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Cambodia HumanDevelopment Report

Societal Aspects of the HIV/AIDS Epidemic in CambodiaProgress Report, 2001

Prepared with the assistance of

KINGDOM of CAMBODIANATION - RELIGION - KING

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It gives me great pleasure to introduce the Cambodia Human Develop-ment Report 2001, which is the fifth in a series of national Human DevelopmentReports published in Cambodia. More than 100 countries throughout the worldhave published national Human Development Reports. These reports have beenimportant tools for the promotion of the cause of human development and a people-centred approach to national policy making. Each of the four previous CambodiaHuman Development Reports has been very well-received by governmentagencies, NGOs, international donors and civil society groups. They have alsoattracted considerable media attention. More importantly, they have providedinformation that is useful for planning and programming purposes to manydevelopment organisations working in the field.

This report is the first Cambodia Human Development Report to be pro-duced within a new capacity building strategy. It was prepared by the newly formedNational Research Team with technical cooperation, and ensured full ownershipof each stage of production. This is an important step towards national autonomyin production and full ownership of the Cambodia Human Development Reports.

Cambodia Human Development Report 2001 focuses on the HIV/AIDSepidemic in Cambodia. Such a research effort will spread over a period of twoyears. This year’s progress report documents the reciprocal relationship betweenthe HIV/AIDS epidemic and human development in Cambodia. The Royal Gov-ernment of Cambodia responded rapidly to the emerging epidemic in Cambodia,and evidence suggests that the HIV prevalence rate may now be stabilising.Nevertheless, Cambodia has the most serious epidemic in the region and its impactis now being felt throughout the country. For this reason, it was important for theCambodia Human Development Report 2001 to focus on understanding themain determinants contributing to the epidemic in Cambodia.

The report details how widespread poverty in Cambodia provides fertileground for the spread of the epidemic and how the epidemic, in turn, underminesefforts to alleviate poverty.

The report highlights the key concept of vulnerability and identifies essen-tial features of present-day Cambodian society that feed this vulnerability. Thus,the report is an important tool for policy and programme design. I would like toadd my support to the report’s recommendation that a people-centred approachis essential in order to build on the achievements of the Cambodian response tothe epidemic so far and to move this response to the next stage.

The Cambodia Human Development Report 2001 is the outcome of anationally executed project funded by UNDP and executed by the Ministry ofPlanning with the technical cooperation of the Cambodia Development ResourceInstitute. This report makes extensive use of the quantitative surveys undertakenby the National Institute of Statistics, Ministry of Planning: particularly, the 1998population census and the Cambodian socio-economic survey 1999, which were

Foreword

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Cambodia Human Development Report 2001

Phnom PenhJune 2002

Chhay ThanMinister of Planning

Royal Government of Cambodia

undertaken by the National Institute under the auspices of the Ministry of Plan-ning. The report also makes extensive use of the HIV sentinel surveillance surveysand behavioural surveillance survey undertaken by NCHADS, Ministry of Healthwith support from FHI, WHO, UNICEF, French Cooperation and the Cambo-dia Disease Control and Health Development Project.

I would like to acknowledge the assistance of several agencies and indi-viduals in bringing out the Cambodia Human Development Report 2001. Firstand foremost, the Ministry of Planning would like to thank UNDP for its manycontributions including mobilizing technical inputs and funding for producing thereport. Ms. Dominique Aït Ouyahia-McAdams, Resident Representative ofUNDP-Cambodia, has been very supportive and encouraging of this new capacitybuilding phase of the Cambodia Human Development Report 2001.

Second, I would like to acknowledge the Cambodia Development Re-source Institute for providing technical cooperation and an appropriate academicand research-focused environment which enabled the development of profes-sional skills among the National Research Team. Particular thanks are due to theDirector of Research for the Cambodia Human Development Report 2001who facilitated this process, Dr. Claude Katz, and to Ms. Eva Mysliwiec and DrSarthi Acharya for their technical cooperation. The members of the NationalResearch Team are: Ms. Khiev Bory, Mr. Maun Sarath and Mr. Chea Chantum(Ministry of Planning), Dr Lim Kalay (National AIDS Authority), Dr. Ly Penh Sun(National Centre for HIV/AIDS, Dermatology and STDs), Mr. Prum Virak, Mr.Deup Channarith, Mr. Long Yav and Mr Rath Sethik (Centre for Population Studies,Royal University of Phnom Penh). Assistance to the team was also provided byMs. Tep Saravy at CDRI. The report was edited by Ms. Alexandra Maclean.

Third, I would like to thank the technical advisory group established bythe Ministry of Planning for the Cambodia Human Development Report 2001,comprising of: Ms. Mom Thany (Child Rights Foundation), Ms. Khieu SereyVutha (Ministry of Women and Veteran’s Affairs), General Meas Sakon (Ministryof Interior), Mr. Lim Kalay and Dr. Tia Phalla (National AIDS Authority), Mr.Veng Bun Lay (Ministry of Defence), HE Kim Saysamalen (Ministry of Planning),Mr. David Salter and Mr. Gunner Walzholz (ILO), Mr. Geoff Manthey (UNAIDS),Mr Sar Nak (Ministry of Education, Youth and Sports), Dr. Yath Yathy (Ministryof Health), Mr. Chea Chantum (Ministry of Planning), Mr. Chea Samnang (Min-istry of Rural Development), Mr. James D’Ercole (UNFPA), Ms. Aye Aye Twin(WHO), Ms. Ingrid Cyimana (UNDP), and Ms. Heang Siek Ly (Ministry ofPlanning). The technical advisory group provided very useful guidance to us inensuring that the report reflects the various concerns and sectors of Cambodiansociety.

I am confident that this year’s progress report will contribute to the nationaldebate and dialogue about the HIV/AIDS epidemic in Cambodia, informing stra-tegic direction and policy and programming decisions.

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Foreword

Cambodia faces an AIDS epidemic that potentially could reverse thedevelopment gains made since peace returned to the country. It is estimated that2.8% of the adult population is infected with HIV, among the highest in Asia; thatmany tens of thousands have already died as a result; and that possibly two hundredthousand people including children will develop AIDS within the next 5-10 years.

The efforts of the Royal Government of Cambodia to achieve effectiveresponse to the HIV/AIDS crisis, including its efforts to achieve the MillenniumDevelopment Goal on HIV/AIDS – to halt and reverse the spread of HIV/AIDSby 2015 – are tremendous. Indeed, the leadership and broad partnership stancethat the RGC has adopted in addressing the HIV/AIDS epidemic by steeringreforms as outlined in the “National Strategic Framework for a Comprehensiveand Multi-Sectoral Response to HIV/AIDS, 2001-2005”is already yielding valuableresults. Of great encouragement for this concerted response are the indications ofa reduction in the HIV/AIDS prevalence rate. In the context of such a broadpartnership on HIV/AIDS, the United Nations Country Team (UNCT) in Cambodiais working to significantly enhance its support to the national response againstHIV/AIDS on the basis of the UNDAF (2001-2005). In doing so, the UNCThas developed a Common Strategy that clearly sets out the future emphasis of theTeam both collectively and individually.

In line with the above, the CHDR has opted to focus on addressing keyhuman development challenges in relation to HIV/AIDS. Such a research effortwill spread over a period of two years. This year’s Progress Report on the “SocietalAspects of the HIV/AIDS Epidemic in Cambodia” sets a framework that outlinesthe fact that HIV/AIDS deepens the poverty of households and nation, whilepoverty favours the spread of the disease by increasing the vulnerability of individualsto infection.

In acknowledging the complex links between the HIV/AIDS epidemic,Poverty and Human Development, the initial research work provides critical analysisto the effect that the HIV/AIDS epidemic is a development issue, striking as itdoes at the social welfare of the population of an already fragile Cambodian society.One of the key message of the Report is the importance of building on achievementsto-date and the adoption of a broad people-centred approach, by giving voice tothe people living with HIV/AIDS, ensuring respect for the rights of people withHIV/AIDS through improved knowledge on the disease, and addressing socialinequity in order to ensure effective participation and mobilization of all socialgroups.

In this regard, I wish to congratulate the National Research Team for theiroutstanding work in preparation of this year’s Progress Report. It is indeed importantto note that the responsibility to prepare the Progress Report was entirely a nationaleffort, with four institutions involved in the research work. These institutions arethe Ministry of Planning, the Royal University of Phnom Penh, the National AIDSAuthority, and the National Centre for HIV/AIDS, Dermatology and STDs. Theoverall coordination for advisory and support services was provided by a national

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research institute, the Cambodia Development Resource Institute (CDRI). Thisnew partnership arrangement is designed to achieve two key objectives. First, itaims at strengthening national ownership on the outcomes of the key findings andpolicy recommendations of the CHDR(s), by allowing for an in-country anddemand-driven research effort. Second, it seeks to adopt an alternative capacitydevelopment strategy capable of providing a more sustainable capacity in theMinistry of Planning, other line ministries and government institutions in relation topolicy analysis and research methods.

I trust that the analysis and recommendations of this Progress Report willcontribute to further support a broad-based national debate on the challenges ofHIV/AIDS, including setting the stage to finalize the Report on HIV/AIDS throughadditional research work aimed at further shaping public policy direction, resourceallocation, priority setting and targeted interventions.

