Micronutrient deficiencies

Vitamin A Access

Adequate micronutrient intake by women has important benefits for both women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation of women during pregnancy protects mother and infant against anemia.

The 2005 CDHS data states that only 27 percent of women reported that they had received a capsule in the two month period following the delivery of their last-born child. With regard to iron supplementation during pregnancy, more than half of women who gave birth during the five-year period before the 2005 CDHS reported that they had taken iron tablets or syrup during the pregnancy preceding their last live birth. Among women reporting that they took supplements, the majority said that they took the supplements for less than 60 days (CDHS, 2005).

Iodine Deficiency

The proportion o f households reporting use of iodized salt has increased from 12 percent in 2000 (DHS data) to 27 percent in 2004 (CSES data). The World Bank 2006 report notes however that the DHS estimates were based on salt that was tested, whereas the CSES estimates are self-reported. There are significant differences between socioeconomic strata: 12 percent of households in the poorest quintile report using iodized salt compared to 50 percent of richest quintile (WB, 2006).

Health, Hygiene and Care Practices

Diseases

Diarrhea

The CDHS reports that dehydration caused by severe diarrhea is a major cause of morbidity and mortality among young children, although the condition can be easily treated with oral rehydration therapy (ORT). Exposure to diarrhea causing agents is frequently related to the use of contaminated water and to unhygienic practices in food preparation and disposal of excreta. Overall, 19.5 percent of all children under five had diarrhea, while three percent had severe diarrhea with blood. The occurrence of diarrhea varies with the age of the child. As with acute respiratory infection (ARI) and fever, young children are more prone to diarrhea than older children. Diarrhea is slightly more common among rural children (20 percent) than urban (16 percent). There are provincial variations in the prevalence of diarrhea. Children living in Kampong Cham are more susceptible to an episode of diarrhea (30 percent) than children living elsewhere. Children surveyed in Krong Preah Sihanouk, Kaoh Kong and Svay Rieng provinces have the lowest prevalence (9 to 10 percent). Comparable data from 2000 CDHS show higher percentages of children that had diarrhea were taken to a health provider in 2005 than in 2000 (37 percent versus 22 percent, respectively).

Malaria

Malaria is a serious public health problem in Cambodia. In 2005, there were over 60,000 reported malaria cases. However, people are not at equal risk of contracting malaria. Some areas of the country are virtually malaria free, while others are malaria endemic. Thus, the country is divided into malaria risk zones, ranging from low to high risk (Table 4.1) and some areas of the country are not in the malaria zone at all.

Table 4.2 : Levels of Malaria Risk by Province

Source: National Institute of Public Health & Malaria Consortium, Cambodia. Cambodia National Malaria Baseline Report 2004

Acute Respiratory Infection (ARI) and Fevers

Acute Respiratory Infection (ARI) is a leading cause of childhood morbidity and mortality throughout the world. The prevalence of ARI is subject to seasonality. With the exception of those under six months of age, prevalence of ARI decreases with increasing age of the child. Children 6-23 months experience the symptoms of ARI (11 percent) in higher proportion than other age groups. There are significant provincial variations ranging from a low in Phnom Penh, Kampot and Krong Kep to a high in Otdar Mean Chey. Children of mothers with a high level of education are more likely to receive treatment for symptoms than those of mothers with low or no schooling.

Malaria and fevers can contribute to high levels of malnutrition and mortality. As with ARI, younger children are more commonly sick with fever than older children. There is no significant variation by sex and little notable difference in urban and rural areas. Provincial variations, however, are significant: the prevalence in Krong Preah Shihanouk and Kaoh Kong is low, but high in Kampong Spueu. The proportion of children for whom treatment was sought from a health facility or provider is highest in Takeo (69 percent) and Svay Rieng (65 percent) and lowest in Kampong Speu (25 percent) and Kampong Thom (28 percent). The highest use of antibiotic drugs to treat fever is in Kandal (28 percent) and Battambang/Krong Pailin (26 percent) provinces (CDHS, 2005).

