Maternal mortality in Cambodia remains quite high, although it has decreased from 900 death per 100,000 births in 1994 to approximately 170 today. POST PIX
On the 11th Anniversary of Cambodian Veterans on June 21 last year, Prime Minister Hun Sen announced a new programme of cash grants to poor pregnant women, which was implemented in June of this year.
The scheme is expected to cost $5 million in the first year and $7 million in the second. It is to increase to $10 million in the third.
Funds will be disbursed in three phases – during pregnancy, delivery, and after birth, for babies up to two years old.
In the first phase, destitute pregnant women will receive four dispersals of $10 whenever they have a pre-natal check-up. At the time of delivery, they will receive a $50 allowance.
Post-delivery, another $10 will be given, with a fourth grant following the completion of a postnatal checkup.
Lastly, the women could receive $10 up to six times, allocated when they take their newborn baby for vaccinations, until the infant reaches two years old. The total allocation per programme participant will be $190.
However, the scheme does not seem to cover all poor women since participation is limited to those who are in possession of a social welfare card, and only 72,000 women have been issued with them, according to the Social Affairs Ministry.
A report by the National Institute of Statistics and UN Population Fund (UNFPA) determined that the rural and urban poor, particularly women from the informal sector, are vulnerable to access to maternal health as they lack information about health services, or face structural barriers to access maternal health services.
The cash provision scheme should expand to those women in the informal sector – both rural poor and urban poor – so they can enjoy access to maternal health services, which play an important role in reducing the maternal mortality rate.
At the same time, the programme as it stands is unlikely to have significant impacts on maternal mortality rates.
The realities of maternal mortality in Cambodia were tragically illustrated by a February 2019 incident in Svay Rieng, in which a mother died due to severe bleeding after the delivery of her baby with only a midwife’s assistance, sparking public outcry.
According to the World Health Organisation (WHO) in 2014, 80 per cent of maternal deaths derive from severe bleeding, infections after birth, high blood pressure during pregnancy and unsafe abortions.
In light of these realities, while the programme is laudable as regards supporting the health of newborn children – its reach remains limited and it still does not address the primary causes of maternal mortality as set out by WHO.
Root and branch reforms
Maternal mortality in Cambodia remains quite high, although it has decreased from 900 deaths per 100,000 births in 1994 to approximately 170 today. In contrast, Thailand’s maternal mortality rate was 20 per 100,000 live births, while Vietnam’s was 54, according to the World Bank (2015).
Among Asean countries from the same statistics, Cambodia had the third highest mortality rate following Myanmar (178) and Laos (197).
Solely focusing on direct cash allocations will not significantly reduce the maternal mortality rate as the causality relating to the problem derives from weakness in the quality of healthcare services currently available, ie: poor health facilities, inadequate staff and lack of staff motivation.
In addition, geographical barriers, availability of health facilities, and affordability of transportation are all major obstacles – particularly for populations residing in remote areas.
To effectively reduce maternal mortality rates, the government should focus on fundamentally reforming the healthcare system root and branch.
Certain first steps in this area should be considered.
First, the health budget should be decentralised to the provincial level.
According to the Annual Health Financing Report (2012), 70 per cent of the health budget was allocated to the Ministry of Health and national hospitals, with only 30 per cent transferred to the provincial level.
Moreover, there are no clear statistics covering maternal mortality rate differences in rural and urban areas – the 2014 Demographic and Health Survey revealed that the fertility rate is higher in rural areas (2.9 children per woman) than urban areas (2.1 children per woman).
For this reason along with poor health facilities and a lack of medical staff, it is likely that the maternal mortality rate is higher in rural areas.
Moreover, the unequal distribution of workforce remains a challenge in rural areas.
Doctors are centralised in central and provincial health facilities, national hospitals and non-profit hospitals with weak service provision in rural locations.
Prime Minister Hun Sen acknowledged that there are not enough specialised doctors in rural areas, and has instructed the Ministry of Health to deploy more doctors to remote areas.
However, concrete policy in this area needs to be further strengthened to encourage medical staff to work in rural areas.
The Thai health system could serve as a model for encouraging medical staff to work at public health facilities in rural areas.
In order to cope with an external and internal brain drain, the Thai government created compulsory contracts that require fresh graduates to work in public health facilities for three years – otherwise they face steep fines.
Medical students who are instructed to deploy to remote areas receive additional salary and further opportunities for professional training.
Systems-level improvements
Cambodia should consider providing similar incentives for doctors who work in rural areas.
Besides decentralisation, there are efficiency gains to be made in health expenditure.
A World Bank Report stated that Cambodian health expenditure on drugs and medical supplies remains quite high as a share of overall spending.
The same report found that if drug and medical supply procurement was efficiently spent, it could generate savings of up to $50 million a year.
Thus, the government could allocate those savings on other health priorities such as increasing medical staff salaries and a renewed focus on maternal health services.
To reduce the maternal mortality rate, systems-level improvements will be more successful than direct cash payments to a small number of expectant mothers.
To make the scheme more effective, it should expand to women in the informal sector, especially the poor, so they can get universal assess for maternal health service.
When the government takes these steps, it will not be only the 72,000 women with welfare cards who reap the benefits, but all Cambodian women.
Tang Vouchnea is a Young Research Fellow at Future Forum, an independent public policy think tank based in Phnom Penh. She is currently conducting a research project on the feasibility of universal health coverage in Cambodia.