Dominique Aït Ouyahia-McAdamsUnited Nations

Development ProgrammeResident Representative

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The 2001 CHDR has many origi-nal features. First, it is oriented towardkeeping national capacity building as aprime concern. This is, indeed, the firstconcrete step to realising the objectivespromoted by the first CHDR: to seethat the HDR is “transferred fully intoCambodian hands”1 . The 2001 reportwas prepared and produced jointly bya national research team and a seniorresearch advisor, under the technicalassistance of a private Cambodian re-search institution, the Cambodian De-velopment Resource Institute.

The 2001 CHDR is also uniquebecause of the specific circumstancesin Cambodia. In addition to seriousconcerns born from the HIV/AIDSepidemic as a major threat for the hu-man development process in all coun-tries, the HIV/AIDS epidemic in Cam-bodia deserves particular attention.Cambodia is one of the poorest coun-tries in Southeast Asia, and the coun-try with the highest HIV prevalencerate, but it seems to have curbed itsepidemic rate. From 1997 onwards, theseries of national prevalence ratesamong adults, as estimated through theHIV Surveillance Surveys, shows asteady decline, from 3.9% to 2.8%.

At the same time, analysing thebackground of human poverty raisesfundamental concerns about the future.The human development perspectivepoints out the structural link betweensocietal balances and the sustainablecapability of a society to respond tosocial threats. Cambodia has one of thepoorest human development perform-ances in the region, its HDI score

(0.541) ranks Cambodia 121st inter-nationally, and the worst but one inSoutheast Asia. Cambodian society ischaracterised by entrenched inequal-ity, in many essential dimensions, suchas income poverty (the consumptionshare of the poorest 10% of the popu-lation being as low as 4%, while therichest 10% share 20%), gender sta-tus and access to education. Markedregional differences within the countryenhance these inequalities.

The aim of the 2001 CHDR is tostudy these diverging aspects charac-teristic of the Cambodian case, and tocontribute, through an effective humandevelopment perspective, to outliningthe ways towards controlling the epi-demic.

Chapter 1 elaborates on the contri-bution of the human development per-spective to an understanding of thespreading of the HIV/AIDS epidemic.The key concept of social vulnerabilitygoes beyond pointing out ‘risk groups’in order to highlight, through a betterunderstanding of sex as a social issue,the circumstances pregnant with op-portunities for the epidemic to spread.Meanwhile, it provides all actors in-volved in the struggle against HIV/AIDS with an effective framework toaddress both immediate and structuraldeterminants of the epidemic.

Chapter 1 then retraces the Cam-bodian situation in relation to the HIV/AIDS epidemic. Particular care hasbeen taken to list the assumptionsneeded to provide estimates: taking intoaccount the level of confidence of aquantitative assessment is needed in

Executive summary

1 Paul Matthews, former UNDP representative, CHDR-1997

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order to accurately interpret trends. Thelarge range of dispersion across prov-inces for all groups surveyed points tothe need for precaution when drawingnational results. Conversely, consistentdeclining trends for most of the groupssurveyed, and indicators drawn fromBehavioural Surveillance Surveys, suchas rising consistent condom use, sup-port the conclusion of a declining preva-lence in the general population.

Chapter 2 reviews the aspects ofCambodian society whose links to theHIV/AIDS epidemic are expected tobe particularly active in the previouslyelaborated framework. The analysistakes into account the specific featuresof the Cambodian population. It firststudies the impact of the epidemic onhuman development achievements.From the household and individual view-point, three main issues typify the mainconsequences of the epidemic. The firstis the impoverishment of the household,in particular through the distressed saleof productive assets. This calls forpublic intervention to enable householdsto avoid the distressed sale ofproductive assets, and also to addressthe difficult question of the cost of healthcare. The second issue is thevulnerability of children, due, in particu-lar, to being orphaned by AIDS. Thisrequires a sufficient input of resourcesto provide support for children affectedby AIDS. It also calls for an open de-bate on the urgent issue of the avail-ability of Anti-RetroviralTherapy(ART), the only means to pre-vent HIV infection leading to AIDS andtherefore to death. The provision ofART is examined in the following sec-tion, which deals with the setbacks inhuman rights achievements, the thirdmain consequences of the epidemicaccording to the present analysis. Fi-nally, although there was no new quan-titative assessment of the HIV/AIDSimpact at national level, a previous studyfrom Bunna and Myers has been used

to point out the hypothesis needed forsuch an assessment and the order ofmagnitude of the results derived.

The main contribution of the Hu-man Development perspective to thestudy of the spread of the HIV/AIDSepidemic and to aid the design of ef-fective responses, is to highlight thestructural features in a society whichprovide the best opportunities for thisepidemic. Four such features in Cam-bodian society are underlined, only twoare examined due to time constraints.The first is the marked gender inequal-ity. The strict division of roles and theseparate and distinct lifestyles of malesand females from a very young ageprovide, among other aspects, a fer-tile ground for the epidemic. The sec-ond feature is the weakness of the pub-lic sector, which deprives the societyof the means to act upon itself. The lasttwo of these features, the issue of mo-bility and migration, and the way inwhich human poverty renders the poorunable to claim their rights, are onlybriefly mentioned. It is to be hoped thata specific in-depth study can be un-dertaken for each. Both features, to-gether with calling for specific interven-tion, also indicate that the challenge ofgovernance will play a key role in scal-ing up the response to the epidemic.

Chapter 3 reviews the main fea-tures of the response to the epidemicso far, a response which testifies to astrong will at government level to es-tablish an effective HIV/AIDS taskforce as early as possible. The ‘Na-tional Strategic framework for a com-prehensive and multi-sectoral responseto HIV/AIDS’ has been produced forthe 2001-2005 period, it draws on theimprovements made in the national re-sponse during the last ten years. Amajor feature of the Cambodianachievement is the successful partner-ship between the national structures,the United Nation system, and the net-work of local and international NGOs.

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The major result that the prevalencehas possibly been curbed relies clearlyupon the development of an impres-sive level of awareness in the popula-tion (the 2000 Demographic andHealth survey found that more than70% of the sampled women knew ofways to prevent infection from HIV),and upon a firm campaign for safecommercial sex. Numerous and vari-ous actions have been undertaken tocare for and support people affectedby HIV/AIDS.

Cambodia is now facing the chal-lenge of scaling up previous achieve-ments in a context marked by signifi-cant disparities and possibly character-ised by multiple epidemic stages, and

weak public means of action. The keymessage of the report is that, given thepresent situation, one of the best meansof ensuring an effective and holistic re-sponse is to adopt a people-centredapproach. It would make possible thecreation of a link between local initia-tives and the sharing of informationbetween these. Such cooperation willprove invaluable in informing, influenc-ing and strengthening the response tothe epidemic at national level.

The readers will find in the conclu-sion of the report recommendationsbased on the analysis presented. Theserecommendations are offered as acontribution to the necessity ofcontinued, coordinated and concertedaction.

Executive summary

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AIDS Acquired immune deficiency syndrome

APN+ Asia Pacific Network of people living with HIV and AIDS

ART Anti-retroviral Therapy

BSS Behavioural Surveillance Survey

CBO Community-based organisation

CDRI Cambodia Development Resource Institute

CHDR Cambodia Human Development Report

CPN+ Cambodia Network of people living with HIV and AIDS

CPS Centre for Population Studies

DHS Demographic and Health Survey

GDP Gross Domestic Product

HDI Human Development Index

HIV Human immunodeficiency virus

HSS HIV Surveillance Survey

MoP Ministry of Planning

NAA National AIDS Authority

NCHADS National Centre for HIV/AIDS, Dermatology and STDs

NGO Non-governmental organisation

NIS National Institute of Statistics

RUPP Royal University of Phnom Penh

SEA-HIV South East Asia HIV and Development Project

SES Socio-economic survey

STD Sexually transmitted disease

UN United Nations

UNAIDS Joint United Nations Programme on HIV/AIDS

UNCT United Nations Country Team

UNDP United Nations Development Programme

UNICEF United Nations Children’s Fund

VCT Voluntary counselling and testing

WHO World Health Organisation

List of Abbreviations

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Table of Contents

Introduction .......................................................................................................................... p.17

a) Human Development: a global effort towards fundamental human rights ........... p.17b) Cambodian strategy for Human Development Reports:

towards national ownership ..................................................................................... p.18c) The HIV/AIDS epidemic in Cambodia: between hope that the current response to the epidemic may have curbed its spread, and major concerns emerging from the present social situation ................................................................................... p.19d) The Human development situation in Cambodia ................................................... p.24 i Persistent widespread poverty ..................................................................................... p.27 ii Encouraging schooling rates marked by spatial and gender inequality ............................ p.29 iii The overall poor health status with sharp local distinctions ............................................ p.31

1. Human development facing HIV/AIDS epidemic: conceptual framework and the Cambodian epidemic situation ....................................................................... p.33

1.1. From the perspective of individual behaviour to the concept of vulnerability: the societal approach.............................................................................................. p.33

1.1.1. Sex is a social issue ............................................................................................. p.331.1.2. Risk and context ................................................................................................. p.34

1.2. Conceptual framework ............................................................................................ p.351.3. Human rights implications of HIV/AIDS ................................................................ p.381.4. The HIV/AIDS epidemic in the Cambodian context: knowledge and lack of knowledge ............................................................................................................... p.39