Immunization

Universal immunization of children against six vaccine-preventable diseases is crucial to reducing infant and child mortality. The following data of the CDHS reflect the coverage for children aged 12-23 months in 2005. Sixty percent of these children were fully vaccinated, nearly twice the proportion of children (31 percent) vaccinated in 2000. Nearly all children (91 percent) received vaccination against tuberculosis (BCG), while 70 percent were vaccinated against measles. While there is no significant difference between children in rural and urban areas, there are substantial differences in coverage across provinces. The percentage of children fully vaccinated is the lowest in the provinces of Mondol Kiri and Rotanak Kiri (35 percent), Kampot and Krong Kep (41 percent) and Siem Reab (43 percent). The provinces with the highest proportion of children fully vaccinated are Bat Dambang/Krong and Pailin (82 percent), Kampong Spueu (81 percent) and Phom Penh (81 percent). The percent of children fully vaccinated increases substantially with maternal education levels and the wealth status of the household.

With regard to measles vaccination by province, the coverage ranges between 55.5 and 89 percent. In Mondul Kiri, Rotanak Kiri, Kampot and Krong Keb, less than 60 percent of children received measles vaccination, while nine provinces have coverage of above 80 percent. These nine provinces would be classified as low chronic food insecure in terms of measles, whereas the rest would be considered as high chronic food insecure.

Figure 4.7: trends in vaccination by 12 months of age (among children 12-23 months)

Maternal Health

Antenatal care has almost doubled since 2000. Sixty-nine percent of women who had a live birth in the five years preceding the survey received antenatal care, compared with only 38 percent in 2000. Antenatal care is more common in urban areas (79 percent) than in rural areas (68 percent). As mentioned above, while most women reported consuming vitamin A rich foods, only 27 percent received a vitamin A post-partum dose. Only 18 percent took iron tablets during the pregnancy.

The health care that a mother receives during pregnancy and at the time of delivery is important for the survival and well-being of both the mother and the child.

Source of Antenatal Care 

The CDHS 2005 survey states that more than two in three women received antenatal (ANC) from trained personnel (doctors, nurses, and midwives) at least once while one-fourth of the women received no antenatal care for births in the preceding five years. For women who had received ANC care; sixty-one percent received care from midwives, 6 percent from a doctor and 2 percent went to a nurse. The 2005 data shows a significant increase in antenatal care compared with the 2000 CDHS, when only 38 percent of women had received ANC care from a trained health professional. In 2000, more than half of women (55 percent) received no antenatal care. Younger women and women experiencing their first pregnancy are more likely to receive antenatal care from trained personnel, compared with older women. There are differences in the use of antenatal care services between urban and rural women. Health professionals provided antenatal care for 79 percent of mothers in urban areas as compared to 68 percent in rural areas. Additionally, in rural areas, 30 percent of women received no antenatal care at all, compared with 19 percent in urban areas.

Provincial differences in the source of antenatal care are significant: 92 percent of mothers in Svay Rieng received antenatal care from a health professional, compared with 28 percent of mothers in Mondol Kiri/Rattanak Kiri (CDHS 2005).

Tetanus Toxoid Vaccinations

Tetanus toxoid injections are given to women during pregnancy to prevent deaths fromneonatal tetanus. Neonatal tetanus can result when sterile procedures are not followed in cutting the umbilical cord after delivery. In the 2005 CDHS, information was collected on the number of doses of tetanus toxoid vaccine the mother received. According to the results, about two-thirds of last-born children (69 percent) during the five-year period before the survey were fully protected against neonatal tetanus. For more than half of births in the past five years (54 percent), the mother received two or more tetanus toxoid injections.

Fertility Rates

The UNDP 2005 report states that the total fertility rate has declined from 4.0 in 1998 to 3.3 in 2005 surpassing the MDG target of 3.8. According to this report the proportion of married women using modern birth spacing methods has increased significantly with 20.1% of married women accessed modern birth spacing methods via the public sector and a considerably higher percentage of women through social marketing systems and the private sector. This is a significant increase from 2000 when 18.5% of women accessed contraception from all sources combined, and only 11.5% accessed contraception from the public sector.

Access to Water and Sanitation

The CDHS 2005 states that “the types of water and sanitation facilities are important determinants of the health and nutrition status of the population and in particular of young children.” Adequate hygiene and sanitation practices can reduce the risk of major childhood diseases, such as diarrhea.

