Results are here separated into the quantitative and qualitative components. The discussion will analyse the main themes that emerged from both sections of the study.
Quantitative results
Socio-economic backgrounds
Of the 160 survey respondents (women with a child younger than five years), the mean age was 29 years and the mean size of household was 5.8 persons. Eighty-four per cent of the respondents were of Khmer ethnicity. Seventy-one per cent of the respondents identified themselves as “migrants”, and 29 per cent identified themselves as “mobile.” On average, the respondents have lived in their community for 7.6 years. Thirty-eight per cent of them moved to their current location from another area in Phnom Penh; 55 per cent came from other provinces. Key professions of the main income earners in each respondent’s family are construction (22 per cent), home or market selling (19 per cent) and motorcycle taxi driving (17 per cent). Other work includes carpentry and electrical repair (11 per cent), secretarial (8 per cent) and government jobs (7 per cent).
Only 57.5 per cent of the respondents had completed primary education. Given the low education levels, it is not surprising that the income levels in the families surveyed are also low. Sixty-two per cent of the respondents stated that the household income is between $1.25 and $5 per day. This contrasts with the last estimate of the Phnom Penh Municipal Government of the GDP per capita for Phnom Penh City was reported to be 820 USD in 2005[
22]. In the three months prior to the survey, the mean expenditure by households on health care was $66. Twenty-five per cent of the respondents’ households spent $100 or more.
Exacerbating the issue of high health care costs is the fact that only 14 per cent had a ‘poverty card’ or ‘insurance card’, which exempted them from fees for certain health care services.
In summary, income and education levels are low, and relative to income, health care costs are high with very limited levels of social protection.
Health service coverage and use
Immunization coverage in the poor communities is satisfactory. The third dose of diphtheria, pertussis and tetanus, and the hepatitis B vaccines was verified by immunization cards for 88 children of an eligible population of 139 (63 per cent). A further 41 children (29.5 per cent) had been vaccinated, according to the oral history from the mothers. Only 10 of 139 children (7 per cent) were reported by the mothers as not having been vaccinated. Sixty-one per cent of respondents had three or more antenatal care visits for their previous pregnancy. The majority of the mothers stated they received most of the recommended antenatal care services (tetanus vaccination, iron supplementation, advice on nutrition and danger signs). The vast majority of previous deliveries were facility-based, with the majority taking place in public hospitals (48 per cent) and health centres (31 per cent).
The private sector is the first choice for child curative care (50.3 per cent indicated this preference for the last child illness) and health centres/government hospitals are the first choice for preventive care (79 per cent reported the child received the last immunization at a government facility, and 66 per cent indicated that the last reproductive health consultation was received at government facilities). The primary reason provided by respondents for the selection of the provider for the last childhood illness was perceived quality of service (refer to section on qualitative findings for description of “quality”).
Overall, the household findings demonstrate reasonable coverage for health service access as measured by immunization and maternal health, with the private sector the preferred option for illness consultation, and the public sector for prevention services.
Qualitative study results
Results are organized according to the main themes that emerged from the FGDs. Table
2 summarizes the main qualitative research findings by theme area.