1.4.1. Prevalence rate estimation: HIV Surveillance Surveys .......................................... p.391.4.2. Behavioural Surveillance Surveys ........................................................................ p.441.4.3. On a knife’s edge between success and threat ..................................................... p.47

2. The Human Development perspective and the dynamic of the HIV/AIDS in Cambodia ................................................................................................................ p.49

2.1. Introduction: Link between HIV/AIDS epidemic and demographic features ....... p.492.2. The HIV/AIDS epidemic threatens human development achievements in Cambodia ................................................................................................................ p.51

2.2.1. The crucial issue of the distressed sale of productive assets .................................. p.512.2.2. AIDS deaths and the vulnerability of children ....................................................... p.542.2.3. Setbacks in human rights achievements ................................................................ p.562.2.4. An example of assessing the national impact of the HIV/AIDS epidemic ............... p.58

2.3. Poverty in Cambodia fuels the HIV/AIDS epidemic .............................................. p.602.3.1. Gender inequality feeds HIV/AIDS epidemic ....................................................... p.60

• Strict division of roles between men and women inside society and inside the family .. p.60• Parallel life education .............................................................................................. p.60

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2.3.2. Poverty and low human development deprive society from the ability to act upon itself. .............................................................................................. p.61

• Social link, public sector and governance issue ........................................................ p.61• The case of the health sector ................................................................................... p.61• The two aspects of the infrastructure issue ............................................................... p.64

2.3.3. Poverty fuels mobility and migration ..................................................................... p.652.3.4. Poverty disempowers the poor from claiming their rights ...................................... p.66

2.4. Conclusion ................................................................................................................ p.66

3. Achievements and Challenges .................................................................................... p.69

3.1. Governmental and public sector involvement ........................................................ p.693.1.1. The HIV/AIDS task force ................................................................................... p.693.1.2. The ‘National Strategic Framework for a Comprehensive and Multi-Sectoral Response to HIV/AIDS, 2001-2005’ developed by the National AIDS Authority ............................................................................ p.71

3.2. Successful partnerships ........................................................................................... p.723.2.1. The United Nation Country Team (UNCT) ......................................................... p.723.2.2. Local and international NGOs ............................................................................. p.73

3.3. Achievements ........................................................................................................... p.743.3.1. Impressive level of awareness ............................................................................. p.753.3.2. Resolute campaign for safer commercial sex ........................................................ p.753.3.3. Care and support for people with AIDS .............................................................. p.76

3.4. Challenges ................................................................................................................ p.773.4.1. The heterogeneous nature of the epidemic in Cambodia ....................................... p.773.4.2. A people-centred approach ................................................................................ p.77

• Giving voice to people. ........................................................................................... p.78• Ensuring respect for the rights of people with HIV/AIDS through improved knowledge of HIV/ AIDS. ..................................................................................... p.78• Addressing social inequity in order to mobilise all social groups effectively ................ p.81

3.5. Summary: Breaking the vicious cycle .................................................................... p.82

4. Conclusion ..................................................................................................................... p.85

• Towards a new stage in the response to the epidemic .............................................. p.85• Action on HIV incidence: ....................................................................................... p.86• Action on the impact of the epidemic: ..................................................................... p.88

List of Annexes

Annex A: Capacity building for national ownership on Human Development perspective ........... p.91Annex B: Large surveys in Cambodia: a wealth of invaluable quantitative data .......................... p.92Annnex C: Measuring poverty ................................................................................................. p.93Annex D: Poverty temporal comparison issues ......................................................................... p.99Annex E: Fieldwork methodology ........................................................................................... p.102

References ........................................................................................................................... p.107

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List of illustrations

BoxesBox 1: Proposal for further investigation on declining HIV seroprevalence rate in Cambodia ... p.23Box 2: Human Development Index calculation ....................................................................... p.24Box 3: Human rights and human development ....................................................................... p.38Box 4: Estimates of prevalence rates are inherently fragile data .............................................. p.41Box 5: HIV/AIDS and the vulnerability of children ................................................................ p.55Box 6: The salary issue ......................................................................................................... p.64Box 7: The provincial HIV/AIDS taskforce ........................................................................... p.70Box 8: Phnom Penh hospital services for people with HIV/AIDS ........................................... p.71Box 9: The 100 percent condom use campaign ..................................................................... p.75Box 10: An example of grassroots action in response to the epidemic .................................... p.76Box 11: Cambodian Network of People Living with HIV ...................................................... p.79Box 12: Rights and responsibilities of people with HIV/AIDS ................................................ p.79Box 13: Poverty is a multidimensional concept ...................................................................... p.94Box 14: The food poverty line .............................................................................................. p.95Box 15: Total poverty line ..................................................................................................... p.96

FiguresFigure 1: The HIV Surveillance Surveys show a decrease in prevalence ................................. p.22Figure 2: Human Development Index in South-East Asia ....................................................... p.25Figure 3: PPP GDP per capita plotted against HDI, South-East ........................................... p.26Figure 4: Urban/rural disaggregation of HDI .......................................................................... p.26Figure 5: Cambodian poverty lines ........................................................................................ p.28Figure 6: Distribution of literacy rates among provinces, by sex and age groups ..................... p.30Figure 7: Gender inequality in schooling enrolments ............................................................... p.31Figure 8 : HIV seroprevalence among sentinel groups in 2000 ............................................... p.42Figure 9: HIV prevalence in high risk groups decreases ....................................................... p.43Figure 10: Improvement in consistent condom use ................................................................. p.46Figure 11: Evolution in commercial sex use ............................................................................ p.46Figure 12: The number of persons living with HIV/AIDS decreases ....................................... p.47Figure 13: percentage of each surveillance group knowing someone sick with AIDS ............... p.48Figure 14: Cambodian population structure (1998 census) ..................................................... p.50Figure 15: Age and Sex Imbalance ........................................................................................ p.50Figure 16: Lorenz curve for the consumption distribution by households (SES 1999) .............. p.51Figure 17: mean expenditure (in US dollars) for a first treatment ............................................ p.54Figure 18: Epimodel projection for cumulative number of AIDS deaths .................................. p.54Figure 19: Gender differential in school drop out (population census 1998 data) ..................... p.60Figure 20 : Knowledge of AIDS ........................................................................................... p.74

TablesTable 1: Global summary of the HIV/AIDS epidemic, December 2000 .................................. p.20Table 2: Regional HIV/AIDS statistics, end of 2000 .............................................................. p.21Table 3: Consumption profile ................................................................................................ p.27Table 4: Head-count indices ................................................................................................. p.28Table 5: Poverty gap indices ................................................................................................. p.29

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Table 6: Summary of schooling rates, by age and sex ............................................................. p.30Table 7: life expectancy in South East Asia ............................................................................ p.31Table 8: Sentinel groups ........................................................................................................ p.40Table 9: Range of HIV prevalences in different provinces ..................................................... p.43Table 10: Quantitative summary of consumption distribution by household .............................. p.52Table 11: Estimation of 1999 HIV/AIDS epidemic cost ......................................................... p.59Table 12: Key milestones in the government response to the HIV/AIDS epidemic .................. p.69Table 13: Key characteristics of the socio-economic survey in Cambodia .............................. p.93

Maps

Map 1: Distribution quintiles of infant mortality rate by province (NIS PopMap software) ...... p.32Map 2: Percentage of persons declaring a previous residence less than 6 years ago ................ p.65

Diagrams

Diagram 1: Construction of the HDI ...................................................................................... p.25Diagram 2: The HIV/AIDS epidemic is a human development issue ....................................... p.35Diagram 3: Links between human development and HIV/AIDS: individual perspective ........... p.36Diagram 4: Links between human development and HIV/AIDS: the national perspective ........ p.37Diagram 5: Mechanisms by which people become landless .................................................... p.53Diagram 6: Breaking the vicious cycle ................................................................................... p.82

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This introduction provides an over-view of previous Cambodia HumanDevelopment Reports and explains thekey principles on which the present re-port is based. The 2001-CambodiaHuman Development Report differssignificantly from the previous CHDR.It is for this reason that this first part ofthe report also sets out the reasons forbringing in new features in the 2001CHDR. It then explains that the 2001topic was selected in response to seri-ous and widespread concerns about theHIV/AIDS epidemic as a major threatto the human development process inall countries. Moreover, the HIV/AIDSepidemic in Cambodia deserves par-ticular attention because of its unique-ness. An early and resolute response,relying particularly on effective partner-ships at the national level between gov-ernmental, non-governmental, andUnited Nations structures, has resultedin a genuine hope with regard to curb-ing the prevalence of HIV. But at thesame time, the low performance levelof crucial aspects of human develop-ment threatens to undermine theachievements already made. It is in lightof this situation, that the human devel-opment situation in Cambodia is re-viewed in order to highlight the contextin which specific aspects of human de-velopment, and in particular the HIV/AIDS epidemic issue, are being ad-dressed.

a) Human Development: a glo-bal effort towards fundamental hu-man rights

The concept of development is of-ten understood in terms of economics:a developed country is characterised bya flourishing economy, leading to a highaverage standard of living based onsufficiently large GDP per capita. For

more than 10 years, UNDP has beenadvocating that development is a multi-dimensional concept encompassing farmore than economic wellbeing at thenational level. To this end, the conceptof human development has regularlyimproved. As the most recent GlobalHuman Development Report (UNDP2001a) states,

Human development is aboutmuch more than the rise or fall ofnational incomes. It is about creat-ing an environment in which peoplecan develop their full potential andlead productive, creative lives in ac-cord with their needs and interests.People are the real wealth of na-tions. Development is thus about ex-panding the choices people have tolead lives that they value. And it isthus about much more than eco-nomic growth, which is only a means– if a very important one – of en-larging people’s choices.

