the groups, including the most populous hill concentration of highland peoples is large in a tribes of the Tampuan, Kui, Jarai, Kroenung, number of these northeastern provinces (20 to and Phnong. 49 percent of provincial populations).

LAO PDR VIET NAM Based on the latest census (National Statistics In addition to the majority Kinh ethnic Center [Lao PDR], 1995), there are 47 population, there are 53 minority groups. different ethnic groups, and ethnic diversity Ethnic minorities account for 13–14 percent of by province is tremendous in Lao PDR. The the total population in Viet Nam, and are scattered across the country in 45 of 61 of 3 A more in-depth discussion of ethnic minority groups and provinces. Minority groups are largely language families is found in each of the four Country concentrated in the mountainous areas. In the Reports prepared under this project (ADB, 2000a, b, d, e). 6 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION north, 31 of 54 groups are found. These and hygiene practices. Poor health is a factor include such large groups as the Tay, Muong, in school attendance and students’ ability to and Thai in the valleys and foothills; the San learn. Chay and San Diu in the more mountainous Furthermore, the generally limited political or areas; and the Dzao, Khmu, and Hmong in social empowerment of highland and ethnic the middle stretch of uplands. In the Central minority populations greatly restricts their Highlands, there are an estimated 19 ethnic abilities to influence the nature of policies, groups, and the groups tend to be more programs, and project interventions designed concentrated. Groups include the Dzao, to service their needs. Generally, they have Muong, Nung, Tay, and Thai that have little influence in resource allocations for migrated from the north, as well as others in social services. Thus, the cumulative effects of the Mon-Khmer and Malayo-Polynesian limited access to services and marginalized linguistic groups. social status add up to very poor standards of living and quality of life among the more than 2.2 Ethnic Minorities and the 21 million ethnic minorities in the GMS. Social Sector National indicators may not identify regional and ethnic disparities well. However, a study The interlocking relationships among poverty, such as this one that looks at specific health, education, and ethnic status are quite geographical areas and population groups is evident from a review of country situations. able to gather information that can then be For example, poor nutritional status and compared to national data sets. There are clear health indicators among ethnic highland disparities among the rich and the poor, and peoples make it much more difficult for these most ethnic minorities are poor. Further, rural poor populations to earn a living and gain areas are consistently poorer than urban areas, adequate income. Limited access to education and it is in remote, mountainous rural areas services contributes directly to unsound health that ethnic minorities are centered. The highland areas in each of the four countries ❖ clearly have lower levels of income, health, Education and School Calendar: and education when compared with the Observations from Cambodia lowlands and coastal areas of the respective countries. Studies that have detailed Field work to Ratanakiri and Mondolkiri in household data show that ethnic minorities are Cambodia helped to highlight the importance of the school calendar and participation. poorer than other populations, even taking Nationally, the school calendar runs from into account the fact that ethnic populations September to July, with two short breaks tend to live in the poorest and most remote during the year. Children in the northeastern areas. provinces play an important role in agriculture and problems arise when they must This study has confirmed a set of trends in the accommodate both the agricultural and GMS countries affecting the health and school calendar. Students often drop out of education of ethnic minorities. school during key agricultural periods, such as field preparation, planting, and harvesting. • The recent economic trends and the general trend toward cost recovery of communal The study team observed many schools during November 1999 and January 2000 that had services may result in reduced health and been temporarily abandoned, largely due to education access for poor ethnic minority agricultural demands. Agricultural demands populations that already tend to be among do affect lowland students, but lowland rice the marginalized groups. Some analysts fields require less time than shifting cultivation have suggested that rural and poor areas often does. These rice fields are often not as were impacted significantly in the Asian far from farmers’ homes, and the children do not need to move periodically, as they do in economic crisis that began in 1997 through the highland areas. reduced funding to health and education that resulted in a lower quality of health THE STATUS OF ETHNIC MINORITIES 7

Phongsali Province, Lao PDR. Children who live in remote villages rarely attend school and lack access to basic health services. Poor nutrition and low immunization coverage contribute to poor health and are a constraint on children’s ability to learn. (Photo by Inthasone Phetsiriseng)

care, fewer teachers, and limited supplies, • Environmental factors loom large in the among other factors (Table 2.1; see also lifestyles and status of ethnic minorities. Chamberlain, 1999; Jong-Wha Lee and Changes in the quality of the natural Chongyong Rhee, 1999; ADB, 1999d). environment—e.g., deforestation, erosion, • Political history in each country and across decline in water quality, lost biodiversity, countries—including ethnic minority and changing agricultural practices—have roles—continues to influence the making changed and are changing the cultures and and implementation of policy, as well as economic opportunity of many minority societal relations. Decades of war have villages. These issues pose policy and ended across the region, but difficult political and demographic issues remain a ❖ Table 2.1: challenge to nation-building. Elements of Public Expenditure on Education as a history remain in societal relations and may Percentage of GNP (1995) be seen today in each of the four focus countries of this research. Country Rate of Expenditure (%)

• Populations are in flux, and rapid popula- Cambodia 1.0 tion growth and migration have important impacts on service reach and delivery. Lack Lao PDR 2.4 of good data and patterns of migration Thailand 4.1 further constrain service planning. Migra- tion within countries and across borders has Viet Nam 2.7 a range of implications, and often involves peoples of diverse ethnic groups. Source: UNESCO, 2000. 8 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

program challenges for managing natural with the degrees of remoteness and resources and human settlement(s), pro- concentration of ethnic minorities. Income moting good health, and valuing the culture and other socioeconomic indicators—low and practices of ethnic minority popula- literacy, limited access to education and health tions. care—confirm a close association between • Income inequalities are growing across the minority ethnicity and lower standards of GMS, although national economic growth living. In Thailand, the average annual income in the focus countries is positive. Regional of hill-tribe people is 25 times lower than the disparities can be seen within countries. In national average (Boonkham, 1997). In Viet particular, some countries—such as Cam- Nam too, the link between minority ethnicity bodia and Lao PDR and the highland areas and poverty may be seen. of Thailand and Viet Nam—are not experi- Understanding poverty requires recognizing encing economic growth on par with their what poverty provides: freedom from neighboring regions. malnutrition, opportunities to use health and • HIV/AIDS poses a special threat to ethnic education systems, and a clean environment, minority populations. Although in some among other factors. Health contributes to cases their relative isolation offers some income and the ability to learn. Likewise, protection, it also is a danger as it blocks education definitely contributes to health the entrance of effective preventive pro- status, to income, and thereby to the grams and thereby risks facilitating the reduction of poverty. spread of the virus. Although there is little Many of these concerns go beyond what any concrete evidence, it appears that HIV/ single household can attain solely with its own AIDS has entered several highland commu- income and therefore require government nities in Thailand. intervention. And there are important • Decentralization poses implementation dimensions to poverty that include links to challenges. Along with decentralization of ethnicity. Policies that may only target poor authority comes risk and opportunity. areas may not fully benefit ethnic minority Where communications are poor, and staff populations, who need to be targeted specifi- capacities uneven at the local level, the risk cally as a people, and not just as residents of of decentralization is that the management an area (van de Walle and Gunewardena, of public and community affairs may not be 1999). strong. One of several opportunities is that Many of these trends and sectoral conditions decentralized management often encourages are highlighted below. The following sections more local involvement and community on education and health—plus a brief review participation in the planning and imple- of the overall environment situation—discuss mentation of social services and infrastruc- the problems and illustrate the specific links to ture development. ethnic minorities. Understanding and appreciating these broad and systemic interconnections and trends is 2.3 The Education Status of difficult, but also is central to adequately Ethnic Minorities addressing the constraints to ethnic minorities’ effective access to health and education 2.3.1 Literacy Rates services in the GMS. There is also another very important linkage Literacy rates are an important indicator of the to consider: that between poverty and problems ethnic minority groups are facing in ethnicity. Extremely poor human capital levels the education sector—and in their in the remote northeastern provinces of participation with the majority of society. Cambodia confirm a close association between Adult literacy in the dominant or national poverty status, broadly defined, and hill-tribe language at the national level is high in peoples. In Lao PDR, poverty rates increase Thailand and Viet Nam, and for Viet Nam— THE STATUS OF ETHNIC MINORITIES 9 given its low average income level—this fact is ❖ an important accomplishment. However, Table 2.2: Cambodia and Lao PDR have rather low Literacy Rate for Ethnic Minorities and Total Population (percent) national literacy rates. These national patterns among the countries also hold true as one looks at the literacy rate of ethnic populations Ethnic Minorities Total in each country, as indicated in Table 2.2. Country Female Total Female Total Highland peoples in Thailand and Viet Nam have higher rates of literacy than minority Cambodia 17 26 55 63 groups in Cambodia and Lao PDR. In all four Lao PDR 17 33 48 60 countries, literacy rates are significantly lower for highland peoples than for lowland peoples. Thailand 80 94 For example, Cambodia’s nationwide literacy rate is 67 percent, yet for Ratanakiri Province Viet Nam 73 86 92 (a province with a high concentration of Source: Cambodia: National Institute of Statistics/ minority peoples), the literacy rate is 23 Ministry of Planning/United Nations Population Fund, percent. Literacy rates among the Kinh 1998. Lao PDR: National Statistics Center, 1995. majority in Viet Nam are over 87 percent, yet Viet Nam: General Statistical Office, 1999. Literacy rates in Cambodia are for age 7 and older. for highland minority groups, rates are much Literacy rate for ethnic minorities is the literacy rate for lower (e.g., Ede, 42 percent; Hmong, 10 the provinces of Mondolkiri and Ratanakiri, which are 67% ethnic minority (source: 1998 census). Literacy percent). rates in Lao PDR are for non-Lao-Phutai speakers (source: 1995 census). The literacy rates in Thailand Thai language skills are very low among hill- for ethnic minorities over the age of 15 refer to reading tribe populations in Thailand. Limited Thai ability in the Thai language. The national figure is for adults, i.e., those over the age of 18. The literacy rates language abilities are an impediment to in Viet Nam are for the population over age 10 educational advancement for highland groups. (source: 1997-98 Viet Nam Living Standards Survey). Field work in Viet Nam and Lao PDR noted that schoolchildren from ethnic populations traditions still factor into families’ decisions to have difficulty entering the early primary invest in and support their children’s grades due to language constraints. Many drop education. In Lao PDR, there is clear out before the third grade from frustration evidence that the higher the elevation, the less and lack of classroom success. The return on access girls have to primary school (ADB, time invested in school is simply not seen as 2000b). positive. This issue of language literacy is also present with respect to numerical ability in the 2.3.2 Gender Considerations dominant, mainstream language. As has been observed in this study’s field work, a large There are important gender considerations as proportion of ethnic or highland commun- one looks at education and literacy problems. ities function in a language other than the Generally the gender gap in literacy is higher national language, and these populations have in ethnic minority communities than the difficulty succeeding in what, to them, are national averages. In Lao PDR, literacy rates foreign language programs and foreign for the majority Lao-Phutai are 84 percent for language use in everyday life. For example, males and 62 percent for females; among the ethnic minorities in Cambodia have difficulty Mon-Khmer, 55 percent for males and 20 operating in local markets in the Khmer percent for females; and among the Hmong- language. Yao ethnic groups, 45 percent for males and 8 Improvements in literacy levels and language percent for females. Field observations do skills are generally quite slow to take hold suggest more girls entering school, although given the number of years of study required to traditional matrilineal and patrilineal achieve literacy and language proficiency. 10 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

Grade 1 class in Virak Chey School, Ratanakiri Province, Cambodia. Students have few books or supplies but are fortunate to have an enclosed classroom and a teacher at this school. Age differences are large within the class, given the high repetition rate and late starts for many grade 1 students. (Photo by Hean Sokhom)

Primary school achievement toward full instruction and the overall health of the literacy takes a number of years. Basic literacy students will have a great impact on is generally thought to be accomplished in educational achievement. Without four or five years of primary education, in continuation in school, all knowledge gained order for one to gain command of letters and in a year or two of education will soon be lost. numbers to communicate in a given language. Adult literacy classes are too often pilot efforts 2.3.3 Teacher Quality and sustained benefits are too often hard to see, as noted in the program experiences in Teachers are perhaps the single most Cambodia, Thailand, and Viet Nam among important input to the educational system. ethnic populations. Literacy classes for adults Teacher availability and quality rank high as have struggled to sustain results, as common education sector problems linked communities such as those in the northeast clearly to student achievement for highland provinces of Cambodia have not been able to minorities. In Viet Nam, 40 to 50 percent of consistently use the skills learned because of primary school teachers in highland areas are their isolation and lack of exposure to media not fully trained. In Lao PDR, academically sources or other ways to regularly apply new qualified teachers and certified teachers are not skills. likely to be found in remote areas, teaching minority children. Even with increases in primary school enrollment rates like those seen in Lao PDR, Across the GMS, it is very difficult to recruit changes in literacy levels will lag a number of and retain qualified teachers in remote, years. And importantly, the rate of enrollment highland areas. Absenteeism is a concern, and alone does not translate into literate turnover is high. Salaries are low—and too populations. The quality of teachers and often, slow to be paid—and there are few THE STATUS OF ETHNIC MINORITIES 11 positive incentives for serving in highland and ❖ remote areas. Education and Gender— A View from the Field Teacher deployment, matching supply with demand, is particularly a challenge in remote Ethnic and gender role models make a areas. In Cambodia, there are not nearly difference in boosting participation and enough teachers for the number of school-age opening up access to services. During a trip children in the northeast provinces. The heavy to Phongsali Province in Lao PDR in use of contract teachers in each of the four November 1999, the study team found that the Ikor ethnic minority has shown progressive countries is a common way to mobilize support for children’s education, at least for teachers to those less-desirable highland areas, boys. Compared to other provinces—such as seen most vividly in Lao PDR and Viet Nam. Louang Namtha, which also has a high Ikor Contract and short-term teachers are often less population—large percentages of Phongsali’s qualified. Even among full-time civil servant Ikor children were enrolled in school. teachers, qualifications are consistently lower This increased enrollment is credited in part to among highland teachers (lower than lowland the significant presence of teachers from the teachers) across the four countries in the Phounoy ethnic group, which is in the same mountainous areas. linguistic group as the Ikor. Also, Ikor parents strongly support the education of their Positive role models among the teaching cadre children. Most Ikor villages have a school are too few. Women are underrepresented, and where the boys are enrolled, and Ikor parents ethnic minorities are greatly underrepresented support continued education at schools outside the villages. Parents build huts for among the teaching force. In Lao PDR, over their children near their schools and bring rice 80 percent of the teachers are from the Tai- and food to them weekly. Kadai language family. Low school Although the Ikor have not traditionally sent achievement and advancement among ethnic their daughters to school, Ikor girls do attend minorities, particularly girls, does not provide the provincial ethnic minority boarding a deep cadre of skilled, locally based staff, to school. serve as teachers and health workers in highland areas. Capable teachers are also a critical component for boosting student achievement, and for gaining community ethnicities is mostly even at the first-grade support and participation for schools. level, this equity rapidly disappears in the upper grades of primary school. Across all four countries, the variation in enrollment rates is 2.3.4 Enrollment great at higher levels of education. Enrollment Enrollment rates tend to be lower for minority rates in secondary school are low nationally, groups than for majority ethnic groups, across and they are particularly low for ethnic the four countries. High primary gross minority populations. The quality and enrollment and net enrollment rates, as well as availability of boarding schools introduce high dropout rates, indicate inefficiency in an important policy and program issues for education system. Data, where available across highland areas. Even within the better-off the four countries, suggest provinces with high economy of Thailand, secondary education populations of ethnic minorities tend to enrollment is low among highland peoples. perform poorly on these measures of success of Further, university enrollments among ethnic the education system. minority populations are extremely small. Advancement to higher grades and higher levels of learning is another important 2.3.5 Facilities indicator that further highlights how ethnic minorities fall behind mainstream society. Supply of education facilities and services is While enrollment across provinces and also a common cause of poor participation and achievement in school for ethnic minority 12 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

physical condition, and only 99 of these ❖ Better Teachers Building Stronger Communities schools are complete (e.g., schools that offer the full complement of grades 1 to 6). Somsy, a former teacher and now teacher Investing in education has many beneficial trainer, recites an impressive story of the multi- dimensional benefits derived from targeting effects. It helps to raise earnings capacity both the improvement of teachers. A Hmong, he in the labor market and on the family’s own bubbles over with pride in talking of the household plot. It also contributes to the benefits seen with teacher improvement and health of ethnic minority families. Returns on community support for the schools. The education can be significant, although the successful completion of the Lao Network Teacher Upgrading Program’s (NTUP’s) two- question remains whether ethnic minorities year training program raised the credentials will be able to take advantage of these of the teachers. Because salary levels are potential benefits. There are both costs and linked to certifications, these teachers were benefits of pursuing education for many able to raise their income level. Such highland families. For many ethnic minorities, incentives helped boost job satisfaction and reduce the turnover rate among teachers. the costs of education may well outweigh the Higher credentials, better incentives, and benefits, especially if the quality of teaching is better practices in the classroom raised the low, students don’t speak the language used in self-esteem of the teachers while raising the the school system, textbooks are in short standards of teachers across the system. supply, and the education is seen as irrelevant The program has given us more opportunity; it for the community. gives us opportunity to upgrade ourselves. Those of us having completed the program have encouraged many others to also 2.4 The Health Status of Ethnic participate.... Demand has grown as teachers Minorities in other districts see our spirits, enthusiasm uplifted. (Study team interview in Vang Vieng The health status of ethnic minorities has Teacher Training Center, Lao PDR) shown signs of improvement in all four of the NTUP supports increased participation of focus countries of this study. That said, many ethnic minority teachers in community serious problems remain. schools. The program has shown impressive results in raising teaching standards, which A child born in the highlands in Thailand has has been directly linked to increased a higher life expectancy than one born in Laos, community support and student participation, performance, and advancement. but life expectancy in each country is lowest among ethnic minorities. Nationally, Lao PDR and Cambodia have among the highest infant mortality rates in all of the Asia region. populations. Limited distribution of facilities and supplies across areas with low population Viet Nam and Thailand have substantially densities makes geography and distance an higher life expectancies, which is impressive important element in school participation. given the low level of income in Viet Nam. This fact is seen most strikingly in Lao PDR, In each of the four countries, infant mortality where thousands of villages have no primary is indeed a major concern in the highlands school; but it is also observed in Cambodia, (Table 2.3). Across countries, variations in the Thailand, and Viet Nam. Although in many infant mortality rate reflect differences in cases the first grades are available, education income, nutrition, and access to health care. may not be available beyond the second or Yet despite the wide variation across countries, third grade, which lowers the value of the highland peoples have the highest infant initial investment. In Cambodia, for example, mortality rates. there are 381 primary schools in the Similar comparisons may be made with northeastern provinces, mostly in poor respect to maternal mortality rates (Table 2.4), although reliable highland data are limited. THE STATUS OF ETHNIC MINORITIES 13

