12.06.2020
Health Care in Cambodia – More Than Money and Medicine
Prof. Dr. Steffen Fleßa Universität Greifswald
Contents
1. Country Profile 2. Social and Health Care Sector 1. Health Care Provision 2. Epidemiology 3. Service Provision 3. Future Developments
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Main Message
• “Central foundation of health care is not medicine, but historical pathway, population, culture and economy”
Health Care in Cambodia
Cambodia Nation – Religion - King • Size: 180,000 sqkm (=1/2 Germany) • Population: 14 Million (= 76 p. sqkm) • Tribes: 90% Khmer, 5% Vietnamese, 1% Chinese • The “micracle of Tonle Sap”
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Historical Pathway
• Angkor • French Indochina • Vietnam War • Khmer Rouge …
Health Care in Cambodia
Khmer Rouge
• 1975-1979: Communist rulers – Leader: Pol Pot – Backing: China • 15-30% of population died (killed, starved) – “Cleaning” of towns – “Cleaning” of intellectuals • Civil war until 1998
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Further Development
• 1975-1989: Vietnam invasion, occupation • 1989-1991: Civil war, fighting until 1998 • 1991-1993: Ceasefire and “United Nations Transitional Authority” (UNTAC) • Since 1993: stepwise development towards democracy and market economy
Health Care in Cambodia
Consequences
• At the end of wars Cambodia had lost about half of its population. • The country is plotted with land mines. – 35,000 lost disabled – 500-800 casualties annually – Several thousand victims annually • There was nobody who was no victim or deliquent – Younger population: there is nobody who has lost a close relative • Cambodia is a play-ground for different countries – E.g. Khmer-Soviet Friendship hospital – E.g. Bank of China –…
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Current System
• Constitutional Monarchy King Norodom Sihamon – God-King Norodom Sihamon – Prime Minister Hun Sen • Cambodian People's Party • Market Economy: Prime Minister Hun Sen – strongly China-driven
Health Care in Cambodia
Religion
• Buddhism
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Theravada Buddhism
• Oldest form of Buddhism – relatively conservative • Features in Cambodia – Animism and syncretism – Importance of God-King and monks – Importance of “spirits” – Prevention and “spirits” – Insurance and “spirits” – Fate and punishment
Health Care in Cambodia
Economy
• GDP 2016 at market prices (current US$) – $20.01 billion – Country comparison: No. 108 • GDP - real growth rate (2016): – +7.0% – Country comparison: No. 31 • Gross national income p.c. 2016: – US$ 1269 – Country comparison: No. 184 – Low Income Country
http://data.worldbank.org/indicator/NY.GDP.MKTP.KD.ZG?locations=KH
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Sectors
GDP Labour Agriculture 35% 58% Industry 24% 16% Services 41% 27%
Health Care in Cambodia
Health Care in Cambodia
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Health Care in Cambodia
Development of Poverty
60
50
40
30 [%]
20
10 Population belowPopulation national poverty level 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 Time [years]
http://data.worldbank.org/indicator/SI.POV.NAGP?locations=KH
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Summary
• The historical pathway, its culture and economy are unique. • Every health care system or development aid that does not take this uniqueness into account is due to fail.
Health Care in Cambodia
Contents
1. Country profile 2.Social and Health Care Sector 3. Future Developments
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Demography
• Life expectancy: 63 yrs. • Population growth: 1.7% • Urbanisation: 20% • Prime City: Phnom Penh (1.5 mio.)
Health Care in Cambodia Population Density
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Health Care in Cambodia
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Health Care in Cambodia
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Epidemiology Burden of Disease in Cambodia (2004)
Death DALYs Condition [‘000] [‘000] Communicable, maternal, perinatal and nutritional conditions 83 2903 Noncommunicable diseases 58 1724 Malignant neoplasms 11 169 Diabetes mellitus 3 39 Neuropsychiatric conditions 3 451 Cardiovascular diseases 24 361 Ischemic heart disease 8 121 Cerebrovascular disease 791 Respiratory diseases 6 132 Digestive diseases 5 122 Other Health Care in Cambodia Total 150 5003
Covid-19
• Erwartung: Desaster! – 1.000.000 Chinesen leben dauerhaft in Kambodscha – Millionen Chinesen kommen jedes Jahr zum Glücksspiel nach Kambodscha – Keine Testmöglichkeiten – Kaum Intensivbetten – Kaum Beatmungsmöglichkeiten • Realität?
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Covid-19
17.4.20: Fälle: 122 Präv.: 8,0 p. 100.000 EW Todesfälle: 0
Health Care in Cambodia
Covid-19
• Verdacht: keine Testung – Aber: „Italienische Verhältnisse“ würde man sehen! • Gründe? – Temperatur??? – Social Distancing als Teil der Kultur – Importierte Fälle: Touristen sind zu groß?? – Bevölkerungspyramide: die primären Risikogruppen existierten nicht! • Alte: Opfer von Pol Pot • Chroniker: haben eh keine lange Überlebenszeit in K.
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Continued inequalities in infant and child mortality within Cambodia
180 160 140 120 100 80 60 40 20 0
Source: CDHS 2010 child MR infant MR Health Care in Cambodia
Service Provision
• Health Centre – no beds – Staffing: 3-6 – Population: 5-10,000
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Hospitals
• Hospital (Level II) – 80-200 beds – Staffing: 100-200, incl. doctors – Population: 50- 250.000 –NB: • 1 hospital bed for 10.000 • 1 doctor for 5000
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Hospitals
• National Hospital (Level III) – Only in Phnom Penh – Training Institutions – Highly specialised • Kantha Bopha (Beat Richner)
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Main problems of Cambodian health care system
• Quality of staff – Training of doctors! • Availability of drugs • Transport • No quality control of private providers • Traditional medicine: mainly lost
Health Care in Cambodia
Contents
1. Country profile 2. Social and Health Care Sector 1. Demography 2. Epidemiology 3. Service Provision 3. Future Developments
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Future Development
• Economic development: “young tiger” • But: “much more than money”: absorption capacity is very limited • “Much more than medicine”: – traditional believes make insurances and prevention difficult • “A tortured nation with strong inequality”: Revolutionary potential?
Health Care in Cambodia
• “„If we, as health workers, or teachers, or students, or civil servants do not feel that we, and the groups or organisations we belong to, have some power to alter policy that affects our lives, or the lives of those around us, why get up in the morning?“ (Gill Walt 1994).
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