The most basic human needs arefood and water. Of the 4.6 billion peo-ple living in developing countries, about1.2 billion (one in four) live on less thanUS$1 a day and nearly one billion peo-ple have no access to safe watersources. However, protection againstcommunicable diseases for parents andchildren, education, and meaningfulcitizenship are also fundamental humanrights (UNDP 2001a):

Fundamental to enlarging thesechoices is building human capabili-ties – the range of things that peo-ple can do or be in life. The mostbasic capabilities for human devel-opment are to lead long and healthylives, to be knowledgeable, to haveaccess to the resources needed for adecent standard of living and to beable to participate in the life of thecommunity. Without these, many

Introduction

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choices are simply not available, andmany opportunities in life remain in-accessible.

Health, education and participationin the life of the community must there-fore be taken into account together withthe standard of living in order to assessa country’s developmental level. Thisconcept of development – of humandevelopment – is closely related to theconcept of human rights. Both share theobjective of human freedom and bothface the challenge of poverty.

While UNDP has been publishingthe Human Development Report(HDR) annually since 1990 to reviewthe state of human development aroundthe world, we have begun to see anumber of countries producing nationalHDRs since 1995. These nationalHDRs have focused on trends in hu-man development and poverty withina country, and highlighted intra-nationaldisparities in human developmentacross regions, economic groups, andgender.

b) Cambodian strategy for Hu-man Development Reports: to-wards national ownership

The UNDP funded project, ‘Ca-pacity Development for Preparation ofthe Cambodia Human DevelopmentReports’, executed by the Ministry ofPlanning, began in 1997. Four impor-tant reports have been produced:

· CHDR 1997: Poverty as-sessment. This first report provided afactual overview of human develop-ment in Cambodia. Relying on the sec-ond Socio-Economic Survey (SES)(see below), conducted in 1996, thereport calculated three human devel-

opment indices: HDI, GDI and a spe-cific Cambodian Human DevelopmentIndex which is based on the monitor-ing of ten indicators2 . In order to illus-trate the main patterns of poverty in thecountry, all analysis was disaggregatedby poverty status.

· CHDR 1998: Women’s con-tribution to development. This sec-ond report was essentially based uponthe 1997 CSES. It provides measuresof HDI, GDI, a third indicator, theGender Empowerment Measure(GEM)3 , and another UNDP indica-tor, the Human Poverty Index (HPI).The HPI measures deprivation in threeessential elements of human life: lon-gevity, knowledge and a decent stand-ard of living. The report sets out thecultural and legal context of the genderissue, and then assesses the gender situ-ation in the main areas of life.

· CHDR 1999: VillageEconomy and Development. Thisreport analysed the role of villages inCambodia’s development, making useof the village questionnaire of the 1997CSES. It thus provides a socio-eco-nomic profile, and information abouteducational and health infrastructures,and an assessment of village-based de-velopment programs. HDI, GDI, GEMand HPI were again presented. As thedata sources were the same as in thepreceding report, the index values donot reflect any evolution, but were up-dated in order to take into account thechange in the HDI formula used byUNDP since 1999.

· CHDR 2000: Children andEmployment. The report documentedthe magnitude of child labour in Cam-bodia, and attempted to understand the

2 The 10 indicators are: percentage of households making use of safe water, same percentage for toilets, same percentage for electricityas lighting source, percentage of households owning radio, average housing space, percentage of children under 5 years old being notstunted, percentage of school enrolment among children aged 6 to 11 years, difference between average age at entry to school and 6 yearsof age, percentage of children aged under 5 years with no diarrhoea disease during the two weeks preceding SES survey, percentage ofchildren aged under 5 years treated for diarrhoea by modern (defined as non-traditional) health service providers.

3 A measure of the relative participation of women and men in political and economic spheres of activity.

19

Introduction

determinants of child labour within thecontext of the overall labour market inthe country. This time the report coulddraw on data from the General popu-lation Census of 1998 and the recent1999 CSES for the computation of thefour indices HDI, GDI, GEM and HPI.

Building on these achievements, anew emphasis was placed on capacitybuilding in the preparation of the 2001report. In line with a fundamental goalof human development, which impliesfull development of personal capacitiesleading to actual ownership of one’sproduction, a strategy to strengthentransfer of skills and knowledge wasimplemented through the recruitment ofa National Research Team to prepareand produce the report (see Annex A).

Thus, this 2001 report differs fromthe preceding reports in a number ofways foremost of which is that it viewsthe need for national capacity buildingas one of its main concerns.

- The report is intended as apedagogical tool for CHDR readers: noautonomy is possible in interpretingquantitative information without suffi-cient knowledge of the conditions inwhich the figures were produced. Ofcourse this does not mean that all policymakers or all users of CHDR have tobecome statisticians. However, peopleand institutions in charge of policy de-sign or active in civil society shouldshare the ability to participate fully, onan informed basis, in the necessary dia-logue between technicians of quantita-tive data production and analysis andpolicy designers. This is reflectedthroughout the report.

- The report fulfils the essentialrequirement of knowledge transfer: itreflects the actual work undertaken bythe National Research Team. Owner-ship is synonymous with full understand-ing, and full understanding is also the

condition of effective dissemination.We hope that this aspect of the reportwill allow exchanges with others aboutthis process of knowledge transfer, ei-ther nationally or globally.

- The methodology employedby the National Research Team dur-ing the study was to combine the useof quantitative and qualitative informa-tion, in order that each approach pro-vides critical understanding of the other.The principle sources of quantitativedata (see Annex B) were the generalpopulation census of 1998, the socio-economic survey of 1999 and the se-ries of HIV sentinel surveillance sur-veys and behavioural surveillancesurveys.4 Throughout the study proc-ess, importance was attached to un-derstanding the conditions in which thefigures were produced, in order tosupport critical interpretation.

The source of qualitative data wasfieldwork, undertaken in four provinces(see Annex E) that aimed at providingan understanding of the consequencesof the epidemic in everyday life farfrom Phnom Penh and to confirm orrepudiate intuitions about the dynam-ics of the epidemic. During the field-work, key importance was attached todeveloping an understanding of theepidemic from the perspective of peo-ple living in rural locations. Given thetime constraints, it was decided to fo-cus on the perspective of health staffwho might be expected to be provid-ing an active response to the epidemicon a day-to-day basis. In addition, theexpertise of professionals working inPhnom Penh informed the work of theresearch team through a series of semi-nars on different topics.

c) The HIV/AIDS epidemic inCambodia: between hope that the cur-rent response to the epidemic may have

4 Unfortunately, the database of the 2000 Cambodian Demographic and Health Survey, which wasexpected to be an extremely valuable source of information, was not available for the NationalResearch Team.

20


curbed its spread, and major concernsemerging from the present social situa-tion.

The 2001 CHDR focuses on thecauses and consequences of the HIV/AIDS epidemic in Cambodia. The firstreason for this focus is the inestimablethreat to the international developmentprocess posed by the epidemic. Thesecond is the importance of lessons,which can be drawn, to-date, from theCambodian response to the challengeof the epidemic. Cambodia, one of thepoorest countries in Southeast Asia,with the highest HIV prevalence rate,seems about to curb the spread of thisepidemic. But, at the same time, ananalysis of the background of humanpoverty in this country raises importantconcerns about the extent to which thisachievement is sustainable. The 2001CHDR aims to highlight these dual, butapparently contradictory, aspects of theCambodian situation, and to contrib-ute, using a human development per-spective, to the determining of an ef-fective way forward.

The HIV/AIDS epidemic presentsa global challenge to human develop-ment and human rights. In the twentyyears since the first observation of thesymptoms of an unknown disease in1981, the global spread of the epidemichas reached every location and everypopulation group. In 2001, a reviewof the current situation by the UNAIDSGlobal Strategy Framework on HIV/AIDS makes for frightening reading:

The scale of the HIV/AIDS epi-demic is now far greater than a dec-ade ago, exceeding the worst-caseprojections made then5 … In just 20years, nearly 58 million people havebeen infected with HIV. Countlessothers have become more impover-ished as a consequence: childrenhave lost their parents; families havelost their property; communitieshave lost teachers, health workers,business and government leaders;nations have lost their investmentsin decades of human resources de-velopment; and societies have lostuntold potential contribution to so-

5 UNAIDS and WHO (2000), now estimate that the number of people living with HIV or AIDS at the end of the year 2000 stands at 36.1 million.This is more than 50 percent higher than the 1991 projections of WHO’s Global Programme on AIDS.