The majority of births occur at home with ❖ Table 2.4: only families and immediate village residents Comparison of National Maternal assisting in child delivery. Surveys of highland Mortality Rates (MMRs) areas do report considerably higher rates of maternal mortality among ethnic minorities. Country National Avg. MMR Prenatal care is quite limited among ethnic Cambodia 650 per 100,000 (1998) peoples, as are high-quality health care, Lao PDR 850 per 100,000 (1995) nutrition, and assistance to women during their reproductive years. Family planning and Thailand 120 per 100,000 (1997) the use of contraceptives also are low among Viet Nam 160 per 100,000 (1996) highland people. Relatively large family size is common. Field surveys suggest that ethnic Source: Cambodia: National Institute of minorities have four to eight children per Statistics/Ministry of Planning/United Nations Population Fund, 1998. Lao PDR: National Statistics family, significantly more than the national Center, 1995. Thailand: Ministry of Public Health, average in each of the four countries. Beliefs, 1997. Viet Nam: Nguyen Van Phai, 1998. distance from services, education levels, and family poverty all are factors. widespread and in many areas are a rising Although many of the problems with access to concern. Likewise, HIV/AIDS is a growing health services are grounded in the lack of threat, and a concern most clearly in health centers and health professionals, the Cambodia and Thailand, although the risk lack of education among the population also crosses all countries. Health education that plays a significant role. Education definitely encourages preventive health practices clearly alters the health-seeking behavior of women, has the potential to make a difference to with benefits for the health of the entire combating these diseases and to improving the household. health conditions in the highland areas. Highland areas, however, are least likely to Diarrhea and malaria rank high as major receive health information. causes of mortality and extended illness across the GMS. Acute respiratory infections and High rates of tobacco and alcohol use are also pneumonia are also dominant health important health factors. Use of such problems. Dengue fever and tuberculosis are stimulants is notably high among children and young adults in many, though not all, highland areas. Traditional use of opium as a ❖ Table 2.3: painkiller is common among ethnic minority Comparison of National and Highland Infant Mortality Rates (IMR) groups, and cases of substance abuse are found, although data are not consistently Country National IMR Highland Area IMR available.

Cambodia 115 per 1,000 N/A Financing and programming for the provision of health facilities, staff, and supplies directed Lao PDR 100 per 1,000 132 per 1,000 (1995)- (1995) Louang Phrabang to highland areas is complex, as these areas Province tend to have low population density. The Thailand 5.8 per 1,000 10.1 per 1,000 (1997) average distance to nurses, doctors, and (1997) - Northern Provinces pharmacies is far greater for ethnic highland Viet Nam 36 per 1,000 52 per 1,000 (1996) - peoples than for lowland dwellers across all (1996) Northern Highlands; four countries. 55 per 1,000 (1996) - Central Highlands Even with some targeting to poor and remote Source: Cambodia: National Institute of areas, the highland areas across the four Statistics/Ministry of Planning/United Nations countries, on average, tend to have smaller Population Fund, 1998. Lao PDR: National Statistics Center, 1995. Thailand: Ministry of Public Health, health budgets per capita than the regions in 1997. Viet Nam: Nguyen Van Phai, 1998. lowland areas (ADB 2000a, b, d, e). Poor 14 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

Ethnic minority village in Phongsali Province, Lao PDR. Basic health and sanitation represent key areas for health education. Diarrhea is a major cause of mortality and morbidity in Lao PDR, and generally in the highlands in the GMS. Lower educational status for many minority populations, especially among women, is a constraint to household health. (Photo by Inthasone Phetsiriseng) roads, low levels of staffing, low quality of ❖ Health Staff and Facilities— facilities, and low population density all As Seen in the Field contribute to limited health system coverage.

Ethnic composition of the staff of service providers, language, and distance are all 2.4.1 Nutrition constraints to access. During a November 1999 trip to Son La Province, Viet Nam, the Caloric consumption and basic household study team observed limited participation of nutrition are poor, again particularly in ethnic minorities in the formal health system. Cambodia and Lao PDR. A majority of Although 60 percent of the health staff were families live at subsistence level. Caloric intake from an ethnic minority—a large percentage levels at or below 2,000 Kcal per capita per compared to many provinces—most of the health workers came from only one of the day are common in the highland areas of the many ethnic groups in the province (Tai). Low GMS. Malnutrition and vitamin deficiencies education levels and lack of qualifications are key factors in childhood deaths, stunted among ethnic minorities hinder the expansion growth, and generally poor quality of life. of ethnic participation in the health care Anemia and goiter are all too common among delivery system in Son La and throughout Viet highland populations. In Cambodia, Nam. Field work in Son La province also found that many rural communities lacked nutritional status is a concern nationwide, but access to pharmacies, and often high-quality particularly in the northeast. The national rate health facilities were too far for many ethnic of low body mass index was 27 percent in minorities to travel. 1998, but 43 percent in Kratie and Stung Treng Provinces, and goiter was the highest in the northeast (Ministry of Planning [Cambodia], 1998). Evidence in Viet Nam THE STATUS OF ETHNIC MINORITIES 15 shows that ethnic minority children are more ❖ Table 2.5: stunted and wasted compared to the national Comparison of Highland averages, which are already low. Immunization Rates

Even in relatively prosperous Thailand, Polio Immunization nutrition is a concern for minority groups in in Highland Areas: the north. While severe malnutrition in Country % Below Age 2 Thailand is rare, it is clear that the largest Cambodia 24% (1998)a levels of mild malnutrition are in the hill areas of the north and northeast; the levels in the Lao PDR 45% (1999)b hill areas are approximately three times the Thailand 68% (1997)c national average (Office of Health Promotion [Thailand], 1998). Viet Nam 92% (1998)d

a Average percentage of children in the four 2.4.2 Preventable Diseases northeastern provinces of Kratie, Mondolkiri, Ratanakiri, and Stung Treng immunized against polio, based on provincial data, January–August 1998. As noted previously, parents in the highlands receive less education than lowland peoples, b A 1999 health survey in Lao PDR (ADB, 1999c) confirmed that 45% of the ethnic minority children and low education levels contribute to poor ages 1–2 had two or three doses of polio vaccine. health practices. Limited access, use, and This compares to a rate of 60% for ethnic Lao people. overall effectiveness of health services also are c Average percentage of children 12–23 months who reflected in the high rates of a number of received polio vaccinations in the five northern provinces of Chiang Mai, Chiang Rai, Mae Hong preventable diseases. Son, Nan, and Tak, based on the Survey of the Hill- Area Peoples’ Health Status (Office of Public Health The low rate of immunization in the Policy and Planning [Thailand], 1998). highlands is a clear indicator of access to d Average polio immunization rate for provinces in the health services. It also is an important issue in Northern and Central Highlands. Although the overall understanding health-seeking behavior of average is relatively high, a number of individual Central and Northern Highland provinces—e.g., Son minority groups. Table 2.5 highlights La (86%) and Yen Bai (88%)—have lower immunization coverage for polio as an percentages of immunization coverage. The national example of the very low rates of coverage in average immunization rate in Viet Nam is 94%. the areas most populated by ethnic minorities. language, they often do not reach a large percentage of the ethnic population. 2.4.3 HIV/AIDS

With the exception of the hill tribes in 2.4.4 Water and Sanitation Thailand, ethnic minority communities have not encountered the HIV/AIDS epidemic so The availability and use of safe water and basic far. For example, despite the fact that hygiene and sanitation practices are linked to Cambodia has one of the highest levels of child and maternal death and illness rates. HIV/AIDS infections in Asia, the level of Standards in these areas have improved in the infection appears to be quite low in the past 10 years, but not rapidly among minority northeast. populations. Poor basic health and sanitation However, HIV/AIDS poses a special threat to practices are a major cause of disease, illness, ethnic minority populations because of their and poor quality of life. In Cambodia and relative isolation from the majority as well as Viet Nam, fewer than half the households language barriers they face. While isolation have access to safe water; in Lao PDR the does provide some protection from infection, figure is around 30 percent in many of the it also limits the entry of prevention poorest northern and southern provinces. campaigns. And because most prevention Even in relatively more prosperous Thailand, campaigns are presented in the national only around 30 percent of hill-tribe households have access to safe drinking water. 16 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

of highland peoples. Income-generating opportunities have been altered; traditional practices have been lost; and water, health, and nutrition impacts may be seen. Forced changes in land use practices and access to natural resources have been a significant concern for minority communities. Forced relocation or encouraged migration from highlands to lowlands (or lower lands) has been applied often as a tool for governments to tackle perceived problems of swidden Ethnic Karen mother and son in a remote agriculture, opium production, or poor resettlement village in Lampang Province, Thailand. highland conditions, in Thailand, Lao PDR, Encouraged migration has moved villagers away from traditional lands. Many challenges remain to and Viet Nam. Other changes, such as major accommodate traditional practices into regulation of infrastructure development projects—notably natural resource rights, national parks management, mining activities, irrigation, and dam and other land use decisions. (Photo by Myles construction—have brought new residents to Elledge) highland areas, and forced highland peoples out and off of traditional lands. In Thailand, Access to sanitation is very low, notably in for example, these factors have been a point of Cambodia and Lao PDR. contention between the government and Although it is not realistic to imagine that indigenous groups that have organized around large-scale water projects will reach isolated concerns for natural resource rights. Forest ethnic minority communities, it is possible to concessions granted to developers and the make important contributions through well- designation of large highland areas as natural tailored environmental health/education preserves have also had major impacts on programming. highland peoples’ lifestyle, residence location, and economic opportunities. 2.5 Environment and Ethnic Population pressures also are important here. Minorities Lowland migration to the highlands and forced and voluntary migration have impacted Environmental change is rapid among ethnic the natural environment. These changes have minority communities. Although it was not altered patterns of farming and basic lifestyle the focus of this study, it is a point difficult to among minority groups. In many cases, the ignore. The impacts of war, rapid changes in livelihood, lifestyle, and quality of life of forest cover, agricultural practices, soil erosion, ethnic minorities have been impacted and water supply have changed and will permanently by these environmental changes. continue to significantly change the lifestyles CROSSCUTTING THEMES 17

CROSSCUTTING THEMES

Applied research on ethnic minorities in the other children find too distant. Solving GMS suggests that ethnic minorities (1) often problems such as these requires supply-side receive low-quality services in health and investments. education as compared to the national norm, The utilization of social services can be (2) encounter numerous barriers to using described as part of a household decision health and education services, and (3) have process. The decision to use a social service is significantly lower health and education status influenced by the cost of the service, the than the national average. The elements that income available, and the expected benefit cause and sustain these conditions are from the service. This approach also complex. Learning about them requires recognizes ethnic minorities as active identifying measures to change or reverse these participants in the health and education conditions, grounded in an understanding of system and as people who constantly must factors specific to the provision of health and make decisions at the household level. education services. It also requires attention to trends affecting the course of development in Factors such as distance, monetary cost, the region, along with knowledge about the waiting time, and subsidies affect the cost of institutional, political, economic, and services. Many families simply are unwilling to geographical conditions for each country. The send their children to a school that is several following section outlines key constraints in hours away, effectively reducing the children’s brief, then later subsections elaborate on each capacity to work at home and creating a of these constraints in more detail. serious opportunity cost. Of course, monetary costs—e.g., cost of travel to school or to a clinic, or the cost of books—also can obstruct 3.1 Constraints to Access access, especially considering the universally Unfortunately, throughout the region there are low incomes that ethnic minorities earn in the multiple barriers preventing the effective use highlands. of services. Many of these barriers apply In addition to considering the cost of services, equally to ethnic minority and other popula- households also must consider the value of the tions, whereas others are likely to be more services that they are using. If services are of severe for ethnic minorities. Table 3.1 presents poor quality, they will not be used regardless some of the key constraints that are likely to of the cost. Ethnic minorities may be impede or prevent ethnic minorities from especially sensitive to considerations of quality using health and education services. or appropriateness. Language barriers make it People often face physical barriers to access. difficult for their children to take full Quite simply, required services may not exist advantage of the school system, lowering its or may be too far for people to take advantage perceived value. Likewise, the health system is of them realistically. For example, schools may aimed at the majority and is not sensitive to simply be too far away for children to attend. the beliefs of ethnic minority patients. In the Physical barriers are relative: A child with a worst cases, health providers do not have the bicycle may be able to attend a school that training to deal with health problems that are common in the highlands. 18 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

❖ Table 3.1: Constraints to Access and Use of Social Services by Ethnic Minorities

Nature of the Locus of possible effect solution

Can impede Can impede With service With physical use of provider community access to existing ("supply" to be services services side) served ("demand" Constraint Description side)

Physical- The ethnic minority groups considered in this study tend to 4 4 4 4 geographical live in rough-terrain highland and border areas of the constraints Greater Mekong Subregion (GMS). The sheer physical geography of these settings poses special challenges, as well as costs, in the provision and maintenance of basic infrastructure (roads, communications, utilities) and social services. Economic Even where services are available, ethnic minority groups of 4 4 4 constraints the GMS shoulder severe economic constraints. Due to their isolation from markets and low productivity (mainly agricultural), many ethnic minorities have very low incomes. People with limited economic means must carefully weigh the opportunity costs and direct costs of accessing services, against the expected benefits. This is especially the case as the private sector and fee-for-service arrangements begin playing a more important role in social services. Fiscal On the supply side, competing demands on limited funds 4 4 4 constraints may result in entire communities that are simply lacking in basic services. The high cost of providing services in highland areas may reduce the availability of services. Likewise, the government might not have sufficient resources to target subsidies for the ethnic minority population. Decentralization (both de facto and de jure) may exacerbate the situation. Legal and The legal status of ethnic minority groups may impede them 4 4 4 policy from taking legal advantage of existing services. The constraints effectiveness of existing policy and the technical competence of policymakers to address the needs of minorities may also be limited at the local and national level. There may not be political will to enact and support policies that favor minorities' access to and use of services.

Lack of Ethnic minorities may have limited knowledge and 4 4 4 4 understanding understanding of the health and education services that are and available in their area. Incomplete or erroneous information information on how to access services, what they might cost, or the about nature of a given service or procedure, can discourage available potential clients and even lead to distrust of service services providers. Lack of understanding about the methods or intended outcomes of education or particular health procedures can lead to doubts about their quality, effectiveness, or relevance. Lack of Service providers, for their part, may lack sufficient 4 4 4 understanding understanding or knowledge about their potential clients' and needs and behaviors to engage their attention, recognize or knowledge appreciate their concerns, or show proper respect. These about the shortcomings will impede the providers from offering population to adequate and appropriate assistance or instruction. be served Differences in language, educational level, class, and ethnicity can create barriers to real communication and effective services. They can lower the "interpersonal" aspect of the quality of the services and make the services less attractive for members of ethnic minority groups. They also can weaken the social services' ties to the community. CROSSCUTTING THEMES 19

❖ Table 3.1 (continued) Constraints to Access and Use of Social Services by Ethnic Minorities

Nature of the Locus of possible effect solution

Can impede Can impede With service With physical use of provider community access to existing ("supply" to be served services services side) ("demand" Constraint Description side)

Competing It has been shown that centrally designed or standardized 4 4 4 knowledge interventions and service delivery programs often fail to systems, acknowledge and validate the use of traditional indigenous practices, knowledge systems. In turn, minority peoples can be and values skeptical of services that challenge traditional knowledge and practices, and resistant to participating in such services. They may view schools that discourage children from using their native tongue, or health care procedures that directly oppose traditional beliefs, as threats to their ethnic identification and welfare.

Poor quality Services that are of low quality or have little relevance for 4 4 and relevance the client population are likely to be not only ineffective but of services also unpopular. Unfortunately, many services that operate in provided remote areas fit this description. Schools in remote areas tend to have difficulty attracting and retaining qualified teachers, which are the key to learning. Likewise, curricula presenting dominant culture models and skills suited to urban, mainstream lifestyles may have, or be perceived to have, little to offer to rural highlanders. Health care posts may have few trained staff and medical supplies and may not be able to offer services of sufficient technical quality.