Cambodia is not short of water in terms of absolute availability, but potable water is scarce. In 2004 the proportion of people getting potable drinking water was approximately 44 percent (WB, 2007 / CIPS 2004 According to the CIPS 2004, only three provinces (Phnom Penh, Prey Veng and Svay Rieng) had a high level of access (more than 75 percent) to safe drinking water. While in three other provinces (Kaoh Kong, Kracheh and Krong Preah Sihanouk) access to safe water is above the national average (44.2 percent of all households). In all other provinces access to safe drinking water is below the average. Kampong Thom, Pursat, Kampot and Kep have the least availability of treated water. Though access to water is relatively low. There has been improvement over the last decade -- 44 per cent of households in Cambodia had access to safe drinking water in 2004 as against 29 per cent in 1998.

Table 4.3 gives the percentage distribution of households by main source of drinking water in 2004. Piped water, water from tube/pipe well and protected dug well, and water bought from market is considered safer than other sources of water. The increase in the proportion of households having access to safe drinking water during the six year period 1998-2004  has been primarily due to people shifting to piped water or tube/pipe well water instead of open well water. While on aggregate improvement has occurred since the last count in 1998, there is still considerable ground to cover. Also, more recent data is urgently required to give a realistic view of the current access and avaliabity of water in Cambodia.

Table 4.3: Households classified by main source of drinking water, Cambodia 2004

Source: CIPS 2004

Map 4.4: Proportion of population having access to potable drinking water, by province, 2004

Source: CIPS 2004/UNDP 2007

Sanitation

Access to an improved sanitation facility, like access to improved water sources, is very low for the country. A household’s toilet facility is considered as hygienic if it is used only by household members (is not shared by other households) and it effectively separates human waste from human contact (CDHS 2005). Households vary greatly in access to hygienic facilities from urban to rural areas. Most of the households in rural areas have no toilet facility and make use of field or bush areas. In urban areas, one of three households has no toilet facility. 

The 2005 UNDP update on Cambodia’s progress towards achieving the MDG states that access to improved sanitation amongst the rural population has increased to 16%, well ahead of the 2005 target of 12%. In the case of urban populations, access to improved sanitation is at 55%, close to but below the 2005 target of 59 %.

According to the CIPS 2004 reports however the access to an improved sanitation at the national level is 21 percent (an increase from 15% access in 1998). About 55 percent of households in urban areas have toilet facility in their homes in 2004 as against 49 per cent in 1998. In the rural areas it has nearly doubled from 8.6 per cent in 1998 to 16.4 percent in 2004 (CIPS 2004). Table 4.4 shows the distribution of households by toilet facility category. In the urban areas majority of households having toilet facility have them connected to sewerage while in rural areas septic tanks are used by nearly half the number of households (having toilet facility).

Table 4.4: Distribution of households by toilet facility category, Cambodia

Source: CIPS 2004

Access to Health Services

According to significant efforts of the Royal Government to improve delivery of basic health services, attendance at public health centres has risen from 0.38 to 0.42 for all age groups and from 0.54 to 0.74 for children below five years (World Bank, 2006) [1] . In 2004, 164 health centres were able to provide integrated management of childhood illnesses, compared to just 45 in 2002. Provision of vital micronutrients to children and pregnant women has also increased. Between 2002 and 2004, the percentage of pregnant women who receive at least two antenatal consultations from public health services has risen from 29 percent to 47 percent; deliveries attended by a trained public practitioner has increased from 20 percent to 32 percent. All 962 health centers and 70 referral hospitals provide the full DOTS program for TB patients (World Bank, 2006).

Table 4.7 shows that the poor find it hard to obtain access to quality healthcare. Less than 60 percent of the poor who are in need of health care use it, compared to 74 percent of the richest. This difference is not that marked in Phnom Penh. The poor appear to have the least access to health care in the coastal zone where only 36 percent of the poorest in need utilize health services, as compared to 67 percent of the richest (Table 4.8).

Table 4.7: Percentage of Persons Reported Ill or In Need of Health Care During The Past 4 Weeks Who Sought Care

Source: CSES 2004

Table 4.8: Percentage of Persons Reported Ill or In Need of Health Care During The Past 4 Weeks Who Sought Care

Source: CSES 2004

Access to health services depends on several factors: physical access (distance, condition of roads); ability to pay (for care and transport); knowledge and information about availability; personal beliefs and perceptions of need and quality of health care; and o f the functioning of referral systems.