People newly infected with HIV in2000

Number of people living with HIV/AIDS

AIDS deaths in 2000

Total number of AIDS deaths sincethe beginning of the epidemic

TotalAdultsWomenChildren < 15 years




5.3 million4.7 million2.2 million600,000

36.1 million34.7 million16.4 million1.4 million

3 million2.5 million1.3 million500,000

21.8 million17.5 million9 million4.3 million

Table 1: Global summary of the HIV/AIDS epidemic, December 2000

Source: UNAIDS and WHO 2000

21

Table 2: Regional HIV/AIDS statistics, end of 2000

Region

Sub-SaharaAfrica

North Africa &Middle East

South & South-East Asia

East Asia &Pacific

Latin America

Caribbean

Eastern Europe& Central Asia

WesternEurope

North America

Australia & NewZealand

Total

Epidemicbegan

late 70s-early 80s

late 80s

late 80s

late 80s

late 70s-early 80s

late 70s-early 80s

early 90s

late 70s-early 80s

late 70s-early 80s

late 70s-early 80s

Adults &childrenliving withHIV/AIDS

25.3 million

400,000

5.8million

640,000

1.4 million

390,000

700,000

540,000

920,000

15,000

36.1 million

Adults &childrennewlyinfected withHIV

3.8 million

80,000

780,000

130,000

150,000

60,000

250,000

30,000

45,000

500

5.3 million

Adultsero-prevalencerate6

8.8%

0.2%

0.56%

0.07%

0.5%

2.3%

0.35%

0.24%

0.6%

0.13%

1.1%

6 HIV prevalence rate (or seroprevalence rate) is the ratio between the number of infected persons (whatever the date of infection) andthe number of persons likely to be infected (the size of the reference population). The incidence rate is the ratio between the number of newlyinfected persons (during a given lapse of time, usually one year) and the size of the reference population.

% of HIV-positiveadults whoare women

55%

40%

35%

13%

25%

35%

25%

25%

20%

10%

47%

Main modes oftransmissionfor adults livingwith HIV/AIDS

Heterosexualtransmission(HS)

Injecting druguse (IDU)

HS, IDU

IDU, HS, Menhaving sex withmen (MSM)

MSM, IDU, HS

HS, MSM

IDU

MSM, IDU

MSM, IDU, HS

MSM

cial, economic, political, cultural andspiritual life. (UNAIDS 2001b)

As noted by the UNAIDS StrategyFramework, the situation differs signifi-cantly according to location. The HIV/AIDS pandemic presently consists ofmultiple, concurrent epidemics.

At the end of 2000, 36.1 millionmen, women and children around theworld were living with HIV or AIDS,25.3 million in sub-Saharan Africaalone. There are 11 countries in Latin

America and the Caribbean whereprevalence in the adult population isabove 1%.

In parts of Eastern Europe therewere more infections in 2000 than inall previous years combined, while inparts of southern Africa, the numberof people living with HIV/AIDS hasincreased by 50% in the last threeyears. In Asia, 5.8 million people areliving with HIV/AIDS and the numberof new infections is increasing.

Introduction

22


Table 2 shows two major features ofthe epidemic in South and SoutheastAsia. The epidemic began probablyabout a decade after it was detected inmost other countries, and, despite theprevalence rate being much lower thanthat of sub-Saharan Africa, it is ratherhigh among adults.

The HIV/AIDS epidemic in Cam-bodia began relatively late, with the firstreported incidence of HIV occurringin 1991.

This broadly coincides with theemergence of the disease in the EastAsian region. Cambodia now has thehighest prevalence rate in the region.The 2000 HIV Surveillance Survey(NCHADS 2001) arrives at a preva-lence rate among the adult population(15–49 years) of 2.8 percent as com-pared to, Thailand (2.15 percent), Laos(0.05 percent), Vietnam (0.24 percent),Malaysia (0.42 percent) and Indone-sia (0.05 percent) (UNAIDS andWHO 2000).

This prevalence rate is calculatedfrom the prevalence rate among a na-tion-wide sample of pregnant womenattending antenatal clinics, among

whom HIV prevalence was 2.3 per-cent. HIV prevalence among men is de-duced from this HIV prevalence rate,corrected to account for the differen-tial infection ratio for men and forwomen. The Behavioural SurveillanceSurvey of 1999 (BSS III) (NCHADS2000) deduced a value for this ratio of1.5:1 (men:women). Thus the preva-lence rate among men is approximatedto 3.45 percent. The adult prevalencerate of 2.8 percent is the weightedmean of both male and female preva-lence rates.

In drawing conclusions and design-ing policy based on these data, the con-text of data collection and analysisneeds to be taken into account. As withfindings from all other countries, it isimportant to allow for an error barwhen working with prevalence data (aswill be discussed in the body of the re-port). Nevertheless, Cambodia doesexhibit an extremely rare feature: thereis a consistent decrease, in the year pe-riod 1997 to 2001, from 3.9% to2.8%7 (see Figure 1). It is, therefore,reasonable to hope that the disease mayhave been contained.

7 The 1998 value is not a measured value, but an interpolation between 1997 and 1999 values. Strictlyspeaking, Figure 1 relies on only three dates, 1997, 1999, 2000.

Figure 1: HIV Surveillance Surveys showing a decrease in prevalence

Source: 2000 HSS dissemination – NCHADS

National HIV Prevalence among adults aged 15-49

23

Box 1: Proposal for further investigation on declining HIV seroprevalence rate in Cambodia

Background and conceptual frameworkSince the first case of HIV in Cambodia was detected by the National Blood Bank, the epidemic of HIV spread

rapidly, Cambodia even having the highest HIV prevalence rate in the region. From 1995 onward, the CambodianMinistry of Health initiated the HIV Sentinel Surveillance (HSS) once a year in order to help the interventionprogram monitor the epidemic and serve as a tool for advocating prevention. Since then HSS continues to showincreasing seroprevalence every year in every target groups, but starting from HSS 1998 the prevalence seems tobe slightly decreasing and the trend continues in HSS 1999 and 2000. Although many intervention activities onHIV have been implemented, Antiretroviral drug access in Cambodia is very limited, therefore the decline ofseroprevalence is most likely due to the increasing rate of AIDS deaths than to the decline of new infections,which is called incidence. In order to investigate the cause of that decline, further study should be done.

MethodologyRetest all positive serum samples that were keep frozen during the 1998, 1999 and 2000 rounds of HSS by

using Deturned ELISA, which has a capacity to detect recent seroconversion (<121 days). Therefore the inci-dence of HIV infection will be detected from samples, for each year, and this will make it possible to point out thetrend of incidence from year to year and to confirm the decline of seroprevalence rate. It should be emphasisedthat such a crucial study could not have been undertaken a few years ago, because Deturned ELISA, whichprovides a unique opening on the degree of new infection, was not available. Such a tool is therefore of the utmostimportance to understand the dynamics of the epidemic.

Source: NCHADS

For the moment, this apparent de-creasing trend in HIV prevalence ratesconstitutes a spark of hope, of greatencouragement for the determined re-sponse from Cambodian authorities,achieved with support from the UNsystem, multilateral and bilateral agen-cies, and with the involvement of a net-work of national and internationalNGOs. This successful partnership isone of the main aspects which needs tobe highlighted, and it may provide valu-able guidelines for HIV/AIDS strate-gies in other countries.

However, alongside this message ofhope, is another message about theneed to acknowledge that reasons forserious concerns continue to persist.Although much still remains to be un-

derstood about the dynamics of theHIV/AIDS epidemic, its persistent andconsistent characteristics over the pastdecades all over the world allow oneto arrive at an understanding of its per-tinent features. Of these, the main fea-ture is that the link between the epi-demic and human poverty is crucial.As the epidemic gradually wanes in thewealthier countries, it has begun todevastate countries already weakenedby conflict, intractable poverty or so-cial upheaval (as is presently the situa-tion in central Europe). Moreover,within countries the same pattern isevident. The epidemic moves from thepopulation as a whole to become con-centrated in socially vulnerable groups.Upon knowing the particular circum-

As will be fully discussed in the re-port, this apparent trend does not nec-essarily imply a declining incidence rate.The rapidly rising number of deaths fromAIDS also contributes to a decliningprevalence rate. Next to nothing isknown, and it is even very difficult todevelop a hypothesis about the scale

and evolution of incidence rates.The 2001 HIV Surveillance Survey

will provide more information aboutthis apparent trend, both through com-putation of an additional point for thecurve and by an original attempt toassess new infections scale(see Box 1).

Introduction

24


stances of Cambodian society —wide-spread poverty and severe social in-equity— it is not possible to be otherthan very concerned about its high sus-ceptibility to a resurgence of the epi-demic.

d) The Human developmentsituation in Cambodia

Human development is a structur-ally complex notion, aimed at goingbeyond the understanding of develop-ment solely in economic terms. Thus,the indicators developed to measure

human development will be complexindicators, gathering in one final valueinformation drawn from different as-pects of life.

UNDP developed a Human Devel-opment Index (HDI) in order to at-tempt to capture part of the complex-ity of the Human Development concept(see Box 2). Since 1990, a global Hu-man Development Report has beenproduced each year that has used thisindex to assess the different situationsof the countries and regions of theworld.