Lack of Cultural values and distinctions regarding acceptable 4 4 4 4 attention to behavior, activities, and relations with others are almost gender-specific universally colored by gender. These values and distinctions, considerations, in turn, create gender-specific patterns in potential clients' especially demand for or resistance to services, in the real and those of girls perceived utility and opportunity costs of the services and women offered, and in the effectiveness of methods used by service providers to reach populations, foster learning, or encourage good health behaviors. These values within minority populations may differ from those of the majority, and social services may have to adjust to these differences to develop services that are demanded by ethnic minority girls and women. Language In the GMS, national policy generally requires the national 4 4 language as the language of instruction and discourages use of ethnic languages in schools. It is often the de facto language in many health services since it is the language that the providers know. Young children who speak only a local language in their homes and communities are likely to have serious difficulty adjusting to school, and often leave school before they do, having learned little in any language. And where teachers and health care providers do not even speak the language of the community they work in, outreach, communication, and ultimately effective assistance to parents and other potential seekers of services surely are seriously curtailed. 20 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

education of children. For example, in Viet 3.1.1 Physical-Geographical Constraints Nam, despite great advances in terms of the This study explicitly focused on ethnic universalization of education, some villages minorities living in highlands, in areas that are still have no schools and many have isolated from rest of the economy. It is not incomplete schools. In Cambodia and Lao surprising that ethnic minorities are largely PDR, a large number of isolated villages have located in the least accessible areas: Although no schools or incomplete schools. For these areas are poorer, they afford a certain example, in Lao PDR, in five mountainous amount of cultural protection. In the past, provinces, fewer than 45 percent of villages isolation limited the contact between the have any sort of school. In lowland provinces, majority culture and ethnic minorities, which this proportion is substantially lower and played an important role in cultural survival. access to schools in other villages is much For example, in Viet Nam, 50 out of 54 of the more feasible given the closer distances and ethnic groups are located primarily in better roads. highland areas. In Cambodia, the only two A serious constraint in the education sector in provinces where the non-Khmer population is all four of the countries is the difficulty in a majority are also the most mountainous and recruiting teachers who are willing to work in isolated provinces of the country. isolated areas. Although numerous factors Geographic isolation and the lack of transpor- make it difficult to attract qualified teachers, tation, however, have serious consequences for the isolation and poverty of the highlands access to health and education services. Formal surely play a big role. Interviews in Cambodia education requires continuous contact with and Lao PDR confirm that it is difficult to the school system over a number of years. convince teachers to move to highland areas Clearly if schools are too distant, it is not and to convince them to stay. Staff turnover possible for children to attend on a regular rates are high across the four countries. basis. Possible solutions include the Viet Nam and Thailand have networks of construction of more schools, improvements boarding schools and hostels to help children in transportation, and the construction of who want to increase their education level and boarding schools and hostels. do not have the opportunity to do so at a local Evidence from all four of the countries shows school. Lao PDR also operates a limited that distance is indeed a barrier to the system of boarding schools, and Cambodia is considering reopening boarding schools, which have not functioned in the northeast for some time. Thailand also has a program of sending mobile teachers (teachers on horseback or motorbike) to isolated villages to ensure some continuity in education. This approach is common in a number of countries beyond the region, such as Mexico, which has sophisticated networks of mobile teachers who supervise education in isolated communities. Physical-geographical constraints on health are more complicated. Individuals often are Dak Lak Province, Viet Nam. These sixth-grade ethnic willing to travel great distances to relieve minority students (Ede) from the Central Highlands share health problems. However, preventive services a dormitory room at their boarding school for minority require more continuous contact with the students. These students spend months away from their health system and followup by health villages in order to attend school past the primary grades. providers. In general, distance is cited as a Only the select students are eligible for post-primary education at such boarding schools, located in larger towns major factor that limits the utilization of all or provincial centers. (Photo by Myles Elledge) forms of health services. CROSSCUTTING THEMES 21

In all of the countries in the study, health care subsidize health and education services, to is largely organized following geographic some degree users are expected to pay the cost boundaries, with hospitals operating at the of the services. provincial and district levels, and primary In Cambodia, it appears that user fees largely health care units centered at a lower level finance social services at all levels; evidence (communes in Cambodia and Viet Nam and suggests that users pay more than 90 percent villages in Lao PDR). This arrangement is not of the total cost of services out of pocket. In a problem for lowland areas, which have a Viet Nam and Lao PDR, user fees are also dense population and good transport widespread, but the governments have been networks, but it is inappropriate for low- able to maintain some subsidies for primary density, remote areas. education and for basic health care. Thailand, Cambodia has been developing a reformed with its larger economy, maintains a system of health system that follows natural boundaries widespread subsidies for basic services. rather than political boundaries. Nevertheless, Whereas this growth has undoubtedly one of the major reasons cited that ethnic benefited a large percentage of the population minorities in Cambodia avoid health centers is in each of the countries, ethnic minority the distance from communities. populations have not benefited much from As in the education sector, it is difficult to growth in recent years and suffer from the attract health professionals to live and work in increasing emphasis on cost sharing for social isolated areas. Field work and interviews in services. Although the lowland populations Son La and Dak Lak Provinces in Viet Nam have benefited from increasing income and showed that health workers are reluctant to the possibility of obtaining better-quality relocate to the highlands and generally try to social services with their income, ethnic leave after a few years. A strategy aiming to minorities have been excluded from the improve health of highland populations must benefits of economic growth and face higher seek solutions to the lack of trained personnel. costs for the same low-quality services that Viet Nam, as in parts of northern Thailand, they have always received. has started an innovative program to train In all of the countries, there is clear evidence some members of the local population to that ethnic minorities have higher rates of provide limited primary health care services. poverty than the average for the rural population. Surveys in Lao PDR confirm that 3.1.2 Economic Constraints the poor largely consist of ethnic minorities in remote areas (Chamberlain, 2000). Viet Nam In the past decade, Cambodia, Lao PDR, and probably has the most detailed studies of Viet Nam have all undertaken significant poverty and ethnic minorities; results there market-oriented reforms, and all three have show that even taking into account other largely abandoned central planning as the factors such as family size, education, and primary means to allocate resources. The distance from urban centers, ethnic minority decade of the 1990’s has also seen an households are poorer than Kinh households. unprecedented growth rate in all four of the There is no reason to think that the results countries in this study. Although the Asian would be any different in the other countries financial crisis of 1997–98 affected the entire in the study. region, there is no doubt that average per capita income rose and poverty fell at The cost of education was cited during field unprecedented rate in all of the countries. observations as a major impediment for ethnic minority children. Education costs include This change has happened at the same time both formal and informal tuition charges, in that the social sectors in all countries, except addition to expenditures on other goods such Thailand, have introduced cost sharing. as uniforms and textbooks. In Viet Nam, the Although the government continues to government has tried to focus scholarship and 22 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

lowland agricultural calendar. During the peak ❖ Case Study: Hoping for a agricultural period, schools serving ethnic Better Life for Her Children minorities are generally closed as both Dao, a Muong ethnic woman from Dak Lak students and teachers are fully occupied with Province, Viet Nam, is married with five the harvest. Education projects should take children, ages 2, 4, 5, 8, and 10. It takes 2.5 into account the labor needs of households hours to reach the nearest road, telephone, and adjust the school schedule to reflect the school, or health clinic. A rough motorcycle agricultural calendar. ride through the forest is the quickest way to such services; a trip by bicycle takes all day. As noted above, the increased cost of health Her family grows rice and maintains livestock care has had a similar effect on health-seeking and chickens. In most years, the family is able behavior. In Viet Nam, as user fees play a to sell a cow and excess rice to make a larger role in financing health care, many modest amount of money. consumers are turning to less formal health Her oldest child goes to school on most days, solutions, such as self-medication and although household demands often require consultations with pharmacists. The lack of her son to miss school. He has one textbook money for health services may reduce the that has been provided by the teacher, but it must be shared among two other students in access that ethnic minorities have to health the village. care. This pattern is also seen in Cambodia She notes that they are lucky to have a and Lao PDR as the health services have to teacher in the village. She knows there really rely increasingly on user fees. Users often seek is no chance for schooling after the fifth alternatives such as self-medication or simply grade, as distance and cost make it no care. impossible for her children to plan for more schooling. She values education, and speaks Interviews in Cambodia showed concerns with emotion of her desire to see her about the cost of health care among ethnic daughters and her sons go to elementary minorities, often leading to households school. She hopes these few years of “cutting corners” when it came to health care. schooling for each of her children—more This situation calls for the introduction of than she ever had—will open up chances for the children to become teachers or nurses for targeted subsidies that provide exemptions or their village. “discounts” for vulnerable populations, such as ethnic minorities. fee exemptions on poor areas, targeting ethnic Viet Nam has a number of programs focusing minorities in particular. Viet Nam also offers on ethnic minorities, including health stipends for some ethnic minority children to insurance for hospitalization, through the attend school. provision of a “health card.” Thailand has also introduced health insurance cards for the poor, Another consideration is the importance of which allow access to hospitals. child labor to the household enterprises (usually farms). As most ethnic minority households are living in a state of poverty, the 3.1.3 Fiscal Constraints labor that children provide is essential for the household’s survival. Schooling tends to be In all societies, the demand for public resourc- very time consuming and many households es always exceeds their availability. This point simply cannot afford to keep their children is especially true in low-income countries like away from the field for long periods of time. Cambodia, Lao PDR, and Viet Nam, where poverty rates are relatively high and the Evidence from the Cambodia field work government has a limited tax base. clearly confirmed this fact; ethnic minority households felt that the school calendar In the specific case of health and education definitely did not match well with the services for ethnic minorities, it is clear that agricultural calendar. There, the highland resources are not being targeted to ethnic agricultural calendar also differed from the minority communities in the study countries. CROSSCUTTING THEMES 23

In most countries, it is common to see beneficiary population is much smaller. Ethnic governments dedicate a significant portion of minorities live in remote areas, which their health and education budgets to services complicates access to hospitals. With the that largely do not benefit poor populations. exception of Thailand, hospitalization tends to In the case of education, a disproportionate be expensive and may be out of the reach of amount of the budget is often spent on much of the ethnic minority population. universities. Although higher education is In most countries, the government only important for development, investments in contributes a small part of total spending for universities tend to be highly regressive, for a health care. In Viet Nam, it is estimated that number of reasons. For example, university the government pays for around 20 percent of students need to have a high initial level of total health costs, while in Cambodia and Lao education. Studies cited in this report show PDR, it is likely that government subsidies that in all cases, children from ethnic minority account for an even smaller proportion of groups have numerous problems attending total spending. In Thailand, the government and completing school. Moreover, universities pays for half of health expenditures while are generally located in urban areas and most households and employers pay the other half. of their students live nearby, which excludes Given the small role of the government in ethnic minorities who live some distance away. most of the countries, the government needs Without significant scholarships and to ensure that its health spending benefits the fellowships, it is difficult for ethnic minority poor and the vulnerable. students to attend university, due to the The four country studies reveal a tendency to associated costs. Finally, individuals with reserve a large portion of the public health higher education generally have higher income budget for hospital care. Even with good than people who don’t attend college, so they primary care, countries do require a hospital are in a better position to pay for their system. However, it appears that these education (through loans or higher tuition countries overinvest in hospital care, with fees). hospital patients generally receiving a larger In the case of Lao PDR, estimates show that subsidy (as a proportion of the total cost of indeed ethnic minorities do not receive a care and in absolute terms). Thailand has particularly large share of the total education made an effort to boost primary health care budget. On average, university students and improve access to health care in rural and receive a state subsidy that is approximately isolated areas. 20 times that of primary students. Viet Nam Both Thailand and Viet Nam have introduced has taken steps to remove similar inequalities insurance programs that give subsidized health in its education funding. National-level cards to the poor. Viet Nam should accelerate evidence suggests that Viet Nam’s allocation of the implementation of this program and its resources is somewhat more equitable than continue to target ethnic minorities as priority in the past and there is a real effort to target recipients of health cards. funding to poor and mountainous provinces. On the demand side, the government of Viet In both the education and health sectors, there Nam has set up a number of programs to are complaints about delays and nonpayment encourage ethnic minorities to continue their of salaries. This problem is most serious in schooling, ranging from school fee exemptions Cambodia and Lao PDR, although Viet Nam to university scholarships. has had problems in the past paying its employees in the social sectors, especially in Fiscal constraints in the area of health are rural areas. The government of Viet Nam has similar. The highest returns to health care taken over the payment of commune health investments are for preventive and primary- workers at many commune health centers in level curative care. Government expenditure poorer regions (including areas with high on hospitals is generally a much worse ethnic minority populations). investment, as the care is expensive and the 24 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

difficult time finding a job and are often 3.1.4 Legal and Policy Constraints hassled by the authorities. The message these Access to health and education services has a persons receive from society is that they do significant legal aspect. In many countries not belong to the country. throughout the world (including the four in The Constitutions of Cambodia, Lao PDR, this study), the Constitution states that, at and Viet Nam all recognize highland ethnic least at some level, education and health are minorities as citizens of their countries. Viet inalienable rights of the population. Although Nam has a long tradition of granting equal there are many ways that the government can rights to ethnic minorities. Lao PDR has been facilitate this right, it is clear that only people increasing its recognition of the ethnic that have full status as citizens can fully diversity within its borders; the 1995 exercise these rights. population census included detailed questions Among the four countries studied, the biggest on diversity for the first time in the history of problems with granting citizenship were the country. Lao PDR is negotiating with the found in Thailand. Indeed, the evidence International Labour Organisation (ILO) to suggests that many hill-tribe members do not sign ILO Convention 169, an international have citizenship (estimates range from 40 to agreement that gives rights to ethnic 80 percent), despite laws dating back more minorities and tribal peoples. than two decades. As part of the discussion Despite these advances, in all countries there is associated with the 1997 Constitution, a tendency for some officials and citizens to Thailand is currently in the process of see ethnic minorities as somehow not being clarifying the citizenship of many of its hill- part of the nation. Social exclusion of tribe groups. As the country is one of the minority groups is all too common. Key richest in the region, it serves as a magnet for stakeholders, such as the government and illegal immigrants. Thus, it is not surprising concerned NGOs, need to take action to that the process of identifying legitimate educate the majority population about the applicants for citizenship is a long one. rights and responsibilities of citizens. This However, the government should make every effort would help to improve the actual status effort to ensure that ethnic minorities that of ethnic minorities, above and beyond what have been long-term residents in Thailand (in the law declares. some case, for a longer period than the Thai- speaking population) receive full citizenship. 3.1.5 Lack of Understanding and The lack of citizenship in Thailand has several Information about Available important, immediate effects on ethnic Services minorities’ access to social services. In the education sector, many children find their Social services have traditionally focused on studies increasingly difficult as they advance access and utilization as being a supply-side through school, and children without problem. However, many service providers citizenship cannot avail themselves of many now realize that increased utilization does not special tutoring programs. In the health simply happen through increased availability sector, the situation is similar. Whereas ethnic of services. The public also has to understand minorities without citizenship can get basic the importance of the services and be willing and emergency care, they are not eligible to to take advantage of them. receive the subsidized health cards or to For many people who live in remote areas, participate in other programs. these services are essentially new. Thus, the However, beyond access to education and clients need education not just on the health services, citizenship has other availability of the services but also on how important effects. In Thailand, ethnic using the services will improve their standard minorities without citizenship may have a of living in a tangible way. CROSSCUTTING THEMES 25

In all countries, field studies confirmed that ❖ Health Education — the ethnic minority population often did not Tailoring Services feel that understanding of services was a problem. For example, in Lao PDR the field Observations from the field work in Sayaburi team reported that in many villages with a Province in Lao PDR tell a rewarding story of large ethnic minority population, it is good program results and the sense of common to see social services simply not ownership fostered by programs tailored to being used. Information campaigns should be meet the needs of the people they serve. informed by the current knowledge and beliefs The Primary Health Care Project in Sayaburi, of the local population. noted as a program of good practice, addresses both curative health and preventive This constraint is associated with the issue of disease issues and needs in Sayaburi. The language in many cases. Often, the district health department and its principal information the social sector provides in the clients, Hmong and Khmu ethnic minority majority language is inadequate, to say nothing residents, have shown progressive support for the health care program, tackling issues of about minority languages. Social sector malaria, diarrhea, nutrition, immunizations, providers should make an attempt to offer and basic health and sanitation practices. “extension services” to the ethnic minority One key factor contributing to this success population to encourage their use. There are has been the development and use of new examples of good practice, as noted in the box health education materials to reach target opposite. groups. Pictorial story boards and other simple educational materials have helped reduce the number of cases of malaria and 3.1.6 Lack of Understanding and diarrhea, and helped communicate the value Knowledge about the Population of immunizations for children. An important to Be Served feature of these materials has been the use of information, education, and communication For service providers to be effective, they need (IEC) videos in the Hmong and Khmu languages. to understand the population that they serve. This includes both the values and the District officials noted with pride that all members of the population now have “equal organization of the population. At the same rights” to access the health services. time, the social system must also be sufficiently flexible to allow for different organizations and values throughout the country. unlikely to develop as solid an understanding The studies found evidence that service of the population that they serve, or to deal providers often do not understand in detail with them as effectively, as locally recruited the needs of ethnic minorities. Many times the workers. Often outsiders view local practices whole system is too centrally organized to as “backward,” which hinders communication adapt to local conditions. Critics of centrally and makes it difficult for providers to integrate designed curricula suggest that indigenous their services with local beliefs. values of family, community, and close ties to natural surroundings are not well represented. This situation creates a demand for locally 3.1.7 Competing Knowledge Systems, adapted curricula, or curriculum flexibility, of Practices, and Values the type that may be seen in some highland All societies have beliefs about the best way to areas of Thailand. maintain health and the proper way to educate In Viet Nam, many teachers and health children and adults. In the case of health, this personnel who were working in highland areas includes beliefs about how people become sick were from the lowlands and did not plan to and what steps should be taken to maintain stay long. Clearly, temporary employees are and improve health. Societies also have beliefs 26 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