Physical access is a significant issue, especially for hospital care. The two richest quintiles use hospital service five times more often than the poorest quintile (Table 4.9). The mean distance to the closest health center for the poorest quintile is 7.6 km and 16 km to referral hospital. This compares to 6 km (health center) and 9 km (hospital) for the richest quintile. In terms of health programs the World Bank 2006 poverty assessment reports that village leaders stated that only the immunization program is available for all segments of the population in their village. The Mother and Child Health (MCH) and family planning programs, HIV testing and iodine programs are all more readily available in communities where rich people reside and in communities closer to urban areas.

Table 4.9: Individuals in the richest quintile are five times more likely to use hospital services than individuals from the poorest two quintiles.

Source: CSES 2004

Cost barriers to access. Health care in Cambodia is relatively expensive. This is true of public health services as well as private care. Because the public health service is desperately under-funded, obtaining service requires high fees at the point of service. From the 2004 CSES, it is estimated that out-of-pocket payments (OOPS) for health care amount to US$15.48 per capita per year. However, this estimate is based on data collected only from individuals who were reported to have had an illness, injury or other health problem during the preceding four weeks and may therefore be under-estimated (WB, 2006). High-out-of-pocket expenditures on health and health services can force a vulnerable household into poverty by using up savings and scarce resources. Households may be forced to sell or mortgage productive assets (e.g. animals or land), or borrow from informal credit sources or simply be forced to cut expenditure (for example on tools, fuel to go to market, children’s education, etc).

Poor quality of care is another factor explaining low utilization of health care. Lack of drugs is the most commonly perceived problem with health services, with expense and distance also accounting for a large proportion of reported health service problems. For example, only 5 percent of the poorest quintile is served by a primary health center staffed with a doctor, compared to 25 percent of the richest quintile (WB, 2006). Similarly, the primary hospital for the poorest quintile had 13 midwives, compared to 18 in the richest. These indicators suggest that, in addition to physical access and financial barriers, the poor are also disadvantaged in terms of the quality of health care facilities that are available to them. The net effect of this is that the rural poor when confronted with potentially high medicals costs for what they perceive to be poor quality services will tend to rely on traditional healers rather than utilize hospital services.

HIV/AIDS

Cambodia has made significant progress in addressing the HIV/AIDS epidemic. The prevalence of HIV/AIDS among adults aged 15-49 has declined from 1.4 percent in 2002 to 0.9 percent in 2006 according to NCHADS Surveillance Data, 2007.

Cambodia is one of the few countries worldwide that has been successful in making anti- retroviral treatment available to AIDS patients and meeting the target set by the global “3 by 5” initiative” (World Bank, 2006).

The data reported in the 2005 UNDP progress report on MDG clearly depicts clear progress in combating the epidemic. The prevalence rate among adults aged 15-49 sharply declined from 3.0% in 1997 to 1.9% in 2005, surpassing the MDG target of 2.3% set for the year. Similarly the prevalence rate among pregnant women aged 15-24 visiting ANC centers had also declined to 2.1% in 2005 from 2.5% in 1998 ( ahead of the MDG target of 2.4%. Condom use by sex workers in 2005 was very near the target of 98%, a improvement from the 91% rate in 2002. The percentage of people receiving anti-retroviral combination therapy in 2005 was well above target at 45%, up from only 3% in 2002. Over 9000 people were receiving this treatment as at the third quarter of 2005.

However, there is concern that the epidemic is shifting. Husband-to-wife infection is now the major mode of transmission and one third of all new HIV infections are from mother to child. Increasing youth risk behavior and illicit drug use among youth and people in labor intensive activities could also become potential drivers of HIV infection (World Bank, 2006).

The 2004 CSES reports high overall knowledge of the disease (over 90 percent) among the population as a whole; however, the level of knowledge among youth is somewhat lower. Knowledge of HIV/AIDS and methods of prevention is lowest among the poor and among women in all consumption quintiles. As access to antiretroviral therapy increases in Cambodia, concerted effort on prevention activities should be maintained to help reduce the incidence of HIV transmission and mitigate the potential resurgence of risk behaviors because of risk compensation (World Bank, 2006).

Figure 4.8: HIV Prevalence among General Population Aged 15-49 Years

Source: NCHADS Surveillance Data 2007