Box 2: Human Development Index calculation

HDI is a composite measure of:

- Longevity, as measured by average life expectancy at birth- Educational attainment. This is constructed from adult literacy rates (which account for two-thirds of the

educational attainment measure) and a combination of primary, secondary and tertiary enrolment ratios (account-ing for the remaining third)

- Standard of living, as measured by real GDP per capita

Each component of this index is expressed on a scale from 0 to 1. These component values are calculatedusing pre-determined minimum and maximum values. The three components are then scaled according thegeneral formula:

Dimension index = (actual value – minimum value) / (maximum value – minimum value)*

In calculating this formula, the logarithm of the values for GDP per capita (actual, minimum and maximum) isused instead of the values themselves, in order to take into account the fact that achieving a respectable level ofhuman development does not require unlimited income. Variation in the high values is less important than varia-tion in the low values, a property well accounted for by the logarithm function.

HDI is then simply the average of the three dimension indices.

Source: UNDP 2000

* Goalposts for calculating the HDI:- Life expectancy at birth: minimum = 25 years, maximum = 85- Adult literacy rate (%): minimum value = 0, maximum = 100- Combined gross enrolment ratio (%) : minimum value = 0, maximum = 100- GDP per capita (purchasing power parity US$): minimum value = 100, maximum = 40,000

25

Dimension A long andhealthy life

Knowledge A decent standardof living

IndicatorsLife expectancy

at birthAdult literacy

rateGross enrolment

(GER)GDP per capita

(PPP US$)

DimensionIndex

Life expectancyindex

Education Index GDP index

Human development index (HDI)

Diagram 1: Construction of the HDI

The following diagram summarises the construction of the HDI:

Globally, the latest HDI values pub-lished for 162 countries by the mostrecent Human Development Report(UNDP 2001a) make use of 1999 val-ues and run from a highest value of0.939 (Norway) to a lowest value of0.258 (Sierra Leone). Cambodia is

credited with a value of 0.541, whichranks the country at 121 out of the 162countries.

The situation of Cambodia amongEast Asian countries is shown in Fig-ure 2:

Figure 2: Human Development Index in South-East Asia

Source: Global HDR 2001

Introduction

26


Source: Global HDR 2001

Cambodia thus exhibits one of thepoorest Human Development perform-ances of its region.

The HDI aims to capture the com-bined picture of three developmentfields, income, health and education.Income poverty certainly explains partof Cambodia’s low ranking for HDI.Nevertheless, if we plot this dimension

against the total HDI, we see that edu-cation and longevity are also responsi-ble for Cambodia’s low HDI. Amongthe four countries with the lowest GDPper capita (and in the same order ofmagnitude), HDI ranks from 0.48(Laos) to 0.68 (Vietnam), with Cam-bodia achieving the relatively low fig-ure of 0.54.

Figure 3: PPP GDP per capita by countries in South East Asia

It is not possible to look for a tem-poral trend in Cambodia’s HDI, as atechnical change occurred in the indexcomputation algorithm of UNDP in1999. So the series of results have tobe cut into two sequences of two years,sequences too short to allow conclu-

sions to be drawn: the 1997 and 1998indices were respectively 0.427 and0.421, and for the last period 1999-2000 respectively 0.509 and 0.517.

Urban/rural disaggregation revealsexpected results, with urban areas inmuch better situation.

Figure 4: Urban/rural disaggregation of HDI

Source: CHDR 2000

Human Development Index

27

An examination of the three dimen-sions of the HDI (the GDP index, theeducation index and the life expectancyindex) shows that each contributes tothe resulting low HDI, together with thespatial and gender differences.

i. Persistent widespread povertyObviously persistent widespread

poverty, as can be established througha study of consumption distribution, hasa significant effect on the Cambodia’sHDI level.

A study of the consumption datafrom the period 1993-99 is possiblethanks to the series of Socio-EconomicSurveys (see Annex B), and providespolicy makers, along with all institutionsand actors involved in social issues,with possibility of drawing poverty pro-files.

However, care is needed with tem-poral comparisons (see Annex D). Letus first compare, over these six years,distributions of per capita consump-tion8 .

8 This requires monetary inflation to be taken into account. The table is given in 1993–94 prices.

Sources: Prescott and Pradham 1997, Knowles 1998, Gibson 1999

Table 3: Consumption profile

Indicators

Average per capitaconsumption, in1993 - 94 prices

Inequality inconsumption: Giniindex*

Consumption shareof the poorest 10%

Consumption shareof the richest 10%

* Gini index is a measure of inequality, which runs from 0 (perfect equality) to 1 (perfect inequality).

Strata

National

NationalPhnom PenhOther UrbanRural



SES 1993-94

2,260 riels perday

0.380.390.440.27

3.4 %2.5 %2.7 %4.4 %

32.8 %31.2 %36.7 %22.9 %

SES 1997(if adjusted)

2,530 riels perday(2,150 Rielsnon-adjusted)

0.420.460.440.33

3.0 %2.6 %2.7 %3.7 %

35.3 %40.3 %37.6 %27.1 %

SES 1999

1,800 riels perday

0.350.380.350.24

3.2 %2.8 %2.8 %4.0 %

30.7 %30.0 %28.4 %20.3 %

Two main conclusions may be drawnfrom Table 3. Firstly, improvement inthe average consumption over the six-year period has been weak or even non-existent. Secondly, there has been apersistent pattern of inequality in con-sumption, with the poorest 10 percentof the population sharing three percentof the total consumption and the rich-est 10 percent sharing 30 percent. This

inequality is slightly less marked in ru-ral areas with the corresponding fig-ures rounding to four percent and 20percent respectively. This context ofpoverty and high inequality is condu-cive to the spread of HIV/AIDS andinhibits society’s capacity to respondto the epidemic.

In order to identify the proportionof the population that should be

Introduction

28


Figure 5: Cambodian poverty lines counted as poor, consumption is compared tothe values of the poverty lines (For definition andcomputation of poverty line, see Annex C). Thepoverty line values are summarised in Figure 5.

The most commonly used index of poverty issimply the proportion of the population whoseexpenditure levels fall below the poverty line andis often called the ‘head-count index’. This in-dex is easy to interpret and provides a strikingview of the prevalence of poverty. However,according to the consumption distribution, thehead-count index may be very sensitive to small

variations of the poverty line setting. Itthus provides important information, butcannot be interpreted in isolation fromother features of the consumption dis-

tribution. The proportion of the Cam-bodian population who is defined aspoor according to this analysis is shownin Table 4.

National

Phnom PenhOther UrbanRural

% under foodpoverty line

SES 1993-94

39.0

11.436.643.1

20.0

SES 1997(adjusted)

36.1 % (47.8unadjusted)

11.129.940.1

17.9

SES 1999(Round 1)

64.4

19.457.370.0

47.7

SES 1999(Round 2)

35.9 %

9.725.240.1

11.5

51.1 %

Table 4: Head-count indices



29

Interpreting this table as a broad in-dication of the Cambodian situationenables a conclusion that between 40and 45 percent of the Cambodianpopulation subsist below the povertyline and that there is no evidence thatthis situation is improving. This is a strik-ing result, which should form the start-ing point for reflection on poverty alle-viation programmes. It is within thiscontext that the HIV/AIDS epidemichas taken root in Cambodia.

However, the head-count indexdoes not indicate how far below thepoverty line the poor are. Whether aperson is just below the poverty line or

very far below, s/he will be countedby the head-count index in the sameway. Thus, it is useful to consider asecond index, which measures the av-erage gap between poor people’sstandard of living and the poverty line.This index is called Poverty Gap In-dex and is expressed as a ratio of theaggregate poverty gap to the total num-bers below the poverty line. The in-dex permits the calculation of the costof eliminating poverty by making per-fectly targeted transfers to the poor (ina hypothetical situation that assumes notransaction costs or disincentive ef-fects).

National

Phnom PenhOther UrbanRural

According to foodpoverty line

SES 1993-94

9.2

3.19.6

10.0

3.7

SES 1997(adjusted)

8.7 (13.7 ifunadjusted)

2.27.59.7

3.5

SES 1999(Round 1)

23.9

5.223.326.0

14.5

SES 1999(Round 2)

6.5

2.06.86.9

2.3

15.4

Table 5: Poverty gap indices

With variations, the poverty gap in-dices show a depth of poverty roundedto 10 percent. This means that, althoughpoverty is dramatically widespread,values of consumption by poor peopleare concentrated around 10 percentbelow the poverty line.

To summarise, there is widespreadpoverty in the countryside (where 84percent of the Cambodian populationresides), high levels of inequality in con-sumption patterns and no clear trendof overall poverty alleviation. Thesesevere poverty related indicators do notmean that Cambodian society is un-changing, nor that the Cambodian gov-ernment is inactive on these issues. Thefirst and second five-year socio-eco-nomic development plans, 1996–2001and 2001–05 respectively, attest toearly and persistent efforts made by the

Cambodian authorities to design andimplement poverty alleviation policies.

ii. Encouraging schooling ratesmarked by spatial and gender in-equality

The circumstances of education isimportant part of the human develop-ment perspective as it reveals both therecent historical context, through thedistribution of literacy among adults,and the current policy orientation,through the school enrolment rates ofchildren and teenagers.