knowledge of germs and infection, they are aware that drinking dirty water leads to illness and they also believe in isolating the sick to prevent the spread of illness. These beliefs do not follow from current medical evidence, but obviously they are not inconsistent with modern views of good health behavior. More importantly, these beliefs have evolved so that they include more modern practices. Likewise, given evidence from the field visits Lampang Province, Thailand. This Hmong village elder (right) is a trusted specialist in the community for her and the anthropological literature in Lao expertise in herbal and traditional medicines. The study’s PDR, it is clear that cultural beliefs have a literature review and field visits confirmed the importance major influence on the choices people make of understanding traditional beliefs and practices among when they face a health problem. While minority groups. Recognizing traditional health and traditionally, an animal sacrifice was offered education practices is critical to sound service delivery to help the sick individual return to health, systems. (Photo by Myles Elledge) many individuals now express greater faith in about what should be taught to their modern treatments and often use the cost of members. It is important to point out that an animal sacrifice as a guide for how much traditional beliefs are not necessarily fixed and they will pay for modern treatment. unchangeable. ❖ Empowering the In education, there is evidence that the Community curriculum is often quite irrelevant for the local realities that ethnic minorities live The Hill Areas Education (HAE) Program through every day. In all cases, the curriculum recognized the importance of recruiting ethnic is largely designed in the capital city with little minority teachers to be among the staff if any local content. In Lao PDR, local administering and serving in the classroom. content is allowed, but in practice, teachers are A conscious attempt to increase the number of ethnic minority teachers active in the village rarely able to teach even the full mandated was seen as vital to inspiring villager curriculum, much less additional units or confidence in the new curriculum and to topics. In Cambodia, it is clear that the boosting the attendance, advancement, and nationally prescribed curriculum is overly overall achievement of the students. ambitious for rural students, to say nothing of Villagers explained their reasons for preferring ethnic minority children in the northeast. Viet ethnic teachers in the community’s Nam does have a modified curriculum that educational system. While noting that a good focuses on learning basic skills, and Thailand teacher is a matter of individual personality, and good performance is not uniquely linked has developed the innovative Hill Areas to ethnicity, villagers noted clear advantages Education (HAE) Program, which focuses on and support for the recruitment of ethnic incorporating local knowledge into the teachers. curriculum. First, when a lowland teacher does something However, modern education (for example, wrong, the villagers dare not report to the authority. With an ethnic teacher, the villages teaching about national history, mathematics, feel it’s easier to make comments or to give and science) need not clash with traditional some advice. Second, a teacher with ethnic beliefs and teaching practices. background will have a better understanding of ethnic culture and its relationship to larger The evidence from fieldwork in Cambodia on society. It is believed that … [the teacher] will health beliefs of the highland population is be more sensitive to the villagers’ problems interesting. Anthropological studies show that and needs. (Study team focus group although ethnic minorities have no indigenous discussion, Chiang Mai Province, Thailand) CROSSCUTTING THEMES 27

One area of particular concern is maternal and ❖ Figure 3.1: child health. Ethnic minority women are far Percentage of Births in less likely to deliver their infants in a health Modern Health Facilities provider’s office or hospital than other women (Figure 3.1). Many women employ dangerous birthing practices, such as cutting the umbilical cord with an unsanitized bamboo knife. Moreover, ethnic minority women in Lao PDR have less knowledge about the importance of fluids for ill children than native Lao speakers.

3.1.8 Poor Quality and Relevance of Services Provided

Providing good-quality services in the social sector is key to ensuring that a target population will take advantage of existing programs. Often, social service providers focus on simply ensuring that the service is offered. Source: Lao PDR: ADB, 1999c; Viet Nam: Viet Nam Living Standards Survey (VLSS), 1997–98 (General Statistical Office However, clients are also concerned about the [Viet Nam], 1999). quality of services. Quality has many dimensions; here we focus on the technical In all of the countries except Thailand, many quality of the service and the quality of related teachers lack the required formal training. In amenities. Cambodia and Lao PDR, most teachers in Isolated populations, such as the highland ethnic minority areas are untrained. As ethnic minorities of Cambodia and Lao PDR, mentioned previously, however, Lao PDR has may not live anywhere near locations where had success in transferring basic skills in social services are being offered, and thus have teaching to unqualified teachers through the no option of using them. In Thailand and Viet Network Teacher Upgrading Program. Nam, where ethnic minorities may have other Ethnic minorities in Viet Nam had similar provider options (especially in the health concerns: Schools were often overcrowded and sector), there may be an underutilization of the quality of facilities was quite low. Many government-subsidized services. In both cases, schools were very poorly equipped with scarce government subsidies are wasted. learning aids, such as maps, pictures, and In addition to not attracting users to social laboratory equipment. Students often lacked services, low technical quality will lead to poor the resources to buy textbooks, and highland results—for example, children not learning in schools were unable to lend them textbooks. school and health services not solving health Schools must focus on education that is problems. relevant to their community. There is a great Low quality was a commonly cited problem in range of livelihoods among the ethnic the education sector. In the northeast of minority population; the perspectives and Cambodia, parents mentioned the lack of educational needs of sedentary rice-growing school materials as one of the principal reasons households differ greatly from those of mobile for not sending their children. The poor hunter-gatherer households, and from those of condition of the school building was a households that depend on shifting common complaint heard from the highland cultivation. One complaint heard in Viet Nam population. and in Thailand was that the textbooks, with their focus on urban life, were often irrelevant to the lives of ethnic minorities. 28 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

The situation in the health sector is quite the welfare of women and their daughters. similar, with the quality of services generally The shortage of educated women makes it described as low. Health centers and posts difficult to recruit female health and often lack essential drugs and equipment and education workers locally. The lack of female the quality of the building is often quite poor teachers may discourage girls from continuing as well. In Lao PDR, for example, the study in school. Families may be unwilling to keep found that district hospitals (which play a key their girls in school with only male teachers. role in attending to the health needs of the The lack of education limits women directly rural population) generally lack equipment. in terms of their ability to interact with the The availability of equipment is often larger world. Finally, numerous studies have determined by what donors are willing to shown that mothers’ education makes an contribute rather than by the health needs; important contribution to the health and much of the equipment is sent to central and well-being of children. provincial hospitals. In Lao PDR, statistics show that girls start out Viet Nam has been more successful in at a disadvantage in terms of enrollment. Even ensuring that health services that serve remote in the first grade, girls are less likely to enroll populations have at least the most basic drugs than boys. This situation is especially true for and supplies. The study team found that most ethnic minority girls. Ethnic minorities are far commune-based units had some drugs and more likely to drop out than ethnic minority that ethnic minorities also had a variety of boys. While few ethnic minority boys advance private options. Clearly, for its health services to the lower secondary level, even fewer girls to be useful to the public, the government has do. These students, if the education system to ensure at least a minimal package of can reach them, will form the core of future supplies and equipment. teachers and education workers in the highlands. In Viet Nam, although the enrollment rates are substantially higher, a 3.1.9 Lack of Attention to Gender- similar pattern exists for ethnic minority girls. Specific Considerations, Especially Field visits confirmed that parents are worried Those of Girls and Women about the safety of their daughters and Attitudes and behaviors toward girls and whether their daughters will learn important women may differ from one ethnic minority skills at school. community to another, requiring alternative In health, it appears that the situation is strategies to ensure that the health and similar: Females are less likely to receive education needs of the entire population are formal health care than males. It also appears addressed, regardless of ethnicity or gender. In that girls and women have a higher mortality all countries, it appears that girls and women rate, although there is little gender-specific have worse health and education outcomes data on the health status of the ethnic than boys and men, and it is clear that special minority population. efforts must be made to include their needs in the design of social policies. Of particular concern is access to reproductive health services, which also appears to be quite The education level of ethnic minority women limited for ethnic minority women (Figure is consistently lower than that of men. In the 3.1). In Cambodia, Lao PDR, and Viet Nam, case of the highland peoples of Lao PDR, most births take place at home, occasionally literacy rates are significantly lower for women in the presence of a traditional birth than for men. For example, among the attendant. It is quite rare for the birth to be Hmong, the literacy rate for men is 45 percent attended by a doctor or nurse. Although there compared to only 8 percent for women. This is little hard evidence, anecdotal evidence situation is similar in the other countries. indicates that the situation is likely to be This low level of female education has a somewhat better in Thailand. number of serious consequences in terms of CROSSCUTTING THEMES 29

Health systems require more of a focus on approach, using the vernacular extensively. reproductive health, through the training of Still others have had an intermediate local health workers. Trained health workers approach, explaining the lessons in both should be provided with a supply of basic Khmer and the vernacular. In all of the health inputs. Once again, the low level of countries, it is quite common for parents and female literacy may prevent the training of a educators to attribute higher repetition rates, significant number of workers in some lower grades, and higher dropout rates to communities. language problems. Many languages spoken by ethnic minorities 3.1.10 Language do not have a commonly used writing system, which also complicates teaching in many In numerous contacts with members of ethnic ethnic minority languages. Although scripts minority communities, the issue of language have been developed for many languages, was raised as a serious constraint. For many speakers often do not know them, or they highland ethnic minorities, the official have not been standardized. national language is for all practical purposes a Many respondents also mentioned that foreign language. In many cases, few members teachers often have little or no knowledge of of the community have mastered the official the native language in the area, which language. obviously limits the possibility of In the education sector, language is a crucial incorporating the vernacular in the school. For issue as the teachers and students must be able example, in Lao PDR, approximately 85 to communicate with each other and students percent of primary teachers and 95 percent of need to be able to understand textbooks and secondary teachers are native Tai-Kadai other learning materials. Policy proposals for (lowland languages) speakers. Given the low language in schools with ethnic minorities literacy rates in many ethnic minority differ greatly. At one end, a common communities, it can often be difficult to recommendation is to teach ethnic minorities recruit ethnic minority teachers with basic in their native language as a way to promote education and training to serve as teachers in both learning and cultural survival. The their communities. alternative is often total immersion in the Despite these challenges, Viet Nam is develop- national language. In practice, total immersion ing some learning material in vernacular. This is the implicit policy chosen by many activity has been limited to a few subjects, governments, largely by default. however, and is only being done in a few Probably the best approach for ethnic languages. minority children, and an approach supported Language also plays an important role in the by a number of policymakers in the region, is health sector. Patients and providers need to an intermediate one that emphasizes the be able to communicate; this is especially true learning of the country’s official language for primary care, which represents the most while taking into account the fact that ethnic cost-efficient interventions for the health minority students are not native language system. A health provider who does not speak speakers and may need additional help, the same language as the patient may have perhaps through a Second Language program difficulties in diagnosing and curing a health (e.g., Vietnamese as a Second Language). problem, or in sharing health information. In Cambodia, schools in the northeast have And without communication, it is difficult for dealt with the language issue differently. Some patients to develop a sense of trust. This has schools use the total immersion approach, negative effects on the health-seeking behavior with teachers talking to students exclusively in of the ethnic minority population. Khmer. Others have taken the opposite All the countries have some form of shortened training for village health workers; these 30 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION programs should be supported and material medical personnel do not speak the local should be developed specifically for ethnic language and few ethnic minorities are trained minority recruits. However, the low level of to provide medical services. literacy (especially among women) may limit the ability of such health programs to recruit 3.2 Country-Based Observations locally. In Lao PDR, the study team found that the vast majority of medical students were on Constraints from lowland ethnic groups. Many trained By way of summary of the above, Table 3.2 medical professionals prefer to work in towns reviews the key constraints and links these to rather than working in poor rural findings from policy dialogue and field-based communities. observations in the four focus countries. At the local level, it appears that ethnic minorities do play a role in providing health 3.3 Finding Solutions care. In Cambodia, for example, the study found that in the health centers, most of the As shown in Tables 3.1 and 3.2, different staff was from the area and spoke both Khmer constraints on access require different and a local language. Viet Nam has an solutions. There are a number of policy extensive network of health training institutes solutions that can help reduce the barriers to throughout the country; in many provinces, access. ethnic minorities constitute a significant proportion of health workers at all levels. In Supply-side solutions focus on changing how Viet Nam, however, mixed residence of ethnic providers interact with the community, on groups is quite common and in many cases, training providers, and perhaps on only a few ethnic groups provide the bulk of constructing new facilities. Such solutions can health workers. In Thailand, evidence suggests improve the ability of the providers to serve that language can be a major barrier, as most the public. Positive steps may take the form of training workers at the village levels, building

Young mother and child with village support network, Chiang Mai Province, Thailand. The majority of births occur at home, attended by family members or a village birth attendant. Traveling village health workers have improved access to vaccinations and maternal/child health education among highland populations in Thailand. (Photo by Preecha Upayokin) CROSSCUTTING THEMES 31

❖ Table 3.2: Summary of Constraints and Country Observations

Constraints Education Health

Physical-geographical • Serious constraints occur in Cambodia • Distance from health services is a constraints and Lao PDR, parts of Viet Nam problem in all countries • Thailand and Viet Nam have denser • All countries are developing locally school networks and boarding schools based health providers

Economic constraints • Education requires some out-of-pocket • Health care costs are a concern for expenses; exemptions are given to ethnic ethnic minorities, due to their general minorities, especially in Viet Nam poverty • Thailand and Viet Nam have health care schemes to insure the poor

Fiscal constraints • Lack of public resources is a serious • Lack of resources is a serious problem problem except in Thailand in all locations • Resources are concentrated on higher • Resources are spent on health services education and cities for urban areas, especially hospitals • Salaries are often late or unpaid • Salaries are often late or unpaid

Legal and policy • Ethnic minority children without citizenship • Access to Thailand health cards is constraints cannot access education in Thailand limited, although some minorities receive basic primary care

Lack of understanding • This problem arises especially in some • This problem affects some ethnic and information about parts of Cambodia and Lao PDR minority groups, especially in Lao PDR available services

Lack of understanding • School calendars do not reflect the local • Information, education, and and knowledge about agricultural calendar communication initiatives do not reflect the population to be local cultural needs and practices served • Strategies to reach girls and boys may not • Traditional birthing and fertility practices adequately recognize different traditions are not fully recognized in service across ethnic groups design and mobilization

Competing knowledge • Materials are often foreign or irrelevant • Beliefs differ about the nature of illness systems, practices, and for ethnic minority students and disease values • National curriculum may not build on • Many women employ poor reproductive traditional values of family, community, or health practices forest

Poor quality and • This problem appears in all countries in • This problem appears in Cambodia, relevance of services remote schools Lao PDR, and Viet Nam; less so in provided • Schools are not well equipped and Thailand buildings are in poor state

• This problem reportedly occurs in all • Reproductive health services are limited Lack of attention to countries gender-specific • Ethnic minority girls stay in school less considerations than ethnic minority boys and majority girls

Language • Language barriers affect primary learning • Patients lack ability to communicate a and are a constraint for advancement to problem higher education • Patients find it difficult to receive health • Ethnic minority students fall behind, then information often drop out 32 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION new schools and health centers, and improving Programs that focus on just one element of the quality of services from existing providers. the health-and-education circle are likely to Health and education systems traditionally are be partially frustrated. For example, experienced with these supply-side solutions; increasing money for education will have a the most cost-effective solutions, however, limited effect if the population is sick, and often are demand oriented. That is, increasing money for health will have a encouraging the participation of students and limited effect if mothers are not sufficiently patients can ensure that resources spent on educated to take advantage of services and education and health services are not wasted. to maintain proper hygiene at home. Policymakers, therefore, should not ignore Ethnic minorities often are at a particular demand-side solutions that focus on changing disadvantage when it comes to escaping the demand in order to increase utilization. In vicious circle of poverty. Nationally addition to focusing better on the needs of designed programs are unlikely to take into potential clients, often demand-side subsidies account local knowledge and constraints. are the most cost-efficient option. That is, it For example, a nationally designed textbook may simply be cheaper to target resources to is of little use if few people speak the the poor than to try to increase the supply to national language. National health benefit the entire population. Demand-side programs, too, may not fully account for solutions include targeted subsidies, discounts, regional differences in fertility, disease and exemptions for ethnic minorities; incidence, or beliefs. Failing to recognize improved transportation to reduce the cost of differences at the subnational level makes access; and better marketing and programs less effective and therefore not informational techniques aimed at ethnic demanded at the local level. minorities. RECOMMENDATIONS 33

RECOMMENDATIONS

Central to this ADB project is the belief that noted are worthy of financial and political development is both possible and desirable in support, and in some cases further expansion a multiethnic society. This study has shown or scale-up. More importantly, these programs that although they are not a homogenous are exemplary for their techniques and group, ethnic minorities—especially those strategies for reaching ethnic minorities, and living in poverty—have special needs thus represent features to be modeled in future stemming from their cultural and geographic programs and projects. Appendix B proposes differences from the majority culture. specific projects that the Asian Development Governments, donors, NGOs, and Bank and other organizations may want to communities are challenged to work together consider for funding. to develop strategies aimed at reducing By comparison, the policy recommendations poverty and raising the level of human capital presented here aim to bring the concerns of for ethnic minority populations. A dichotomy ethnic minorities into the project and policy that is often raised between cultural survival design process. They provide the framework on one hand and globalization and for developing steps that bring sustainable development on the other hand is a false one. development and poverty reduction to Ethnic minorities do not live in a bubble highland ethnic minorities in the GMS. separated from the rest of the world and they deserve to benefit from development. 4.1 Replicate Good Practices in The health and education needs of ethnic minorities in the GMS countries have many the Social Sector dimensions, and there are numerous causes for Across the countries of study, a number of the constraints that highland minority groups important programs and projects have demon- face. Appropriate responses require tailoring strated some good practices in reaching policy to individual countries and to the needs minority populations.4 As noted above, the and circumstances of multiple minority study team’s report on Programs of Good groups. At the same time, there are Practice (ADB, 2000c) provides a qualitative crosscutting regional recommendations that review of a range of health, education and may be furthered through the sharing of integrated programs active in Cambodia, Lao opinions, information, and approaches to PDR, Thailand, and Viet Nam (see Table 4.1). better serve the needs of ethnic minorities.