Table 2
Summary of qualitative findings and policy and practice implications
Social Structure
| Poor communities are complex in structure and do not rely solely on the administrative leadership for social cohesion or social action. Community members often identify more closely with community subgroups, community leaders, NGOs and even resident health private practitioners, and are primarily reliant on their own family and neighbours for assistance. This supports a case for a health promotion strategy to work locally with community subgroups and families and their networks rather than relying solely on the administrative organization and procedures. |
Social Insecurity
| There are many aspects of social insecurity in communities that impact on health and well-being. These include physical, income and health insecurity. This social context for health and well-being indicates that the primary determinants of poor health in these communities can best be understood in structural rather than behavioural terms. This supports a case for a more comprehensive social policy approach to address the structural factors rather than a reliance on health education strategies for individual behaviour change. |
Social isolation
| There are particular subgroups of the poorest families in the four communities that are particularly at high risk of social exclusion and social isolation – these include single mothers, young school-age children (but not attending school) and teenagers. Social programmes should target these most vulnerable groups to provide them with a minimum level of social opportunity for development and social protection. |
Social Protection
| Health workers assess the poverty status of their patients, and patients know they are being assessed for their capacity to pay. As a result, mistrustful relationships can develop between government health centre staff and community members. On the other hand, those people with exemption cards expressed confidence in attending health facilities. This makes the case for extending the health equity fund or related health protection schemes to increase the use of health care services by the very poor. |
Health Networks
| Informal networks are likely to be the most influential factor in determining health care-seeking behaviour. The quality and cost of health care services are routinely discussed among families, friends and neighbours. This being the case, the most powerful advertisement for improving health care and health care access is the quality, attitude and cost of services provided directly to the communities, enabling community members then to share this information through their local social networks. |
Health Markets
| There is no single unified health care system in the urban context. There is instead a health care market with a wide range of choice of provider and type of service, even for the urban poor. The poor are “shopping for health.” A better understanding of the dynamics of this health care market for the poor could guide policy makers towards improving mechanisms for quality health care and social protection. |
Health and social insecurity among the very poor
Many of the focus group participants expressed feelings of insecurity, which very much relates to their social context rather than individual behavioural constraints. Physical insecurity was expressed in terms of night-time disturbances, assaults and abuse of alcohol and drugs. But it was social and income insecurity that was the most predominant theme in the discussion of social context.
Social insecurity was expressed in terms of insecurity of land tenure. “We don’t know what will happen to us” and “we don’t know when we will have to move” were common statements from community members in two of the communities.
Income insecurity was often expressed in terms of irregularity of income of the main earners in households. Motorcycle taxi drivers, construction workers, hairdressers and markets sellers are all subject to the vagaries of the market place. For most income earners in society, variation in income can be managed through savings or borrowings. But for income earners of US$1–$2 per day, their family lives in a chronic state of insecurity – uncertain of the income that will come, especially for daily nutrition and education needs for children. This is especially the case when income is irregular.
The researchers found that in many cases, the income insecurity led to restrictions on food purchases and indications of under-nutrition. Notably, families will borrow or sell household items when they need to pay for health services, but the daily education costs are often deemed non-affordable. There were frequent reports of children dropping out from school or attending irregularly due to lack of family income.
Surprisingly, health insecurity was s not often expressed in terms of the inability to afford health care services. Rather, health insecurity predominantly referred to the poor access to water and sanitation, with the absence of any institutional mechanisms for waste management being a key preoccupation. Community members, local authorities and health workers consistently identified poor waste management, water supply and sanitation as the main threats to the health of families. Most childhood illnesses and even adult illnesses were attributed to uncleared rubbish, lack of toilets, standing water and mosquitoes. Sometimes the problems were attributed to personal and household behaviour, but more often, they were identified as community characteristics that people – even the local authorities – felt powerless to resolve. “The words of the poor are cheap,” explained one long-term resident.
Given these conditions, it is hardly surprising that there is a heightened sense of ‘living for the moment’. It is difficult to undertake or envision long-term community or household planning in this chronic state of daily insecurity and powerlessness. Frequently, the researchers heard community members say they are “living for the day”. One local authority member indicated that many community members do not even live for the day but live from “moment to moment” in order to cope with each day’s needs.
Social exclusion and isolation
Participants in both the in-depth interviews and focus group discussions talked of exclusion and social isolation, mostly related to the structural determinants of income capacity, education access and powerlessness previously noted.
Single mothers in particular are at high risk of exclusion due to absolute income poverty. In one case, a single mother was completely dependent on her neighbours for income and social contact. Because they dropped out of school, many young adults are exposed to risks of drug abuse and prostitution.
The researchers found limited examples of community activities or structured gathering locations for young people. In one community, an NGO was active in providing therapy for injecting-drug users, and in other communities, home care visits were conducted by an NGO supporting people who are HIV-positive. Overall, structured services or social activities are not in place for young people in the four communities.
The process of social exclusion starts very early. Repeatedly, community members highlighted the daily income demands of education as a major strain on family income and on social participation. In some cases, NGOs provide education programmes for young children within the community. In other cases, NGOs provide income support for children to attend schools. Local authorities try to help the children of poor families through the provision of a letter to the school teacher exempting them from paying school fees (as is the case with certain health care services).