A Box-and-Whiskers plot of theadults’ literacy rate, as reported in the1998 Cambodian national census,showing the dispersion by province fortwo age groups and by sex, illustratesbeyond doubt the current pattern ofinequality in terms of literacy (Figure

Introduction


30


Table 6: Summary of schooling rates by age and sex

6): a strong gender inequality essentiallydue to a marked disparity in the oldergenerations:

- the male literacy rate was approxi-mately 80% (79.5%)9

- there was a marked gender gap,with the rate of female literacy (57%)being some 25% lower than the male

rate. This inequality was less apparentamong young adults.

- the significant dispersion range byprovince, especially for women (withabout a 60% discrepancy between thesituation in the capital and the situationin the remote and poorest provincesalong the north-east border).

9 Further investigations undertaken by UNESCO in Cambodia conclude that the 1998 Census results are overly optimistic, and that the literacylevel is, in fact, much lower. A reason for this discrepancy may be that the Census recorded literacy levels by declaration, while UNESCOasked respondents to perform a practical test.

Figure 6: Distribution of literacy rates among provinces by sex and age

This pattern of inequality by sex andlocation is common to all dimensionsof human development in Cambodia.The present report aims to show thatit, specifically, must be taken into ac-count when attempting to understandand/or make efforts to monitor the

HIV/AIDS epidemic.Further, the schooling rate distribu-

tion for children and teenagers doesallow for some optimism: the markedgender inequality that is characteristicof the schooling rates among the olderage groups, is almost imperceptible

Children schooling rates distribution parameters (%)

Teenagers schooling rates distribution parameters (%)

Age

Sex

Median

Max

Min

Male

15.6

38.7

5.91

Female

14.9

37.6

4.66

Male

31.4

63.4

10.8

Female

31.3

63.1

9.96

Male

45.5

77.3

11

Female

44.8

76.4

11.6

Male

58.6

85.2

17.7

Female

57.3

84.9

17.2

Male

64.8

87.9

17.6

Female

63.5

86.9

15.3

Male

72.6

91.3

26.7

Female

71.3

90.2

22.2

Male

75.9

90.8

28.2

Female

72.4

88.3

21.6

6 7 8 9 10 11 12

Age

Sex

Median

Max

Min

Male

75.7

91.3

30.7

Female

69.42

86.44

20.74

Male

73.1

90.4

33.9

Female

60.2

80.75

21.33

Male

63.5

85.4

22.7

Female

44.73

69.8

11.95

Male

53.1

80.1

28.2

Female

34.27

57.85

13.32

Male

42.1

71.1

17,6

Female

22.1

44.16

11.91

Male

31.9

60.5

17.3

Female

16.14

31.52

5.9

13 14 15 16 17 18

Literate male19-39

Literate female19-39

Literate female40-99

Literate male40-99

100

80

60

40

20

0

O 12

O 16

O 22O 1116

O 1116

O 12

O 22O 16-11

*

*

31

Figure 7: Gender inequality in schooling enrolments

Source: CPS 2000

10 It should nevertheless be added that curricula are often very delayed. Many 14 year old pupils are stillenrolled in primary school.

among the very young (Table 6).As gender inequality is an essential

dimension of the HIV/AIDS issue, it isworthwhile examining the situation inregard to schooling at greater length.Figure 7 shows that up to the age of12, gender inequality is minimal, with agrowing but still marginal dispersion by

province. However, from the age of 12to 16, the difference in the genderschooling rate increases sharply asdoes the increase in dispersion accord-ing to province. The marginal decreasein the gender discrepancy observedfrom the age of 16 to 18 are related topoor schooling rates for both sexes.

In summary, although the schoolingsituation is characterised by markedspatial and gender inequality, reason forhope can be found in the high level ofschooling rates for young teenagers10

and the reduced gender discrepancy inenrolment rates for the youngest agegroups.

iii. The overall poor health statuswith sharp local distinctions

Life expectancy is a striking indica-tor of global inequality. As the GlobalHDR declares, leading a long andhealthy life is among most basic as-pects of for human development. Lifeexpectancy in Cambodia, at approxi-

Introduction

Note: de-viation from 0shows the ex-tent of inequal-ity. The widthof the rect-angles showsthe extent ofprovince-spe-cific disper-sion.

Table 7: Life expectancy in South East AsiaCountry (projectedfigures for 2000)

Brunei DarussalamCambodiaEast TimorIndonesiaLao People’s Dem. Rep.MalaysiaMyanmarPhilippinesSingaporeThailandViet Nam

Male

7455496554716168756766

Female

7857506957756471807371

Both

7656506756736269787069

Infant mortalityrate (/000lb)

890

12039769

65305

2532

Life expectancy at birth

Source: PopMap software, World application.

Age 6 7 8 9 10 11 12 13 14 15 16 17 18

32


Source: Census 1998

mately 55 years, is poor and amongthe worst in the region (see Table 7).

As already shown in terms ofschooling rates, the spatial distributionof social indicators is highly heteroge-neous in Cambodia. As a consequence,any policy, and in particular those ad-dressing the HIV/AIDS epidemic, mustgive due consideration to this impor-tant feature. To highlight further this fea-ture in the case of the health status, theinfant mortality rate, one determinantof the life expectancy, is consideredhere. The reason for choosing the IMRis the fact that the life expectancy indi-cator is highly model-dependent and,when applied, the model relies on thepopulation age and sex structure. InCambodia these structures have beenseverely distorted because of its recentbloody history. An analysis of the in-fant mortality rate in these circum-stances is, by contrast, more reliableas it permits a direct approach, and ismore susceptible to policy initiatives.

Table 7 shows that the overall fig-ure for infant mortality is high in Cam-bodia. Moreover, from recent meas-urements (see, for example, the Demo-graphic and Health Survey 2000) it ispossible to conclude that there has beena slight worsening in the situation. TheDHS found that no more than 40% of

the children between 12 to 23 monthsat the time of the survey had been fullyimmunised. Using an international scale,the DHS reports that 45% of the chil-dren were stunted, 45% underweightand 15% were too thin for their height.

Map 1 provides a striking exampleof unequal human development inCambodia. The mortality rate rangesfrom 1 to 3 (64 percent to 170 perthousand) (1998 population census).

Map 1 showing the IMR again at-tests to this inequality across the prov-inces of Cambodia. Not only is thispattern evident for other aspects of thepublic health status, but also for manysocial phenomena.

As will be explained in the body ofthe report, this spatial inequality is acritical feature, which cannot be ignoredwhen assessing the HIV/AIDS situa-tion and designing appropriate re-sponses.

This is the context in which Cam-bodia is facing HIV epidemic, a con-text that, as will be advocated in thebody of the report, provides a fertileground for the epidemic, as well as in-hibiting social capacity to respond tothe epidemic. Nonetheless, as will beshown also, Cambodia is not withoutresources with which to respond to theepidemic.

Map 1: Distribution quintiles of infant mortality rate by province (NIS PopMap software)

33

1. Human development facing HIV/AIDS epidemic: conceptual frameworkand the Cambodian epidemic situation

1.1. From the perspective of in-dividual behaviour to the concept ofvulnerability: the societal approach

Among four principal means of HIVtransmission (sexual intercourse, bloodtransfusion, re-use of needles for injec-tions,11 parent-to-child transmission),heterosexual intercourse is the pre-dominant means of transmission inCambodia,12 with parent to child trans-mission increasing as more and morewomen become HIV positive.

The strong association between theHIV/AIDS epidemic and sexual activ-ity has often, at least in the global be-ginnings of the epidemic, obscured un-derstanding of mechanisms spreadingthe epidemic. Sex is usually thought ofas a private domain, an individualchoice. This conceptualisation gave riseto the notion of risky behaviour that hasplayed a major role in epidemic de-scription. The task became to identifythe sub-populations most likely to adoptrisky behaviour and to develop inter-ventions in order to bring about behav-iour change.

This approach, useful as it may be,turned out to be highly insufficient forreducing the spread of HIV. Two mainfactors may help account for its short-comings: the social determinants of hu-man behaviour and the necessity of un-derstanding “risk” within a particularcontext.

1.1.1. Sex is a social issueThe main shortcoming of the “risky

behaviour” perspective is that it doesnot account for the fact that sex, like all

other human activities, is a social is-sue. As such, sexual behaviour patternsare constituents of overall social de-sign, linked with other constituents bydouble bonds of action and reaction.Gender inequality, average age at mar-riage, personal and social insecurity,employment patterns, role of womeninside the family, quality of citizenship,education levels and so forth, result inspecific sexual patterns, some of whichprovide fertile ground for the epidemicto spread.

The social determinants of sexualbehaviour result, in particular, in dif-ferences between countries, andamong their social groups, as to theircapability to respond to a given threat.This mechanism of behaviour driven bycircumstance is well known in relationto many social issues. For example, inthe case of threats to public health,some social patterns so seriously de-prive the concerned social groups ofcapability that the disease is likely tooppose more resistance in thesegroups. This can be observed in de-veloped countries where tuberculosispersists in the poorest segments of thepopulation. Another similar example ofthis relationship is the persistence of themedically understood disease, leprosy,in developing countries, despite the lowcost of the drugs required for treat-ment.

A dramatic illustration of the aboveanalysis may be found in the evolutionof the HIV epidemic in the USA:

A new pattern is emerging, withthe epidemic shifting towards poorer

11 HIV is transmitted through the introduction of infected blood or sexual fluids into the body. 12 It is assumed that sexual transmission is mostly heterosexual. There is little information available about men having sex with men (UNAIDS 2001c).