This section presents two types of 4 Ethnic minorities in the GMS countries share many recommendations. First, we summarize “good features and concerns. However, addressing the health and education needs requires grounding in the distinct features practice” programs, named in the report of a given country. The specifics of geography, economic Programs of Good Practice (ADB, 2000c), systems, government and policy, institutions and which offer examples of interventions that structures, and programs shape the demand for and effective provision of services in each country. Appendix A have shown strong benefit to ethnic minority summarizes the country research reports for Cambodia, populations. The overall recommendation Lao PDR, Thailand, and Viet Nam, giving an overview of data and policies on health and education conditions for inherent in this discussion is that the programs ethnic minorities in each country. 34 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

❖ Table 4.1: Programs of Good Practice (Note: See legend for sponsor abbreviations)

Country Program Health Education

Cambodia Integrated Community Development Program (CIDSE, HU) 4 4

Primary Health Care Project (HU) 4

Support for Primary Health Care in Mondolkiri Province (MDM) 4

Community Development Projects for Ethnic Minorities in 4 4 Ratanakiri Province (NTFP)

Network Teacher Upgrading Program (NTUP) and Basic 4 Lao PDR Education for Rural/Minority Children (MOE, UNICEF, CWS, AusAID, JSRC)

Primary Health Care Project (SCA) 4

Clean Water Supply and Hygiene Education Project for Ethnic 4 Minorities in Laos (ACF)

Hill Areas Education (HAE) Project (DNFE, DPW, DETC, and Thailand 4 USAID)

Basic Education and Learning Promotion (IMPECT, Provincial 4 Primary Education Department, UNICEF, National Education Commission)

Highland Health Development Center (HHDC) Program (Family 4 Planning and Population Division, Department of Health)

Mae Chaem Hill Tribe Health and Family Planning Program 4 (Provincial Health Office)

Viet Nam Primary Education Project (MOE, WB) 4 Program to Develop Education in Mountainous and Ethnic 4 Minority Areas, Isolated Areas, Islands, and Other Disadvantaged Areas - Program VII (MOE)

Support for Disadvantaged Areas Project (Vietnam-Sweden 4 Health Cooperation)

Primary Health Care (PHC) Program in Lao Cai and Dak Lak 4 Provinces (Danish Red Cross and Vietnamese Red Cross)

Table 4.1 sponsor abbreviations: ACF Action Contre le Faim IMPECT (Association of) Inter-Mountain Peoples for AusAID Australian Aid Agency Education and Culture in Thailand JSRC Japa Sotoshu Relief Committee (Japanese NGO) CIDSE Cooperation Internationale pour le Développement et Solidarité (Cambodia) MDM Médecin du Monde CWS Church World Service (international NGO) MOE Ministry of Education DETC Department of Economic and Technical NTFP Non-Timber Forest Products (Program) Cooperation (Thailand) SCA Save the Children Australia DNFE Department of Nonformal Education (Thailand) UNICEF United Nations Children’s Fund DPW Department of Public Welfare (Thailand) USAID United States Agency for International HU Health Unlimited (UK NGO) Development WB World Bank RECOMMENDATIONS 35

Ethnic minority students in primary school in the highlands, Ratanakiri Province, Cambodia. School facilities and instructional aids, as well as books and pencils, are extremely limited. Allowances for highland, low-income children will help many overcome the economic constraint of school fees. Credits and other support can help boost the quality of instruction, thereby providing greater incentives for school attendance. (Photo by Hean Sokhom)

Common “good practice” features were found the programs are national in scale and are to include: managed by government agencies. The presence of international financial assistance in • The program is or was successful in the initial stages of these programs is universal, recognizing the uniqueness of ethnic although several of the noteworthy minority populations and in meeting ethnic interventions have operated without foreign minorities’ needs for health and education assistance in later stages of implementation. access and service quality; Case studies of selected programs were • The program was cost effective, sustainable, developed based on the programs’ good participatory, and flexible; practices. Exemplary programs selected for • The program had a high beneficiary impact, case study development included the with evidence of beneficiary and Cambodia Primary Health Care Program, Lao implementing agency ownership; PDR Network Teacher Upgrading Program, • The program facilitated learning among Thailand Hill Areas Education, and Viet Nam users, providers, and/or funding agencies. Primary Care Program. The programs included in the Programs of Good Practice review represent international 4.2 Strengthen Policies and and domestically supported programs. There Programs is interesting diversity among the types of programs found to have positive From a regional perspective, this section characteristics. Many of the programs are outlines seven recommendations that emerge small-scale activities coordinated by national as pivotal for addressing the health and or international nongovernmental education needs of ethnic minorities. A organizations. At the same time, a number of program intervention aimed at improving the 36 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION living standards of ethnic minorities ideally successfully communicate with clients. Local would support one or more of these policy staffing also is a core strategy necessary to recommendations. promote community participation and long- term support for programs. A program is much more likely to be sustained if it is staffed 1 Introduce incentives to boost by people who know and are known by the demand. community. A program with a succession of Development projects often focus entirely on workers who only stay for a year or two is the supply side, directing resources to unlikely to offer the quality of service and improving the quality and availability of commitment to the community that are providers. This strategy ignores the important necessary for success. Peers have the best demand side; in many cases highlighted in the opportunity to deliver well-designed and study, the problem is not just ensuring appropriately administered programs. physical access, but also encouraging people to take advantage of services. With the private Recruiting local health and education workers sector playing an increasingly important role will require both improving the education in the allocation of goods and services, ethnic level among these groups and introducing minority populations may simply not have specific training activities. Concerted efforts— enough money to pay for basic social services. through scholarships and other incentive mechanisms—to recruit and train ethnic Governments and donors must work to minorities beyond the most basic levels will enhance incentives and allowances to help improve health and education efforts. ensure program access and service use. Programs similar to Affirmative Action to Payments to help offset the costs of ensure ethnic balance among cadres of transportation, supplies, school uniforms, and teachers and health workers will be beneficial. other items and services for minority groups Recruiting ethnic minorities will facilitate the seeking access to services, are recognized to be development of community role models, as valuable. Such support mechanisms would well as promoting language and cultural work to overcome economic and geographic understanding. These efforts also will enhance constraints to service use that are prevalent the acceptance and effectiveness of programs. among minority populations across the GMS They will boost community involvement, region. Credits, subsidies, or other incentives both directly and indirectly, in program design to support the use of health services, and to and delivery, and strengthen the voice of facilitate participation in secondary and higher minority groups and communities. The education, would likely boost demand. Thailand Hill Areas Education program and Examples of such initiatives are seen in the the Lao Network Teacher Upgrading Program GMS. In Viet Nam, the health card system are both noted as programs of good practice helps poor and minority populations by the study. Each of these programs includes overcome monetary constraints to health care an important emphasis on targeted use. Scholarships for secondary and higher recruitment. education, like the programs in Thailand and Viet Nam, also boost demand for education Target ethnic minorities. and facilitate minority student advancement 3 in the formal education system. Recognition of both the diversity and the uniqueness of ethnic populations is central to developing interventions that are better 2 Recruit ethnic minority providers. tailored to address the social service demands Recruiting ethnic minority teachers, nurses, of minority groups. There is strong evidence and other service providers is vital to ensuring that official, public recognition of vulnerable that programs serving ethnic minorities are groups such as ethnic minorities is required in culturally appropriate and that providers can order to reach them and improve the living RECOMMENDATIONS 37

Successful programs, such as those noted in this project’s report on Programs of Good Practice, may be found. Lessons from these experiences across countries illustrate the advantages of targeting ethnic minorities, and highlight program success when services are adapted to meet unique cultural and geographic constraints.

This primary school in Ratanakiri Province, Cambodia, 4 Expand access to services. serves ethnic minority populations. Many students travel Negative indicators related to core human 1 to 4 hours by foot or bicycle to attend the school. The development are associated with ethnic cost of uniforms and supplies as well as time and distance minority communities across the GMS. Basic affect school attendance and participation for ethnic availability of high-quality facilities and access minority families. (Photo by Hean Sokhom) to them remain key constraints. Investment in standards of the poor. It is important to constructing facilities and expanding service directly involve minority communities more networks is essential for improving basic in identifying what programs and policies are social indicators and quality of life. most appropriate, and what methods of Schools, hospitals, and clinics are not now in program delivery are in demand and adequate supply. Schools and health facilities acceptable. Simply focusing on “the poor” will either do not exist or are too distant for many not effectively capture the diversity found in ethnic minority communities to use them. most countries. Distance, and the cost of travel, are It is appropriate to see ethnic minority constraints seen across all four countries, with populations as heterogeneous. The number of conditions particularly acute in Cambodia, groups is large and there are significant Lao PDR, and parts of Viet Nam. differences in cultural practices, fundamental Governments and donors should continue to values, beliefs, behaviors, and views of the focus on constructing and rehabilitating social world. Thus, interventions require tailoring to sector infrastructure in remote areas. The better fit with the cultural uniqueness of social sector also should work with the highland ethnic minorities. To be most transportation sector to ensure that effective, outreach and program interventions transportation projects are designed so as to need to be designed by highland minorities improve the access of ethnic minorities to themselves, adapted to the unique culture of vital social services. each ethnic group served, available in the language of each ethnic minority group served, and led by ethnic minority people. 5 Develop institutional support. Both quantitative and qualitative studies play Building awareness, strengthening capacity, a role in improving the cultural and developing advocates will lead to better appropriateness of specific interventions. awareness of ethnic differences and improved Concretely, donors such as the Asian service targeting and reach. Specifically, Development Bank are challenged to consider groups that target geographic areas and their including ethnic minority specialists in the minority populations are recognized to be process of designing projects that affect ethnic effective at drawing attention to these groups minority populations. Expanding and at building informed advocates. Examples consultations with local communities in order include the Inter-Ministerial Committee in to understand the local sensitivities and Cambodia, the Lao Front for National opinions will enhance project and program Construction (LFNC), and the Committee success. for Ethnic Minorities and Mountainous Areas (CEMMA) in Viet Nam. These types of 38 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION committees and interagency groups are opportunities. As evidenced in the study’s field valuable over both the short and the medium work, Thai language skills are important for term for encouraging attention to the unique advancement to upper secondary and higher challenges of minorities. Donors should focus education, and Khmer language skills are on improving the capacities of groups such as recognized by minority groups in the these so that they are better able to northeastern provinces of Cambodia as communicate the needs of ethnic minorities to important to participation in local markets. mainline ministries. In the longer term, it is important to spotlight 7 Educate the majority on diversity. vulnerable groups such as ethnic minorities Diversity can be a strength in a society, and through sector programs. This will require need not be seen as a threat to national unity. investment in the human capacity of the To reduce the perceived threat, however, policymakers (ministries, local governments, members of the majority (those outside the and NGOs) to build wide awareness and targeted regions and groups) require further advocacy for issues involving highland and learning to better understand ethnic minority indigenous peoples. life and customs. Many of the programs and policies that are ineffective are based on an 6 Clarify and relax language policies. incorrect understanding of highland ethnic Language is a difficult issue for most minority lifestyles and customs. Stereotypes countries. The adoption of one national held by planners are not a sound foundation language is seen as important for maintaining for the development of effective policies and unity, but at the same time, the national programs. language may be “foreign” to a significant Training of teachers, health workers, and percentage of the population. Accepting the provincial and district-level planners to share country’s ethnic and linguistic diversity will information about ethnic minority conditions lead to a more unified country in the long and culture may help. More expansive, run. nationwide programs to reach both Multilanguage programming expands schoolchildren and the general public are also acceptance. That is, services and education avenues to develop deeper societal materials delivered in local languages are far appreciation for minority peoples. more effective at reaching the desired Participation by ethnic minorities in the population groups. The converse is also true: development of policies and programs will Minority groups in Thailand, for example, help educate planners and others about the life have had difficulty understanding HIV/AIDS and customs of the different highland ethnic educational materials in Central Thai minority groups. Publication of materials and language. Local language learning is observed curriculum components for the majority of to be an important feature of success and society will help broaden the understanding of advancement in primary education among cultural diversity, traditions, beliefs, and minorities across the region. Pilot programs practices. In Chiang Mai Province, Thailand, experimenting with local language curriculum the NGO IMPECT has led a highly successful are present in selected provinces in Lao PDR initiative to share information on highland and Viet Nam. These programs have focused beliefs and customs with Thai education on teaching students in their local language officials at the district, provincial, and national while simultaneously also teaching them the levels. This work has supported the national language. development of a flexible curriculum for Majority language learning is also critical to children and adult learners. improving conditions and expanding INTRODUCTION 39

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Ministry of Interior [Thailand]. (1999). Population Office of Public Health Policy and Planning Statistics. Bangkok, Thailand: Bureau of [Thailand]. (1998). Report on the Survey of the Registration, Department of Local Hill-Area Peoples’ Health Status. Bangkok, Administration, Ministry of Interior. Thailand: Ministry of Public Health. Ministry of Planning [Cambodia]. (1998). Pen Dareth. (1996). Cambodia and Its Ethnic Cambodia Nutrition Investment Plan, 1999– Minorities Policy. Presented at International 2008. Phnom Penh, Cambodia. Conference on Asian Minority Cultures in Transition: Diversity, Identities, and Ministry of Public Health [Thailand]. (1997). Encounters. 12–15 December 1996, Münster, Report on Health Information. Bangkok, Germany. Thailand. Tribal Research Institute. (1998). Hill Tribes in Narayan, Deepa, with Raj Patel, Kai Schafft, Anne Thailand. Chiang Mai, Thailand: Department Rademacher, and Sarah Koch-Schulte. (2000). of Public Welfare, Ministry of Labor and Voices of the Poor: Can Anyone Hear Us? New Social Welfare. York: Oxford University Press, published for the World Bank and the International Bank United Nations Development Programme for Reconstruction and Development. (UNDP). (1999). Socioeconomic Statistical Bulletin. Hanoi, Viet Nam: UNDP. National Institute of Statistics [Cambodia]/ Ministry of Planning/United Nations United Nations Educational, Scientific and Population Fund. (1998). General Population Cultural Organization (UNESCO). (2000). Census of Cambodia, 1998. Provisional “Public Expenditure on Education” (on-line). Population Totals. Funded by United Nations http://unescostat.unesco.org. Population Fund, July. van de Walle, Dominique and Dileni National Statistics Center [Lao PDR]. (1995). Lao Gunewardena. (1999). Sources of Ethnic Census: Preliminary Report. Vientiane, Lao Inequality in Viet Nam. Washington, DC: PDR. World Bank. Nguyen Van Phai. (1998). Report on Population Witter, Sophie. (1993). Working with Ethnic and Family Planning. Hanoi, Viet Nam: Minorities in Viet Nam: An Introduction to the General Statistical Office. Issues. United Kingdom and Hanoi: Save the Children Foundation (unpublished). Office of Health Promotion [Thailand], Department of Health. (1998). Report on Nutritional Follow-Up and Care for Children Ages 0-60 months. Period No. 1/1998. Bangkok, Thailand: Ministry of Public Health. APPENDIX A: Country Summaries A-1 APPENDIX A COUNTRY SUMMARIES

crisis of 1997 have slowed a renewal of The Needs of Ethnic Minorities positive economic performance. One of the principal long-term constraints to economic As a nation, Cambodia has had a particularly and social development remains the poor difficult recent history and is still in the early quality of human resources. Low levels of stages of a long process of reconstruction and education and poor health and nutrition status development. This political and economic impede the development of human capital. reconstruction has sought to bring rights and services to all Cambodian citizens, including ethnic minority populations. The government Ethnic Diversity in Cambodia recognizes the ethnic diversity of the nation and has emphasized the needs and interests of Cambodia, like its neighboring countries of all citizens. Lao PDR, Thailand, and Viet Nam, shares borders and large and diverse population In recent times, the indigenous people who groups. In Cambodia, the Khmer represent live over a wide and scattered area in the almost 90 percent of the nation’s population, northeastern provinces have faced although there are significant non-Khmer unprecedented change. The ever-evolving groups including Vietnamese, Cham, Lao, political environment, new administrative Chinese, and indigenous ethnic groups. practices, the rapidly changing economy, and the migration of groups from the lowland There are hill tribe or ethnic minority peoples areas have had a major impact on the ethnic living all across Cambodia, although the minority groups who reside in this region. concentrations are highest in the four With greater integration of the national northeastern provinces. The indigenous ethnic economy, the northeastern highland areas are minorities concentrated in the northeastern increasingly exploited for commercial provinces of Kratie, Mondolkiri, Ratanakiri, purposes. and Stung Treng represent perhaps the most disadvantaged population group in the Government policies that implicitly support country. Due primarily to the region’s these changes are also inadvertently geographic isolation, these marginalized encouraging the “Khmerization” of the populations have not been integrated into highland populations by moving them close to mainstream society and face numerous roads, encouraging the practice of settled problems. agriculture, and trying to integrate them into the national economy. This offers both The first national population census was opportunities and risks for the indigenous conducted in the 1960’s, and the second population. general census was conducted in 1998 with support from the United Nations Population The economic growth Cambodia enjoyed in Fund (UNFPA). the mid-1990’s halted in 1997–98 and the nation has seen an erosion of these gains. The According to the first analysis of the 1998 nation remains one of the poorest in Asia, data, the total population of Cambodia is with per capita income at US$240/year and around 11,426,000 and is projected to reach more than 40 percent of the population below 19.3 million by 2020 with an average growth the poverty line (ADB, 1999a). Continued rate of 2.4 percent (National Institute of political instability and the Asian financial Statistics [Cambodia]/Ministry of Planning/ United Nations Population Fund, 1998). A-2 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