The depth of social exclusion is perhaps expressed most clearly in Dam Slaeng where makeshift homes crowd around burial plots in the cemetery and children run between the tombstones. “The children are not afraid of the ghosts – the ghosts are afraid of the children,” one resident commented. In one abandoned building, six families had set up blanket partitions to serve as makeshift walls to separate sleeping areas. Some of the current residents in the community had only recently moved there due to newly impoverished circumstances. One woman said she had lived there since the early 1980s.
Social vulnerability and protection
The social vulnerability of the urban poor in these communities was expressed in both behavioural and structural terms. In terms of behavioural expression of vulnerability, community members reported that they are “looked at” by health staff to determine whether they had the capacity to pay, in order to decide who is treated first. “You have to have money. If you do not have money, they won’t pay much attention to us,” explained one resident. In all four communities, health centre staff indicated that they exempt the very poor from payment for certain health services. However, those health workers also indicated that in the absence of a poverty card or a letter of exemption from the local authority, they will look at the clothing or personal items of a patient to make an on-the-spot poverty assessment.
The absence of systematic social protection mechanisms increases the risk of a mistrustful relationship between health professionals and clients. This equally applies to the relationship between the education sector and community, with some people indicating that children are “afraid” of the teacher if they do not have enough money to pay for school expenses.
There were many examples of vulnerability determined by structural factors. The daily struggle to manage family food, education and health care costs with a low income was a consistent theme spoken of throughout this research.
According to one local authority official, “So if we think about it, health and education and food, they spend more on education – they have to spend on education every day…when they do go to school they often stop at level two or three…they just don’t have the capacity to send them to school.”
And one mother commented, “I have two children going to school, but one has had to stop…because we have no money for the teacher. Our family is spending more money than our income. We have no rice field or garden. For health care, we pay money every now and then, but for education you have to pay every day and for food we have to spend most of all.”
Families use various coping mechanisms for their day-to-day survival and basic needs. For health care, they typically sell household or personal property, borrow from a family member or neighbours, seek out NGO or pagoda support, or ask for assistance from the local authority (letter of poverty status to exempt them from certain fees). Health centre staff indicated that they do not ask the poorest of the poor to pay, but there were many cases in which people did not seek out health care, opting for exclusion or social restriction.
Demand and supply of health care services
Perception of quality of care was the main determinant from a client perspective for selection of provider (refer also to quantitative findings). From the community perspective, quality was often defined in terms of hygiene or technology, such as “the hospital is very clean” or “they have all the modern equipment”, or in terms of outcomes, such as “the medicine is very effective” or “the child gets better quickly”. The community members often cited the perceived skill of the provider as being critical when they were seeking health care. On the other hand, a provider with a poor attitude is viewed very dimly by clients. The poor attitude was interpreted mostly in terms of waiting longer because you are poor, being looked at judgmentally to see if you are poor or not, and impolite speech. All of these quality factors seem to influence people’s selection of provider.
What was apparent from the provider perspective was that, since the closure of outreach services in 2007 and the switch to a “fixed facility” approach (where services are only provided at the health centre and not in the community), there has become less clarity as to where the unreached populations are situated and what needs to be done to reach them. When marking hard-to-reach or slum areas on health centre catchment maps, the health centre workers demonstrated knowledge in locating them but they expressed less confidence in identifying pockets of non-immunized children. Comments, such as the following, indicated the health centre staff’s uncertainty of population coverage in high-risk areas:
"“We are not sure what is going on there now.”"
"“Funding for outreach has stopped so we cannot be sure where they are.”"
"“These places are confusing – people are coming and going all the time.”"
It was also not clear whether social mobilization and communication meetings were taking place regularly enough with local authorities and village volunteers. Even though a fixed-facility site strategy relies on population demand, funding is still required for health education and social mobilization in communities for the fixed facility strategy to work. Yet when asked to define their function in relation to health, local authorities saw their role more in terms of gathering statistics and social mobilization and less so in actually mobilizing resources for public health interventions.
In summary, as previously noted, although community members, health workers and local authorities consistently pinpointed social and economic conditions as the prime determinants of poor health, there was little evidence that health service systems are oriented to public health or on taking actions on the social determinants of health.