Ratanakiri Province in north-east Cambodia is home to seven indigenous ethnic groups living in scattered villages. While health service delivery has improved, villagers do not always exercise their right to access the services.
Cambodian mother and children in village
Hok Sochanda and Mong Vichet from Health Unlimited are taking a rights advocacy approach to improving public health.
Cambodia’s recent history of genocide, war and forced resettlement left Government services in a desperate state. Since 1990, when Health Unlimited began operating in Ratanakiri, work has concentrated on building infrastructure, providing health workers, and training health staff and communities on malaria, water and sanitation, nutrition, HIV and maternal health issues. Remoteness of villages and bad roads are still problems, but each district has a health centre and several health posts supported by a provincial referral hospital.
Despite improvements, indigenous people do not always use public clinics. Pregnant women are still at high risk. Traditional birth attendants – women from the local community, usually untrained, who will deliver a baby for a small fee – are still the main source of maternal care. Most pregnant women do not attend antenatal checkups and less than 20 per cent deliver at a health facility. They say this is because they are not aware that health is a Government role, medical staff discriminate against indigenous people, services are not culturally sensitive and there is a high cost, which often involves unofficial ‘fees’.
Service delivery is only part of the solution. People also need to understand their right to health care and how to exercise it: a rights-based approach.
There is an equity fund to cover the cost of medical treatment for marginalised people and poor families, but villagers seldom use it because they do not know they can. Salouy, a 16 year old Kreung girl, was abducted and forced into prostitution. Eventually she escaped and returned to her village and farm work with her parents. For a year she was unaware that she was living with HIV and received only traditional herbal treatment for other sexually transmitted infections (STI), because the family could not afford to send her to the health centre. When the local women’s association learnt of Salouy’s case, they told her she could get help to attend an STI clinic and HIV counselling and testing centre. With the help of the equity fund she has received STI treatment and is now arranging to have antiretroviral therapy (ART).
These services are not available in Ratanakiri – the nearest place is in Stung Treng, a four hour trip each way if the road is good – so advocating for a local ART service is a high priority for our team.
Our teams are conducting Participatory Action Research (PAR) on barriers to good health and specifically maternal health for indigenous communities. This qualitative data will help us to plan our project activity. We will also use it as a tool by showing the stories to decision makers, to demonstrate to them the real situation in the villages and what needs to be done. Early results from the PAR show that achieving good health means addressing all issues that affect health. In Cambodia, land issues and their effects on livelihood security have taken centre stage, but we must also look at poverty (in households and in public- spending), birth spacing and unsafe abortion, trade in fake medicines, ethnic discrimination, cultural practices, gender violence, lack of respect for women, and the role of traditional medicine and birth attendants.
Our baseline surveys and PAR also show that for the health system to reach villages, there must be participation by three groups: the health department, local governance structures and community members. If any of these are unaware of their rights and responsibilities, the system does not perform well.
For example, to avoid patients being charged illegal ‘user fees’ at clinics, we need health department managers who understand their responsibility to pay health staff on time without taking corrupt ‘commissions’; medical staff who understand client and provider rights; a community that understands their right to low cost health care; and a strong local body to monitor the system’s workings.
The Government has made positive steps by publishing a policy on health sector client and provider rights and by establishing Village Health Support Groups and a Health Centre Management Committee in each district to link villagers, medical staff and provincial government. For these initiatives to work, education and support are needed. Health Unlimited has begun Maternal Health Rights Advocacy (MHRA) and Indigenous People’s (IP) Rights projects alongside its traditional disease prevention interventions. These aim to improve access to existing resources through rights education, collecting and sharing information, and strengthening the linkages between the three key groups.
The MHRA team has selected Safe Motherhood volunteers who will form working groups in each commune (local district) with representatives up to provincial level. The IP Rights project has established a local advocacy organisation, Indigenous Peoples’ Health Action, as an independent representative body for the seven ethnic minorities.
These networks of volunteers and community leaders will provide a base for education programmes, to develop awareness of the rights to good health and safe motherhood, build communication skills, and to gather and disseminate information. They will then provide a platform for indigenous people to have their voices heard by decision-makers at local, provincial and national levels.
The rights-based approach is an exciting addition to the ‘vertical’ service delivery programmes, because it locks three important aspects into the process: effective community participation, an examination of the wider determinants of health and the promise of sustainable outcomes. NGOs have been helping to fill the gaps in the health service, but if we can get everyone to understand about health rights then we are on the way to making those gaps disappear forever.
Hok Sochanda is Team Leader of the Action Research to Advocacy maternal health rights project.
Mong Vichet is Director of Indigenous Peoples’ Health Action.
Tony Hobbs is an Australian Volunteer Management Trainer.
All work at Health Unlimited Ratanakiri Office in the Kingdom of Cambodia.
www.healthunlimited.org
Filed under: Rights to health