1996). According to this estimate, the total highland ethnic minority population was 70,030, representing 0.99 percent of the total population of Cambodia in 1995. However, according to a paper prepared for the Highland Peoples Programme/PP/ UNDP/ILO conference on Grassroots Development in Chiang Mai, Thailand, in 1997 (IMC, 1997), in the three northeast Cambodia. Indigenous ethnic people represent a high provinces of Mondolkiri, Ratanakiri, and percentage of the population in northeast Cambodia. The Stung Treng, the ethnic minority population hill-tribe peoples live in remote, rural settings and are was nearly 105,000. The lack of reliable generally physically and culturally isolated from larger Khmer society. (Photo by Hean Sokhom) information—demographic, socioeconomic, and cultural—on this segment of Cambodia’s The average household size of the country is population has contributed to misunderstand- relatively high, at 5.2, with the average ings and tensions and, in some cases, household size in urban areas larger than in discriminatory practices against members of rural areas. The population is mainly rural; these groups. only 22.2 percent of the people live in urban areas, in Phnom Penh and provincial capitals. The Cham are the largest ethnic minority Although the average population density is 64 group in Cambodia and account for nearly 50 persons per square kilometer, there are percent of the total ethnic (non-Khmer) important provincial differences, and the population of Cambodia. The Cham gained population ranges from 2 to 301 persons per Cambodian citizenship in the 1950s and square kilometer in Mondolkiri and Kandal, 1960s. The Khmer Rouge targeted the Cham, respectively. The five provinces of Stung forcing them to adapt Khmer names and Treng, Ratanakiri, Mondolkiri, Preah Vihear, requiring that they give up Islamic practices. and Koh Kong are regarded as remote and are The Khmer Rouge killed or exiled much of sparsely populated. Although together they the population and destroyed many mosques. form 33.75 percent of the country’s area, their The Vietnamese population traditionally has total population of 458,630 is only 4.01 been divided into four distinct groups, each percent of the country’s population, with the with separate histories of immigration. These density being a mere 7.8 people per square are the rice farmers, urban population, kilometer (National Institute of Statistics fishermen, and rubber plantation workers. [Cambodia]/Ministry of Planning/United Many Vietnamese came to Cambodia during Nations Population Fund, 1998). the French colonial period and before The currently available statistics on the ethnic independence; indeed, under French rule, it minority population are based mainly on was often said that Phnom Penh had more estimates from different government agencies Vietnamese than Khmer. Tension has often and independent observers and researchers. In existed between the Khmer and the 1992, the Department of Ethnic Minorities of Vietnamese ethnic communities. Much of this the Ministry for Religious Affairs stated that reflected the tension between the governments there were 36 ethnic minority groups with of Cambodia and Viet Nam. The Lon Nol 309,245 persons, which was about 3.5 percent government forced much of the Vietnamese of the total population of 8,900,000. In 1995, community into exile. The Pol Pot regime the Ministry of the Interior stated that there targeted the Vietnamese community and were 442,699 ethnic minority peoples, or 3.83 forced virtually all of its members to leave the percent of the total population of 9,672,000. country, killing many in the process. Under The Ministry of Interior includes the Chinese the People’s Republic of Kampuchea policy of and Vietnamese ethnic populations within the 1982, the Vietnamese community residing in ethnic groups of Cambodia (Pen Dareth, Cambodia was divided into three categories: APPENDIX A: Country Summaries A-3 former long-term residents who lived in ❖ Table A.1: Cambodia before 1970, Vietnamese who Estimation of Ethnic Minority arrived after 1979, and those who arrived after Population in the Northeastern the 1982 policy directive. Only the first Provinces category of Vietnamese was recognized as Percentage having Cambodian citizenship (Article 1, of Total 1983 policy directive). Population Hill Tribe Total from Population, Historically, Chinese traders were present in Province Population Hill Tribes by Province Cambodia from the Angkor period. In that Mondolkiri 32,407 71.1 23,041 period, they were not numerous because Angkorian Cambodia was largely Ratanakiri 94,243 66.0 62,200 economically self-sufficient and did not rely on foreign trade. The Chinese in Cambodia Kratie 263,175 8.3 21,843 derive from four regions and five language Stung Treng 81,074 6.6 5,350 groups (Hokkien, Hainanese, Cantonese, Source: National Institute of Statistics [Cambodia]/Ministry of Teochiu, and Hakka) in southeastern China. Planning, 1998. Traditionally, the Chinese community has enjoyed an economic position envied by many data was 112,340. There are hill tribes in Cambodians. The Chinese often were targeted other provinces, but without precise data, they by the Pol Pot regime due to their wealth, are excluded from this table. although not with the same fervor as the Cham and the Vietnamese. The term “ethnic minority” appears to be a misnomer in both Ratanakiri and Mondolkiri Technically, the Chinese are foreign residents because the ethnic minority populations are in in Cambodia and not a national minority, fact the majority of the total population in even though many of them are second- and these two provinces. Historically, these third-generation Cambodian-born. This is populations lived in these remote northeastern based on a 1954 law that requires adoption of wooded highlands for centuries, while the a Cambodian name and descendence from a Khmer, Lao, and Chinese have only recently Cambodian father. However, in practice, settled along the rivers of the two northeastern many of these Chinese residents have provinces. Cambodian passports. The indigenous ethnic people found in Ethnic Minority Populations Face Ratanakiri, Mondolkiri, Stung Treng, and Kratie represent about 66, 71.1, 6.6, and 8.3 Great Challenges percent, respectively, of the total population Geographic, economic, and cultural within these provinces. As a whole they constraints limit access that ethnic minorities represent 0.95 percent of the total population have to both health and education services. In of Cambodia, according to the Inter- Cambodia, where the service standards and Ministerial Committee for Highland People’s levels for both sectors are low, the physical and Development (IMC, 1997). Although a cultural isolation of ethnic minorities further significant number of ethnic groups are found contributes to very poor conditions. in other provinces, such as Preah Vihear, Pursat, and Banteay Mean Chey, they represent only about 0.04 percent of the total Education population. Considering the low base, Cambodia has Table A.1 shows the distribution of the hill- made strides in the past decade to raise the tribe population in the four northeastern educational levels of the population. The provinces. Based on the percentage estimated overall adult literacy rate is estimated to be by IMC in 1997, the total ethnic population around 62 percent, with the rate for women in these four provinces using the 1998 census lower at 55 percent. The total gross A-4 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

is extremely difficult to train and retain teachers for the schools. Thus, the limited supply of teachers impedes increasing enrollment and achievement. Schools tend to be clustered around district and provincial towns, so the lack of availability of school facilities is a constraint to ethnic minorities. Access or distance to school is also a large factor for secondary schools, and few ethnic Highland populations in Cambodia have limited access to minority students pursue secondary school. education. Where primary education is available, it is Field work in Ratanakiri confirmed the generally of poor quality. The low education base, poor presence of only one secondary school in the curriculum, lack of materials, and limited supply of teachers create a very challenging environment for school entire province, and none of the districts with achievement. (Photo by Hean Sokhom) high ethnic minority populations were located near this secondary school. enrollment rate in primary school is 88 percent. Additional factors affecting education include the curriculum, lack of materials, the distance Education conditions in the northeastern to school, and the costs of attendance such as provinces of Cambodia, where the uniforms, notebooks, and the opportunity concentrations of ethnic minorities are cost of work not completed due to highest, are much worse. Literacy rates by participation in school. Conflicts between province range from 23 percent in Ratanakiri family income needs and the agricultural to 33 percent in Mondolkiri, 48 percent in calendar are impediments to ethnic minorities’ Stung Treng, and 61 percent in Kratie. participation in primary and secondary school. Primary school enrollment, especially for girls, is far worse in the northeast than for other Financing for the education sector, while parts of the country. increasing, is still very low. The majority of public sector investment in education comes Language is also an important factor, as many from foreign assistance. Very low teachers’ ethnic minorities do not speak Khmer in the salaries are a significant disincentive for home, putting these students at a disadvantage attracting and retaining teachers. Many as they enter schools with Khmer as the supplement their income by providing private language of instruction. Retention and tutoring services. Government expenditures by repetition are known problems, again with province vary greatly on a per capita and per higher rates for girls than for boys. In the student basis. Low-population provinces in northeast, fewer than 10 percent of the total the northeast have higher per-student population completes primary school. government education expenditures than do As in many low-income countries, Cambodia large provinces such as Phnom Penh. Local shows differences in net and gross enrollment school operations depend heavily on local rates. For the northeast provinces, gross support to supplement national funding. In primary enrollment is 72 percent, while net the northeastern provinces, resources are few enrollment is 62 percent. The large and these northeastern provinces, districts, and discrepancy between net and gross enrollment local communities are not able to contribute rates reflects over-age enrollment, which in resources to supplement limited national-level turn is due to delayed entry into school and funding. high repetition of grades. Students in the northeast often start school much later than Health the official age of six. Cambodia suffers from a range of health The low education base in the northeastern problems that shorten the lives of its provinces, combined with the remote and population and reduce the quality of its poor conditions, creates a situation in which it APPENDIX A: Country Summaries A-5 human capital. Average life expectancy at Health and education are often closely linked. birth is 54 years, very low among Asian Well-educated parents are more likely to countries. This life expectancy is likely lower provide better education and to encourage in the northeastern provinces, although good health practices in their children. Lack of reliable data are not available. clean water and basic sanitation is linked to The principal health problems relate closely high mortality and morbidity due to diarrhea. to the natural and socioeconomic Preventive practices for tuberculosis, HIV/ environment. The northeastern provinces AIDS, malaria, and dengue fever might be have a high incidence of infectious-contagious more widely practiced if families were better diseases. The most common problems include educated and had better access to health care malaria, diarrhea, acute respiratory infections, support services. The lack of good health tuberculosis, and intestinal parasites. Malaria practices, while bad across the country, is is the most common problem and the most worse in the northeastern provinces, and common reason for hospital admissions in the especially serious for women, as women are far northeastern provinces. less likely to be educated than men. Infant mortality in Cambodia is the worst in The health system in Cambodia has been Asia, at 115 per 1,000 live births, and the under tremendous reform from top to bottom under-five mortality rate is 181 per 1,000 in the past decade. However, access to health births. Infectious diseases, along with low care and quality of services remains a major vaccination rates and poor nutrition, account problem due to low socioeconomic for most infant deaths. Maternal mortality is development levels, low literacy, and financial also high at 650 per 100,000 live births. The constraints on the health system. The system most common causes are complications still struggles to rebuild facilities and related to abortion, eclampsia, and personnel lost during the Pol Pot era. Facilities hemorrhage. Prenatal care services and are simply not available, are poorly facilities to handle complicated births usually distributed, or are in poor condition. The are not available for highland peoples. supply of doctors, nurses, and health workers is limited, as are their training and supplies. Mental health concerns and substance abuse Ethnic minority families often live far from (drug and alcohol), while not well roads and district or provincial centers, documented, are perceived problems. effectively restricting their access to formal Cambodia’s tumultuous history may account health services. And when the services are for mental health and psychosocial issues, available, they are often of lower quality than which are a concern for health planners and might be found in other parts of the country. practitioners. Social and cultural factors are important in the use, and potential abuse, of Financing for health services, like education, drugs, tobacco, and alcohol. Field visits comes largely from international donor suggest that use of tobacco and alcohol is very organizations. The government’s commitment high among children in the northeastern to financing the health care sector is provinces. significant and shows its strong support for enhancing primary health care and thus Cambodia, as a country, has been especially improving rural health conditions. However, hard hit by HIV/AIDS and has one of the household contributions to health average highest infection rates in Asia. Although there US$100/year, 10 times the per-capita level of is no evidence of infection yet among the the government’s contributions. Public health ethnic minority population in the northeast, care is officially free, although there are experience from Thailand suggests that the widespread informal systems and user charges minority peoples may be especially vulnerable in practice in order to provide supplementary to HIV/AIDS precisely because they do not income to workers or better access to have the same access to preventive measures. medicines and drugs. A-6 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

Needs of Ethnic Minorities in an Ethnically Diverse Society Like Cambodia, the government of Lao PDR has recognized that theirs is an ethnically diverse country, and that ethnic minorities may require special attention due to socioeconomic, geographic, or cultural differences. The 1995 population census of Lao PDR reported 47 different ethnic groups. The largest of these, the Lao, accounted for This ethnic minority student in Lao PDR (foreground) is only 52.5 percent of the total population. The one of a few pupils chosen to attend the boarding school for Lao are the majority in 8 out of 18 provinces secondary school students. Spaces are limited and only a and are the predominant group in lowland few get the opportunity to attend school beyond the fourth areas of the country. grade. Access for girls, especially ethnic minority girls, is even more restricted. (Photo by Myles Elledge) The 47 ethnicities are members of four ethnolinguisitic superstocks (also known as Austro-Asiatic superstock largely occupies the linguistic families) and six groups (Table A.2). upland areas of the country and corresponds The Tai-Kadai superstock is primarily a roughly to the Lao Thueng group. The lowland group and is approximately Hmong-Yao and Sino Tibetan superstocks are equivalent to the Lao Loum, which was primarily highland peoples and correspond to formerly the official classification. The the Lao Soung group. Although the former terminology is no longer official policy of the ❖ Table A.2: government, it is often still used for statistical Ethnic Composition of Lao PDR purposes. The government now recognizes that three categories are not sufficient to Superstock and Percentage of Total Group Population capture the true ethnic diversity of the nation and is moving to encourage the use of more Tai Kadai 66.2 realistic ethnic classifications. Lao-Phutai 66.2 Although still classified as a low-income Austro-Asiatic 23.0 country, Lao PDR has seen rapid economic growth and development in the past decade. Mon Khmer 22.9 The Asian economic crisis of 1997 has slowed Viet-Muang 0.1 the development process and led to a sudden increase in inflation and the rapid depreciation Hmong-Yao 7.4 of the kip. Hmong Yao 7.4 In 1992, 47 percent of the population was Sino-Tibetan 2.7 classified as poor and 21 percent were in a state of extreme poverty. These rates were Tibeto-Burman 2.5 higher in both the north and south of the

Hor-Han 0.2 country, inhabited primarily by ethnic minorities. Others and not specified 0.7 Geographically, Lao PDR has no direct access Source: National Statistics Center [Lao PDR], 1995. to the sea and depends on its relations with other countries for overseas commerce. It is a APPENDIX A: Country Summaries A-7 highly mountainous country, with only 4 ❖ Table A.3: percent of the total land area suitable for Adult Literacy, by Ethnic Group, farming. The population density is among the 1995 lowest in Asia. The low population density Overall Male Female and the mountainous conditions make it Ethnic Group Literacy Literacy Literacy difficult for social services to reach a significant portion of the population. Lao-Phutai 72.9 84.4 62.3 Mon-Khmer 36.9 55.6 19.9

Minority Groups Face Special Hmong-Yao 26.5 45.7 8.1 Challenges Tibeto-Burman 17.0 22.3 12.0

Geographical, economic, and cultural Others 46.8 60.8 32.9 constraints often limit the access that Lao PDR ethnic minorities have to both education Total 60.2 73.5 47.9 and health services. In general, according to Source: National Statistics Center [Lao PDR], 1995. the census and numerous surveys, ethnic minorities have poorer housing and sanitary conditions, less access to roads and markets, clearly have literacy rates that are well below poorer health, and lower levels of education. both the national average and the average for In rural areas, nearly 70 percent of the the Lao-Phutai-speaking population population live 4 kilometers or more from predominant in the lowlands. For all groups, basic health services. In many cases, ethnic the differences between male and female minority communities do not value social literacy are significant. The Lao-Phutai group services, often because providers have little has the smallest gap, whereas for minority understanding of their needs or values. The groups, the gap is substantial. Typically men low quality of services in isolated areas with a are more than twice as likely to know how to high ethnic minority population also read as women; in some groups the difference contributes to this perception. is more than five times. Girls and women are especially limited in their This difference in literacy rates is matched by access to social services. In many households a difference in school enrollment rates. While with limited resources, girls are often required enrollment in first grade seems to be relatively to stay at home to help with household chores equitable, ethnic minorities quickly fall while their brothers attend school. Boys are behind in the upper grades. Students in upper often given priority access to limited secondary school and tertiary-level education household resources. are predominantly from Lao-Phutai-speaking groups. For girls, especially ethnic minority girls, the access to education at all levels is Education even more restricted. Many do not enter Considering the low base, Lao PDR has made primary school. important progress in raising the educational levels of the population. The overall adult Supply Constraints in Education literacy rate is estimated to be around 60 The problems that the rural ethnic minority percent and the net primary school enrollment populations face are often related to supply. rate is 76 percent (Table A.3). However, this Approximately 70 percent of villages have at progress hides important differences among least one grade in primary school, although ethnic groups and between boys and girls. many of these schools are incomplete. In general, provinces with high ethnic minority Literacy is one measure of the cumulative populations have more villages without effects of schooling. The differences among schools at all and more incomplete primary groups reflect important historical differences schools. in access to education. Ethnic minorities A-8 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

