Health trends
Health indicators show a decline in infant and under-five mortality rates between 1990 and 2000, but there was a slowing down of this trend in the second half of the 1990s, possibly due to an increase in post-neonatal mortality. In 2000, the infant mortality rate was estimated to be 95 deaths per 1000 live births and the under-five mortality rate 124 per 1000 live births. The Inter-Censal Survey in 2004 suggests a decline in child mortality rates to 66 per 1000 live births for infant mortality and 82 for under-fives, confirmation of which is awaited through the Cambodia Demographic and Health Survey (CDHS) 2005. Post-neonatal mortality is estimated at 58 per 1000 live births. The leading causes of deaths are neonatal conditions, including tetanus; acute respiratory infections, mainly pneumonia; and diarrhoeal diseases.
Malnutrition among women and children is a major health problem. Fifteen per cent of children less than six months of age have stunted growth, increasing to 53% of children aged three to five years. Twenty-one per cent of 15-49 year-old women are underweight. Widespread nutritional deficiencies among women represent the biggest risk factor for childhood mortality. Poor infant and child feeding practices, lack of access to health services and inappropriate health-seeking behaviour are other major contributing factors. Malaria and dengue fever pose a considerable burden of mortality and morbidity in certain remote geographical areas and during certain periods, with a malaria incidence rate (treated cases) of 752 per 100 000, with
404 malaria deaths, in 2004 (routine HIS 2004), and a dengue fever rate of 70.7 per 100 000 (2005).
Cambodia is ranked among the 22 high tuberculosis burden countries in the world. The National TB Prevalence Survey 2002 estimated incidence of smear-positive cases at 229/100 000. The case detection rate under DOTS was 64% in 2004, with the cure rate exceeding 90%. DOTS coverage reached 100% in 2005. A HIV sero-prevalence survey in 2005 among TB patients found one in ten is HIV-positive.
The prevalence of HIV infection among adults appears to have levelled off over the last few years to a rate of 1.9% in 2003. However this is still the highest reported prevalence in the Asia Pacific region. The Government has accelerated the decentralized implementation of continuum-of-care services, currently available in almost all operational districts, including more than 12 400 people living with HIV/AIDS receiving antiretroviral therapy, thus becoming one of the few countries worldwide to achieve the 3 x 5 target.
Limited access to skilled health workers is reported to be a significant factor in the high maternal mortality rate. The majority of deliveries are still attended by untrained birth attendants. Direct causes of maternal death include haemorrhage, eclampsia, sepsis and abortion; the indirect causes are related to poor access to emergency obstetric care. The proportion of women using modern birth spacing methods has increased significantly from 2000, when only 18.5% accessed contraception from all sources combined, to 21% of married women accessing modern spacing methods via the public sector and considerably more through social marketing systems and the private sector in 2004.
Cambodia has the highest rate of amputation due to landmine injury in the world. Currently, there are about 40 000 people with amputations in the population. However, since 1995, road traffic injuries have started to exceed those due to landmines. In 2002, the Department of Transport reported a fatality rate of 13 per 10 000 vehicles, one of the highest rates in ASEAN countries.
There are few data on the prevalence of mental illness in Cambodia. However, several small studies have shown high levels of depression among adults and behavioural problems among children and adolescents.
There are no official data available on the incidence of noncommunicable diseases. However, a diabetes survey in 2004 unexpectedly found a prevalence of 5% in a rural and 11% in a semi-urban setting. Tobacco use is one of the leading causes of preventable death, disease and disability in the world today. The national prevalence of smoking among men of 20 years and over is 54%. On average, Cambodian families spend similar amounts on tobacco as they do on health, and significantly more than on education, housing and clothing. Cambodia ratified the WHO Framework Convention on Tobacco Control in 2005. Increasing use of illicit drugs, especially by young people, sex workers and those in labour-intensive activities, are putting such people at risk of HIV/AIDS and other health problems.
Health systems
In the 1990s, the Government introduced health system reforms to improve and extend primary health care through the implementation of a district health system that focuses on the distribution of facilities in accordance with a health coverage plan and the allocation of financial resources to provinces. Operational districts are composed of 100 000 to 200 000 people, with a referral hospital providing a ‘comprehensive package of activities’ and health centres delivering primary health care to a target population of 10 000 through a ‘minimum package of activities’.
Government health expenditure has been increasing in recent years. In 1999, the approximate total government expenditure on health was US$ 2.85 per capita; that figure increased to
US$ 4.09 per capita in 2005. Overall, health sector financing absorbs approximately 10% of GDP, the highest percentage among developing countries in Asia. An estimated 70% of health sector financing is from out-of-pocket payments, representing approximately US$ 24 per capita, with donors paying approximately two-thirds of the remainder.