Part of the problem is the lack of teachers. morbidity. Indeed, malaria is the disease most Many schools have only one teacher, who may often reported in villages in Lao PDR, not be trained or equipped to handle a multi- followed by diarrhea and tuberculosis. Malaria grade classroom. is very area-specific and tends to be higher in Due to the lack of ethnic minority students in areas inhabited by ethnic minorities. The lack lower secondary school and above, it is not of adequate hospital facilities probably also surprising that there are few ethnic minority contributes to high mortality rates for ethnic teachers. Many of the more isolated schools minorities. must depend on “unqualified” teachers, local In addition, ethnic minorities are subject to residents who have some (often limited) great risk from unexploded ordnance, located formal education but who do not meet the predominantly in areas where they live. In official requirements to be teachers. At the 1975–97, there were more than 3,000 same time, many fully trained teachers leave amputations as a result of unexploded the teaching profession (or never join in the ordnance, and although nongovernmental first place) to take up more lucrative positions organizations are active in reducing the risk, with the government or in the private sector. much work needs to be done. The curriculum is also not geared toward the Lao PDR also suffers from a relatively high needs of ethnic minority children. The level of maternal mortality, with rates of national curriculum is designed to be taught approximately 850 deaths for every 100,000 in Lao, a foreign language for ethnic minority births. About 60 percent of the deaths occur children. Many teachers come from outside during childbirth itself. More than 90 percent the community, do not speak the local of births occur at home, often with only a language, and thus have a difficult time relative or occasionally a traditional birth communicating with (and teaching) young attendant present. Rural women, especially children. ethnic minorities, rarely have any form of antenatal care for births. Likewise, postnatal Health practices, such as cutting the umbilical cord with unsterilized instruments, can put both Lao PDR still suffers from a variety of health the mother and the child at risk. problems that unnecessarily shorten the lives of its citizens and retard their development. Health Practices This is evidenced by the infant mortality rate, Good health is as much a product of which for the country averaged above 100 per household behavior as of the regular use of 1,000 live births in 1995. This rate was even formal health services. Children whose higher in the northern provinces, which have a mothers have no education are more than high proportion of ethnic minorities. For twice as likely to die before the age of five example, in the province of Louang Phrabang, than those whose mothers have secondary or the infant mortality rate was 132 per 1,000 in university education. Evidence from surveys 1995. Although little health information is shows that ethnic minority mothers have less available specifically by ethnic group, in 1993 basic health knowledge than ethnic Lao the mortality rate was 132 per 1,000 births for mothers do; this is likely to impact the health ethnic minorities (people from groups other of children directly. than Tai-Kadai superstock). In 1995, in two Diarrhea is a major cause of mortality and northern provinces, the under-five child morbidity in Lao PDR and is often the result mortality rate was about 230 per 1,000 live of poor sanitary practices (the lack of a latrine, births among some Austro-Asiatic groups. use of untreated water, etc.), which could Likewise, concise data on causes of death are easily be addressed if the population had more scarce. Among deaths in hospitals, malaria is education. Likewise, adequate prevention and the leading cause of both mortality and treatment of tuberculosis and sexually APPENDIX A: Country Summaries A-9

Hmong village, Vientiane Province, Lao PDR. These Hmong children collect water for their family after leaving their village primary school. This one water tap—the village’s only source of drinking water—serves 300 people. Household and agricultural chores place a high demand on children’s time, and these responsibilities often prevent school attendance. (Photo by Myles Elledge) transmitted diseases (including HIV/AIDS) personnel. Indeed, only 35 percent of district are inhibited by the lack of knowledge of hospitals have water, and fewer than half have proper procedures. Indeed, some 60 percent equipment to properly sterilize surgical of women in the north have not even heard of instruments. AIDS. This percentage is even higher among Ethnic minority families often live far from women from ethnic minorities. roads and regional centers, effectively Clearly the ethnic minority populations are at restricting their access to formal health a disadvantage due to their lower education services. Many ethnic minority villages are levels and isolation from schools and modern hours from health centers and hospitals. health services. This situation is especially Likewise, ethnic minority villages are far less serious for women, who are far less likely to be likely to have medical professionals and basic educated than men and who tend to be the medical supplies. first line of defense in providing health care to It is not surprising that only 15 percent of the the household. population prefer public hospitals or health centers for health problems; self-treatment and Supply of Health Services private sector health services are by far the The Ministry of Health of Lao PDR has been most popular options. In addition, few of the expanding the coverage of health services public sector medical personnel are from throughout the country. However, this minority groups, which limits their ability to coverage often is not very effective; of 117 communicate with patients and to bridge the district hospitals, only 20 operate fully. The cultural gap. In 1998, only 2 percent of rest suffer from a lack of supplies, public students studying to be physicians were from services (electricity, water, etc.), and trained ethnic minority groups. A-10 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

In Thailand, ethnic diversity and national ❖ Table A.4: identity as ideas have, over the years, been Hill-Tribe Population Compared with issues whose emphasis has ebbed and flowed that of the Whole Country with the personalities of the nation’s leaders, at Area Total Hill-Tribe % times with tension and at other times Population Population harmoniously. Whole Kingdom 61,466,178 752,728 1.2 Estimates of numbers of “hill tribes” (or chao Bangkok 5,647,799 — — khao in Thai) vary depending on the data source. (The data here and in Table A.4 come Central Regiona 14,279,504 46,734 0.3 from Tribal Research Institute, 1998.) Hill- Kanchanaburi 775,198 31,323 0.4 tribe peoples are clustered in towns and villages across 20 provinces (out of Thailand’s Phetchaburi 456,527 3,659 0.8 76 provinces). Hill tribes compose 1.2 percent Prachuap Khiri Khan 473,335 1,331 0.2 of the total population of Thailand. A number of northern provinces have large populations Ratchaburi 819,360 8,307 1.0 of highland people. Provinces with highland Suphan Buri 858,750 2,114 0.2 populations that total more than 10,000 per province include: Chiang Mai, Chiang Rai, Northa 12,159,930 704,697 5.8 Mae Hong Son, Tak, Nan, and Kanchanaburi. Chiang Mai 1,582,222 190,795 12.1 Mae Hong Son has the largest relative Chiang Rai 1,268,569 145,136 11.4 population of ethnic minorities, with 41 percent of the population being members of Kamphaeng Phet 770,667 9,149 1.2 hill tribes, while Chiang Mai has the largest Lampang 809,185 12,222 1.5 concentration at 191,000. Because the overall hill-tribe population is relatively small, there is Lamphun 409,091 25,418 6.2 a lack of quantitative data on hill-tribe Mae Hong Son 232,938 95,233 41.0 populations. Nan 488,192 79,880 16.3 There are nine principal hill tribes, with a total population of 752,000. These groups are: Phetchabun 1,049,516 12,378 1.2 Pga Ker Yaw (Karen),1 Hmong, Lahu, Lisu, Phayao 517,731 13,962 2.7 Mien, Akha, Lua, Htin, and Khamu.2 The Karen account for nearly 50 percent of the Phrae 495,722 10,655 2.1 populations in these nine groups, with the Phitsanulok 868,684 5,845 0.7 Hmong and Lahu the second and third largest. Sukhothai 630,292 2,315 0.4 Tak 479,105 96,979 20.2

Many Challenges Remain Uthai Thani 331,295 4,730 1.4

Services targeting hill-tribe populations and Northeasta 21,312,166 1,297 — highland programs have a long history in Thailand, dating back to the mid-1950s. Yet Loei 635,845 1,297 0.2 Southa 8,066,779 — — 1 There are several subgroups of Karen, many of whom refer to themselves as Pga Ker Yaw. a Column 1 lists only the provinces with hill-tribe populations, rather than all provinces in the region. 2 Throughout this section, the designations for ethnic groups are those used by the groups themselves, rather Estimates are based on Tribal Research Institute, 1998. than the ethnic Thai names. Source: Ministry of Interior [Thailand], 1999. APPENDIX A: Country Summaries A-11 despite rapid national economic growth and a series of highland programs, geographical, economic, and cultural constraints often limit the access that ethnic minorities have to both education and health services. Hill-tribe populations have poorer housing and living conditions and have less access to roads and markets. In the social sector, they have lower levels of school achievement and poorer health. Often hill-tribe communities see limited returns on their investments in education. The lower quality of services in isolated areas with a high ethnic minority population contributes to mixed perceptions Lampang Province, Thailand. A mother sits in her home regarding the value of services. with her newborn child. Poverty rates are highest among hill-tribe peoples. This young mother, aged 13, has less Historically, girls and women are especially than one year of schooling and few means to support limited in their access to social services. Boys herself. (Photo by Myles Elledge) are often given priority access to limited household resources. In many households, The poverty rate among hill-tribe peoples is girls are often required to stay at home to help significant and well above the national with household chores while their brothers average. More than 46 percent of the hill-tribe attend school. However, this pattern varies population received welfare services in 1998. greatly from group to group and there is some Rapid changes in lifestyle, through forced evidence from field surveys and enrollment relocation and changing agricultural practices, data in schools that the pattern is changing. are an important factor in explaining the difficulties many households face in earning a The annual population growth among living. highland populations was 2.9 percent according to the 1995 census and represents a rate much higher than the national average of Education 1.2 percent. With respect to settlements, a Thailand has made important progress in large number of hill-tribe households are not raising the educational levels of its population officially recognized as being in clusters or in in the past 20 years. The overall national adult recognized villages, thus preventing access to literacy rate is high, but hill-tribe populations many government-operated services. Similarly, lack of citizenship remains an issue among remain at much lower literacy levels. Limited highland peoples and a constraint to social access to school, and difficulties in learning services. There are many ethnic villagers who the Thai language (often the language of were born in Thailand but do not have instruction), limit progress in eradicating officially registered status. They are essentially illiteracy. treated as foreigners. Registration is a key Thai language literacy is quite low among factor in villages receiving assistance, in highland peoples: Only an estimated 20 students gaining access to school, and in percent of hill-tribe people had complete residents being granted health insurance cards. literacy in the Thai language in 1998. Despite Registration also shows that the state this fact, the national curriculum remains recognizes ethnic minorities’ rights and designed to be taught in Thai, a foreign responsibilities as being equal to those of any language for ethnic minority children. other citizen and that it will treat them Moreover, many of the teachers are from other accordingly. communities and do not speak the local language. Two major problems result from this A-12 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

Lampang Province, Thailand; ethnic minority children playing outside their house. These children rarely attend the primary school that is a 30-minute walk from their village. The challenges of learning the Thai language and the incidental costs of school participation discourage their regular attendance. (Photo by Preecha Upayokin) situation. First, repetition rates are high among other groups. Except for the Hmong, among primary schools in provinces with high the figures for educational attainment beyond concentrations of hill-tribe peoples. Second, primary school for every group were less than years of low student achievement cannot 5 percent in 1998. This figure was well below produce large numbers of well-educated the national average and even below the highland peoples entering the teaching pro- average in rural areas. fession. Clearly, alternative methods are Thailand has a number of nonformal needed to better educate highland peoples. education programs in highland areas that use Enrollment in preschool ranges from 20 to 30 local ethnic languages; the Hill Areas percent of the total eligible children in the Education (HAE) program’s centers represent northeastern provinces that have the highest one model. Experiences such as this one, concentrations of ethnic minority families. whether led by public agencies or by Among primary school students, enrollment is nongovernmental organizations, have had higher than at the preschool level for both mixed success, but do offer examples of formal and nonformal education programs. targeting and tailoring approaches to ethnic Hill-tribe populations often depend on minority populations. welfare schools, as these schools are completely As in the other study countries, the problems free, unlike other school programs. faced by ethnic minority populations are often Interestingly, welfare schools show nearly related to supply. For example, schools are equal enrollment among girls and boys. more widely dispersed in highland areas. The Examining different ethnic groups, there is numbers of teachers, and the quality of the some evidence to suggest a high demand for teachers serving in these areas, are not equal to education among the Hmong people. the standards in lowland areas. Welfare schools Demand for schooling appears to be less in particular have notably fewer qualified APPENDIX A: Country Summaries A-13 teachers, and these are the very schools hill- numbers of low-income hill-tribe people tribe students are most likely to attend. involved in the commercial sex business and Another constraint is that lack of citizenship low rates of condom contraceptive use elevate papers restricts access to education to grade 9. the risk of HIV/AIDS among highland Numerous entities in the Ministry of communities. Education play important roles in educating Some health education programs have been highland children. Various schools operating shown to be effective in the highlands. For in the highlands do model both formal and example, family planning programs have nonformal education, but overlapping produced strong results in a number of areas, programs and poor quality of services remain and significant progress in immunizations has constraints. been made. Yet many health education programs—as well as treatment programs— Health still do not adequately adapt to the cultural and language needs of hill-tribe peoples. This Thailand has made important strides in raising is especially important with HIV/AIDS; the overall health status of its population. because currently there is no prospect for Basic health indicators have seen significant either a cure or a vaccination, prevention is the improvement, even for hill-tribe peoples, but only means to fight this disease. hill-tribe households still lag behind the Access to health care is still difficult for ethnic overall national levels for most health minorities. For instance, although services indicators. Child and maternal death rates themselves may be free, there are many hidden have decreased nationally, yet the highland costs, such as the expense of traveling to north and northeastern provinces have seen facilities in more urban areas. Thailand’s less progress and have infant, child, and ethnic minority families often live far from maternal death rates above the national roads and from regional health centers and average. Lower rates of immunization in the hospitals. Likewise, ethnic minority villages areas of the country heavily populated by hill are much less likely to have their own medical tribes illustrate the disparities among lowland professionals and basic medical supplies. The and highland populations, and the impact of Ministry of Public Health in Thailand has limited access and poor coverage. been expanding the coverage of health services Health and hygiene remain concerns in the throughout the country, but the distribution highland areas. As of a survey in 1997, only 29 of health workers is lowest in the highland percent of hill-tribe households had access to areas, and too often the quality of care safe drinking water. Approximately 70 percent providers is below the national average. had a latrine attached to or near their house. Some discriminatory practices also restrict Diarrhea, respiratory infections, and access. Many ethnic minorities are barred tuberculosis remain major concerns in the from government health care services because highlands. Malaria cases have declined of lack of registration or citizenship, which considerably, although malaria remains a prevents them from obtaining health prominent concern in the highland provinces. insurance and welfare cards. Others find that The gravest public health concern in highland their limited ability to speak Thai results in border areas is now HIV/AIDS. Large discrimination. A-14 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

Needs of Ethnic Minorities ❖ Table A.5: Classification and Composition of The variable conditions of ethnic minority Viet Nam's Ethnic Groups populations living in the highland and Linguistic Families Percentage of the mountainous areas raise important concerns and Ethnic Groups (No.) 1989 Population for government officials of the Socialist Austro-Asiatic Republic of Viet Nam. A review of conditions in Viet Nam suggests that ethnic minorities in Viet-Muong (4) 88.26 Viet Nam face both supply-side and demand- Mon-Khmer (21) 2.61 side constraints and that policymakers must H'mong-Dzao (3) 1.67 take both into account. On the supply side, additional investments are needed in the Tay-Thai (8) 4.28 provision of materials, infrastructure, and Ka Dai (4) 0.02 human resources. These investments will Malayo-Polynesian lower the effective price of services and improve their quality, which will lead to an Malayo-Polynesian (5) 0.96 increase in the quantity demanded. Han-Tang

Han (3) 1.51 Ethnic Diversity and Viet Nam Tang-Mien (6) 0.06

Of Viet Nam’s total population of 70 million, Source: Institute of Ethnology, 1978. ethnic peoples other than the majority Kinh represent approximately 13 percent. According to the 1989 census, the 53 ethnic Development Challenges minority groups ranged in population size from 232 Brau or 227 Ro Mam to 1.19 Despite Viet Nam’s noteworthy progress in million Tay. These groups are scattered across economic growth over the past decade, Viet 45 of the 61 provinces, although there are 13 Nam today remains poor. While the provinces in the Northern Highland region socioeconomic situation continually changes, and Central Highlands, where ethnic minority the lives of many Vietnamese, including those people account for 30 to 90 percent of the of ethnic minorities, remain burdened by population. These 13 provinces also have a hardship. Among the major issues affecting large number of poor and disadvantaged ethnic minority populations are poverty, communes, and account for 694 of 1,568 environmental degradation, forest loss, poor mountainous communes in the country. There and inadequate infrastructure, and population are significant differences in language and growth from both high birth rates and in- culture among the groups. migration. Since the 1970’s, ethnic groups in Viet Nam Poverty remains a chronic problem. Of 8,759 have been classified on the basis of language, communes in the country, 1,715 are currently ethnic awareness, and cultural criteria. identified as the poorest and most According to a 1978 state publication disadvantaged. Of these, 1,568 are in the (Institute of Ethnology, 1978), Viet Nam’s 54 mountainous and predominantly ethnic ethnic groups (including the majority Kinh) minority regions. The incidence of hunger and belonged to three main linguistic families: the poverty in the highland provinces is higher Austro-Asiatic family, the Malayo-Polynesian than in Viet Nam as a whole and a very family, and the Han-Tang family (Table A.5). APPENDIX A: Country Summaries A-15 significant percentage of the poor communes are located in ethnic minority highland areas. Despite significant increases in income in minority highland areas over the past decade, the disparity between rich and poor in various regions and among ethnic minorities has increased. Broadly speaking, the situation of Viet Nam’s mountainous and ethnic minority regions remains problematic. The lack of food security, the degraded environment, and inaccessibility all remain key issues that have a profound impact on education and health Son La Province, Northern Highlands, Viet Nam. Poverty remains a chronic problem and is most pronounced in the care. highlands. The lack of food security, poor nutrition, and The Doi Moi reform process, which started in limited access to basic services are most pronounced among 1986, introduced new fees and charges in both highland, minority populations. Improved targeting of resources to poor areas with large ethnic minority popula- the health and education sectors. Although the tions will help address the needs of such vulnerable groups. reform has been associated with economic (Photo by Vuong Xuan Tinh) growth and a reduction in poverty, there is evidence that some vulnerable groups, cultural, and social fields, plus policies that including ethnic minorities, have been “left apply to certain regions for specific behind” and are unable to afford many socioeconomic development. Several policies essential social services. (ADB, 2000e). The that have had a major impact on the government has attempted to improve the socioeconomic life of ethnic minorities in Viet targeting of resources to poor areas with large Nam are the policies on building of new ethnic minority populations, but this problem economic zones, resettlement to sedentary still persists. cultivation, land use, hunger eradication, and poverty alleviation. These policies have had many positive impacts but also have led to Ethnic Minority Policies imbalances in the existing ecological systems Policies toward ethnic minorities in Viet Nam of the mountainous areas and have had some are expressed not only through social policies other negative impacts on the life of the ethnic but also through the political program of the minority populations in these environments. state and along political party lines. The Communist Party of Viet Nam has outlined Education: Instruction and Policy relations for ethnic minorities which foster equality, unity, and mutual help among ethnic Viet Nam has made great strides over the past groups; creating favorable conditions for all 50 years to eliminate illiteracy and encourage ethnic groups to develop and catch up with universal primary education. Significant the general growth of the whole Vietnamese growth has been recorded in terms of community; and respecting the interests, educational opportunities. The number of traditional cultures, languages, customs, and children who have finished primary and lower beliefs of the ethnic groups, especially ethnic secondary school has doubled since 1989. In minority groups. The 1946 Constitution and Viet Nam’s ethnic minority and mountainous particularly the 1980 Constitution of the regions, all communes have primary schools, Socialist Republic of Viet Nam acknowledge and the number of villages and hamlets having the position, rights, and obligations of ethnic no schools and classrooms has decreased groups living in Viet Nam. substantially. Besides common policies, which serve as However, significant problems for education general guidelines and strategies, there are in ethnic minority areas remain. Illiteracy concrete policies covering all economic, remains high in various ethnic minority areas, A-16 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

Dak Lak Province, Central Highlands, Viet Nam. High rates of illiteracy, high dropout rates, and poor school infrastruc- ture define education in many highland areas populated by ethnic minorities. There are significant differences in quality for pupils in the ethnic minority mountainous areas and in the plains of Viet Nam. Subsidies for highland students, and special budget arrangements for teachers working with ethnic minority pupils, are positive steps to raise educational achievement among ethnic minority populations. (Photo by Myles Elledge) where differences among ethnic groups, Tay Nguyen, are significantly higher than in between boys and girls, and between men and other regions. Early childhood (preschool) women are critical. This fact is well expressed education has not been carried out widely in in both the literacy rate and the number of the mountainous region, with only 1–2 pupils attending school. percent of children in the regions having been In relation to basic supply, the shortage of sent to crèches, 10 percent to kindergartens, schools and classrooms remains an extensive and 30 percent to preschools. problem in the highland, remote, and out-of- The educational system in the ethnic minority the-way areas. As many as 2,000 villages and and mountainous region is also largely part of hamlets in these regions do not have any a contracting public school system; very few school facilities. This problem is due first to a private schools are found in the highlands. lack of teachers. In 1998 Viet Nam lacked And although many people in the 58,000 primary school teachers, and in the mountainous areas have contributed to the ethnic minority and mountainous provinces, construction and maintenance of public each province lacked anywhere between 1,000 school facilities, communities have not been and 1,500 primary school teachers. Moreover, able to participate in curriculum development. teaching and learning aids and other school Language is a major barrier for many ethnic supplies and equipment are in poor supply minorities, particularly for those in the first and certain areas face serious shortfalls. years of primary education, as many ethnic In terms of quality of education, there is a minority pupils have difficulties learning the significant difference in quality for pupils in Kinh language. The shortage of ethnic the ethnic minority and mountainous regions minority teachers is another common and in the plains and urban areas. The problem; at present, fewer than 15 percent of numbers of school dropouts, particularly in the primary school teachers in ethnic minority APPENDIX A: Country Summaries A-17 and mountainous regions are from ethnic years, from 90 per 1000 live births before minorities. Also, teachers’ instructional skills 1980, to 44 in the period 1989–93, and to 36 sometimes are poor. Given the shortage, in 1996. The Northern and Central Highlands numerous teachers are recruited as volunteers lag behind, with 1996 rates of 52 and 55 or are hired by contract, with or without respectively. Overall the maternal mortality proper qualifications. rate is 110 for every 100,000 live births in Since 1987, Viet Nam has implemented an Viet Nam. It has been reported that this figure educational reform, which in part has paid may reach 160 in rural areas and be four times special attention to the development of as high in remote mountainous areas (ADB, education and training needs of ethnic 2000e). minority populations. Although the educa- With maternal and child health services tional system for ethnic minority and limited in many remote mountainous areas, it mountainous areas is similar to that in the is not entirely surprising that only 44.6 lowland areas, there are several special percent of rural women of reproductive age facilities, including boarding schools, pre- reported having received prenatal care when university schools, a teacher training school, a they were pregnant during the past three years, medical school, and a university for ethnic as opposed to 75.6 percent of Kinh or Hoa minority students. At the Ministry of women in rural areas. This figure was similar Education and Training, there is a Center for for both the Northern and Central Highlands. Ethnic Minority Education. Moreover, delivery at home among ethnic Over the past three decades, Viet Nam’s minority women is very common, with only education policies for ethnic minorities in about 2 to 3 percent going to public hospitals mountainous areas have emphasized literacy or to commune health centers for delivery. programs and universal primary education, the Women in mountainous areas have a much promotion of ethnic minority languages in higher number of children than those in the primary schooling, the development of rest of the country, and particularly so for boarding schools for ethnic minority children, those within the poorest quintile of the job-training and vocational schools, and population. special budget arrangements for teachers who Other specific health threats encompass both are teaching ethnic minority students in noncommunicable and communicable mountainous areas. diseases. For example, malnutrition in broad Although these policies have achieved terms remains a prominent health problem, as significant results, much work remains. does chronic protein-energy malnutrition. Government agencies as well as multilateral, Incidence is higher in the Northern and bilateral, and nongovernmental organizations Central Highlands than in other parts of the are funding and implementing programs and country. This problem remains particularly projects on education for ethnic minorities in relevant for poor and ethnic minority mountainous areas. populations. Acute respiratory infection (ARI) is a leading cause of infant mortality in mountainous areas. This cause is followed by Health diarrhea, which is prominent in the Northern and Central Highlands. Although the Overall human development indicators in the expanded program of immunization in Viet mountainous and ethnic minority areas of Nam is recognized as being relatively Viet Nam, particularly in the Northern and successful, the rate of immunization in both Central Highlands, are lower than for other the Northern and Central Highlands is lower parts of the country. The health status of this than the national average, leaving children in population remains characterized by relatively particular more vulnerable to preventable high infant and maternal mortality rates, diseases. Malaria also remains a major concern although the infant mortality rate in Viet in the two main mountainous regions. Nam has declined remarkably over the past 20 A-18 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

Migratory movement among ethnic minority affected by poorly trained health workers or groups has been identified as a key factor lack of any health staff at all, poor hygienic causing epidemic outbreaks of malaria (ADB, conditions, insufficient equipment and 2000e). medicines, and distance required to reach As in the education sector, poor health among health care facilities or health workers. With Viet Nam’s ethnic minority populations health worker salaries low and user fees requires both supply- and demand-side leading to confusion in many mountainous solutions. These will include both renovating areas, the public health sector’s priority existing health infrastructure and targeting function of providing preventive health care is resources and materials to ethnic minorities to being eroded. Effective community health ensure that services are readily available and interventions and well-functioning extension relevant to the needs of ethnic minority services for ethnic minority populations in patients. mountainous areas are seen as crucial primary health care objectives. Health System in the Mountainous Region Health Policy Although Viet Nam has developed an With mountainous regions facing increasing extensive network of hospitals, medical clinics, and commune health centers, the current state problems over the past few years, the of public health facilities—both the hospital Vietnamese government has been developing a network and primary health care—are in series of social welfare and development decline and a large portion have been policies that are intended to alter health neglected. This is particularly so in conditions in Viet Nam’s mountainous areas. mountainous areas. Moreover, since the Since 1991, the Ministry of Health has introduction of private sector provision in developed a health care strategy for the 1989, utilization of health services has northern mountainous region, with the overall declined and there are widening disparities objective of providing better primary health across regions; among urban, rural, and care services for ethnic minority people and remote areas; and between different social reducing the disparity between the lowlands groups. With less than 20 percent of all and highlands. This strategy has included medical treatment involving contact with the controlling malaria and goiter, strengthening public sector, services utilization has decreased health care for mothers and children, ensuring most strongly for those in the lowest income that under-five and particularly under-one brackets and this decrease is evident in the children have adequate nutrition and access to Northern and Central Highlands of Viet disease prevention and treatment, extending Nam. and increasing the quality of basic medical services in remote areas, and encouraging the At present the quality of commune health use of traditional medicine and health care. services in mountainous areas is adversely APPENDIX B: Potential Health and Education Programming B-1

APPENDIX B POTENTIAL HEALTH AND EDUCATION PROGRAMMING TO ASSIST ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

The ADB study titled Health and Education Needs of Ethnic Minorities in the Greater Projects and Programs Mekong Subregion has reviewed policies and programs across the countries of Cambodia, 1 Regional Program on Minority Lao PDR, Thailand, and Viet Nam. The Populations and Highland Peoples broad sector focus and geographical coverage of this project’s policy review took the analysts Conduct household survey and series of into a wide range of topics. The following participatory poverty appraisals in selected illustrative list outlines a set of potential highland provinces in Cambodia, Lao PDR, projects and program interventions that have Thailand, and Viet Nam, following the World been identified as priority areas for further Bank’s Voices of the Poor approach (Narayan et study and project development. al., 2000). Facilitate dissemination of findings to national and provincial leaders. The project ideas offered here correspond to a number of the recommendations contained in Further targeted work to understand the four Country Reports. The concepts and constraints facing ethnic minorities is ideas emerged directly from in-country important, as data availability and consistent dissemination workshops held in Vientiane, data quality are major concerns for planners Hanoi, Phnom Penh, and Chiang Mai in July and policymakers looking at the conditions and August 2000. The projects were selected among highland, minority populations. based on analysis of key issues, and on in- The project would expand the coverage of country consultations with key stakeholders living standards surveys in respective during these in-country forums. In all cases, countries. It also would support the further project preparation activities will be development of a sound database on poverty required for development of these potential status among minority populations, as there is interventions. a lack of focus on ethnic minorities in In general, the projects listed here suggest household surveys, particularly in Cambodia geographic targeting in areas with high and Thailand. The process would be part of a concentrations of ethnic minorities. The short strategy to increase awareness of ethnic descriptions are a basic outline of the minorities’ issues through a stronger intervention, often at the country level—the information base of official statistics, and at level at which it is often easiest to work with the same time, to build capacity within key stakeholders and to develop capacity and statistical agencies. analytical tools within channels for service Geographic focus on border-area provinces in delivery. For a given country, the projects are the selected countries will look at issues of prioritized based on the study team’s analysis concern and cross-border problems. of priority needs. The budget information is Candidate provinces might include: Ratanakiri very preliminary, and each project requires and Mondolkiri in Cambodia; Phongsali and further review and development to more Sekong in Lao PDR; Chiang Rai and Mae accurately estimate activities and cost Hong Son in Thailand; Cao Bang and Lai requirements. Chau in the Northern Highlands and Gia Lai and Kon Tum in the Central Highlands of Viet Nam. B-2 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

Assign US$750,000 for regional technical incorporate local knowledge and language. assistance, plus US$350,000–500,000 per Develop model curricula to facilitate the country, as costs vary by country. incorporation of local cultural practices and traditions. There is a need to develop new models for community schools, and to open 2 Cambodia: opportunities for teaching (flexible schedule, HIV/AIDS in the Northeastern multigrade), teacher training, and recruitment Provinces and staff-retention incentives. Develop community education and outreach Select priority provinces across the country, programs for ethnic minority communities including coverage of four northeast through training of local leaders and provinces. Cost of project preparatory activity information dissemination, while developing a is estimated at US$750,000 for consulting quantitative database of infected and high-risk services, teacher training, and materials populations in the northeastern provinces. development. A two-pronged approach should be employed to disseminate information on HIV/AIDS and 4 Thailand: to gather information on HIV/AIDS North and Northeast Poverty prevalence. Under ADB RETA 5794, Survey consultations with MOH staff and provincial leaders have highlighted the need to educate Expand knowledge about the poverty situation the populations in the northeastern provinces in registered and nonregistered villages in to HIV/AIDS risk, while quantifying the highland areas. The study team confirmed an infected and high-risk populations. Highland absence of data, particularly among estab- populations are both protected by their lished but not officially registered villages. isolation, and at risk due to limited awareness. Survey would model living standards survey This suggested project focus is consistent with approach. highland development plans of the Inter- Estimated budget is US$600,000 for Ministerial Committee for Highland Peoples’ consulting services, survey development, and Development (IMC). Emphasis should be analysis. placed on developing material and disseminating this material in native languages. Program should build upon ADB 5 Thailand: AOTA CAM 33385-01 and ADB RETA No. Basic Education and Learning 5881 on high-risk and mobile populations, to Promotion the extent possible; and on ADB RETA No. 5751 on prevention and control of HIV/ Scale up the community learning model and AIDS in the GMS. ethnic minority language education system Target the provinces of Ratanakiri, developed by such nongovernmental Mondolkiri, Stung Treng, and Kratie, which organizations as the Association of Inter- have high concentrations of ethnic minorities. Mountain Peoples for Education and Culture Allot US$450,000 for consulting services, in Thailand (IMPECT) in Chiang Mai, training, and materials development. Thailand. This successful project has developed an integrated curriculum inclusive of national course priorities and indigenous 3 Cambodia: life skills. The approach is well placed to be Primary Schools in Remote Areas further institutionalized to cover other communities. The program consultative Develop a system of education that meets approach has helped secure national, regional, local demands, including multigrade teaching, and local support for the intervention. Further a flexible school calendar, and curricula that efforts are called for to develop an expanded APPENDIX B: Potential Health and Education Programming B-3 inventory of community-based materials by Lao PDR: scaling up this program to additional areas. 8 Primary Schools Target the north and northeastern regions to expand the model and curriculum materials Develop a system of education that meets available. Allot US$450,000 for advisory local demands, including multigrade teaching, services, training, and materials development. a flexible school calendar, and curricula that incorporate local knowledge and language. Fundamental investments in facilities and 6 Lao PDR: curriculum are required to meet demand for Teacher Upgrading education in remote and highland areas. Greater acceptance of education services is Broaden and deepen the human resource base proven to follow from tailoring services to to sustain the Network Teacher Upgrading local communities. Program (NTUP), a highly successful program targeting the upgrading of teacher skills and Budget suggested is US$150,000 for technical qualifications. Support expanded training and assistance services to support stronger curriculum material development. The integration of ethnic minority issues into program, while adopted nationally, is ongoing donor school expansion programs underfunded in many areas and curriculum (World Bank, UNICEF, ADB). Target four and materials require revisions. southern and northern provinces in which primary school coverage is low and the Target remote areas where the NTUP has not minority population is high. fully reached all districts and teachers. Assign US$1,000,000 to support training, workshops, and materials development, with 9 Viet Nam: the aim of covering 40–50 percent of all Teacher Quality Improvement for teachers in this program. Highland Areas

Modeled upon the successful NTUP in Lao 7 Lao PDR: PDR, assist the government to identify and Environmental Health prepare a national program to upgrade the skills and qualifications of teachers, with a Develop and disseminate the information base focus on the highland areas. Strengthen the to quantitatively demonstrate the relationships competencies of untrained and underskilled among environmental improvement, poverty teachers in remote provinces. Teacher quality reduction, and better public health. Introduce is a key link to improve student performance a pilot program in highland areas in which and to strengthen community support and education materials are tailored to local participation in the schools. communities to reduce disease and illness incidence. Focus geographically on provinces with the highest levels of unqualified and underskilled This demonstration project would target four teachers. Explore loan financing, estimated at selected provinces. Estimated budget of $15 million–20 million, to support facilities US$400,000 to support training and improvement, teacher training, an advisory consulting services to develop model approach network of skilled and experienced teachers, and tools for information, education, and teacher aides, and curriculum materials communication (IEC) in highland and remote development. areas. B-4 HEALTH AND EDUCATION NEEDS OF ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

10 Viet Nam: determined through further consultations with key stakeholders. Explore a decentralized loan Highland Secondary Schools program allowing provinces to respond Assist the government in identifying and differently to the needs of their populations. preparing for the expansion of secondary school facilities and curricula tailored to the 11 Viet Nam: needs of ethnic minorities in the Central and Northern Highlands. The program would seek Nutrition Education to build upon an ADB-financed master plan Despite Viet Nam’s gain in health status, on secondary education (ADB AOTA VIE nutrition is still a serious issue. This 34050-01). Secondary education support intervention would support the government in services are limited, particularly in highland developing and delivering well-tailored areas covering minority populations. Boarding nutrition education programs for ethnic and semiboarding schools are one option; minority and highland communities. It also transportation and school supply credits are would develop greater understanding of why also important incentives. Support minority malnutrition is such a problem among populations through expanded opportunities highland populations. Nutrition is a key for secondary education, essential both to constraint to overall health, and a major skills development and to the development of concern for highland areas. a cadre of community residents capable of serving as teachers or as health workers, or Target selected provinces in the Central entering other important occupations. Highlands in which nutrition is poor and minority populations are large. Allot Focus geographically on the Central and US$400,000 for advisory services for training Northern Highlands, where secondary schools needs assessment, then development of are underserving minority populations. The training materials and outreach programs for software and facilities budget should be nutrition education.