34


people ... who face disproportionaterisks of infection and are more likelyto be missed by prevention cam-paigns and deprived of access totreatment. (UNAIDS 2001a)

For example, the report quotedabove goes on to describe how the rateof newly reported AIDS cases in theUSA, disaggregated between whiteand black communities, shows a per-fect mirror trend. There was a constantdecrease from 1985 to 1999 for thewhite community and a constant in-crease over the same time period forthe black community. The two curvescrossed in 1995.

Another highly worrying example isprovided by Eastern Europe and Cen-tral Asia. These societies have under-gone deep socio-economic transfor-mations in the last ten years. TheUNAIDS (2001a) report notes:

Infection rates are climbing omi-nously in Eastern Europe and Cen-tral Asia, where overlapping epidem-ics of HIV, injecting drug use andsexually transmitted infections areswelling the ranks of people livingwith HIV/AIDS. Most of the quartermillion people who became infectedin 2000 were men - almost all inject-ing drug users living in the marginsof the society. In some parts of theregion, more infections occurred in2000 than in all previous years com-bined.

This shows that the pattern of indi-vidual behaviour is significantly deter-mined by the social context, and somecontexts are inevitably disastrous.Assessing the social context through theperspective of human developmentachievements, the relationship betweenthe HIV/AIDS epidemic and humandevelopment achievements has to beclearly delineated in order to render thisperspective effective and result in rel-evant recommendations for allstakeholders.

The key feature of such a societalapproach is its incorporation of theconcept of vulnerability, and the wayvulnerability is then viewed in relationto social stratification. The concept ofvulnerability complements the HD per-spective, as it deals with the availabil-ity, or otherwise, of a range of choicesin a given social context. Addressingvulnerability calls for an understandingof the relationships which shape thestructural dynamics of a society, if suchan approach is to go beyond wordsand become effective. The appropriacyof this conceptual framework will beillustrated in this chapter.

The validity of this approach is evi-dent in relation to gender. Examining asociety from this perspective does notmean restricting the analysis to a casestudy of women. It means questioningthe balance of the differential socialposition of both men and women andtheir respective roles. Similarly, a vul-nerability perspective does not meanrestricting the study to only the poorergroups, but seeing poverty as a condi-tion shaped by human relations withinparticular structural dynamics. Thismeans taking into account the differ-ential social positions that constitute allthe elements of that society, in order tounderstand the different behaviouralresponses and the consequent differ-ent effectiveness of these responses toa social threat.

1.1.2. Risk and contextThe second main shortcoming of the

individual behaviour-based approach isthat it supposes that vulnerability to in-fection is dependent on defined sets ofbehaviour. This is wrong. It supposesthat behaviour can be separated fromthe social context – such as local gen-der and power relations - in which ittakes place. A behaviour is not riskyor safe in or of itself. Central and SouthAfrican women learned this tragically:in high prevalence regions, to be a mar-

35

ried woman is to be at extremely highrisk of infection. Accordingly, the sexratio of persons with HIV inverted froma predominance of men to a predomi-nance of women.

This finding leads to an importantobservation: the ways in which the epi-demic spreads are not uniform, but de-pend upon the way a country respondsto it. Global evidence shows that theepidemic in its primary stage settles inthe general population through malebehaviour, and in predominantly urbanareas. For example, high rates of earlysero-prevalence have often been foundamong civil servants such as male teach-ers. Without timely and sufficient atten-tion to this stage of the epidemic, theinfection among spouses will play, inturn, the next main stage in the spreadof the epidemic. Educated people maybenefit from information campaigns ear-lier and in a greater number than thenon-educated. Thus the epidemic islikely to move into pockets of poverty,which will include the rural areas.

Therefore, considering sexual be-haviour patterns is fundamental to un-derstanding how the epidemic may haveestablished itself in a specific countrycontext. Given that vulnerability to HIVinfection is closely related to social fac-

tors, one should consider that the dy-namic of the epidemic is a social issue,and related to its relatively recent emer-gence and responses to it. The remain-ing part of this chapter is first devotedto illustrate the proposed conceptualframework, and then to record the cur-rent stage of the Cambodian HIV/AIDS epidemic. The CHDR 2001 willthen focus on the social vulnerabilityissue in Cambodian society.

1.2. Conceptual frameworkThe concept of Human Develop-

ment embodies far more than eco-nomic wealth. The present report willemphasise some its major aspects.Readers must bear in mind that such apicture is not exhaustive, but aimed atproviding relevant examples of the so-cial mechanisms under examination.

The HIV/AIDS epidemic is similarto all other social phenomena: it par-ticipates in and inevitably affects theoverall social balance between variousgroups. It develops in a given socialcontext, and in turn, it alters that con-text. Diagram 2 illustrates some of thereciprocal links between key aspectsof human development and the HIV/AIDS epidemic drawn from the glo-bal experience.

Diagram 2: The HIV/AIDS epidemic is a human development issue

Lead long and healthy life

Be knowledgeable

Decent standard of living

No discrimination according origin,religion, sex

Participate in the lifeof the community

Economic achievements:economic growth, GDP per capita

Effective public sector(health, education)

Security

Gender equality

Country image in the world

HIV/AIDS

epidemic

1. Human development facing HIV/AIDS epidemic: conceptual framework and the Cambodian epidemic situation

36


Diagram 2 illustrates two dimen-sions of the same issue. Both sides ofthis diagram address the question ofhow people organise themselves to livetogether: the left side reflects the indi-vidual perspective, while the right sidereflects the perspective at the nationallevel. The arrows directed towards theHIV/AIDS epidemic ellipse illustrate akey premise of this report: the levelof national development and theextent to which individuals partici-pate in and benefit from that devel-opment are key factors determin-ing the spread of the epidemic. Thearrows directed away from the HIV/AIDS epidemic ellipse in Diagram 2 il-lustrate the reciprocity of these relation-

ships: the HIV/AIDS epidemic impactsheavily on development achievements,thereby lowering overall standards ofliving. A descending spiral, if set inmotion, can be disastrous.

To make some aspects of theselinks explicit, Diagram 3 illustrates theindividual perspective, focusing on fivekey areas of human development.Again, the arrows pointing towards theHIV/AIDS epidemic ellipse offer someexamples of how the level of humandevelopment influences the spread andimpact of the epidemic. The arrowspointing away from the HIV/AIDSepidemic ellipse illustrate some exam-ples of how the epidemic undermineshuman development achievements.

Diagram 3: Links between human development and HIV/AIDS: individual perspective

Lead long and healthy life

Be knowledgeable

Decent standard of living

No discrimination accor-ding origin, religion, sex

Participate in the lifeof the community

Better health practices, fewer entry points for the virus(e.g., less STIs) Higher resistance to opportunistic diseases

Long intermittent morbidity phase100% mortality in the absence of specific treatment (ART)

HIV/AIDS

epidemic

Better understanding of the nature of the epidemicMore autonomy in personal life

Widespread withdrawal from school of children affected by HIV/AIDS

Better access to education and to high quality health facilitiesBetter and earlier access to information

Expenditure on traditional and biomedical health services leads toasset sale. Loss of income or labour

Capability for women to negotiate safe sex

Rejection of specific groups of persons

Participation in the dissemination and sharing of information,particularly among peers

Stigmatisation and subsequent loss of social safety net

A high standard of health protectsindividuals, especially as the link be-tween HIV infection and STIs is wellestablished. Conversely, HIV infection

results in the infected persons havingan increasingly poor health status(death being unavoidable without spe-cific treatment): the reciprocal influence

37

between the health situation and theepidemic is obvious. It is only one ex-ample of a general mechanism linkingtogether essential social structures.Reciprocity is an important character-istic of these links, despite the fact thatone direction of the relationship is of-ten acknowledged more readily than theother.

Restricting comments on these linksto some of the fields illustrated in Dia-gram 3, it is apparent that an educatedperson has more resources and is,therefore, more able to benefit fromHIV prevention campaigns, and willalso have more opportunities to modifyhis/her behaviour. At the other end ofthe educational scale, are children af-fected by the HIV/AIDS epidemic.They lack both resources and oppor-

tunities. Active participation in civil so-ciety life, through community struc-tures, for example, places the individualinside a beneficial net of information anddiscussion. In turn, this increases his/her range of possible effective reac-tions. In contrast, the stigmatisation, sooften associated with a seropositivestatus, forces the people concernedinto isolation and silence, depriving thecommunity of their participation in in-formation sharing.

This mechanism of reciprocalforces, which exists at an individuallevel, is also effective at the level ofsociety. Diagram 4 provides a similarillustration of links between the HIV/AIDS epidemic and key aspects ofhuman development from the nationalperspective:

Diagram 4: Links between human development and HIV/AIDS: the national perspective

Economic achievements:Economic growth, GDP per capita

Effective public sectors(health, education)

Security

Gender equality

Country image in the world

A wealthy economy can allocate sufficient resources toprevention and cure programmes

Mortality due to AIDS is highest in the youngest half of theworking-age population, weakening both the public and

private sectors

Public sectors with qualified staff and good infrastructurescan address optimally the HIV/AIDS epidemic

AIDS deprives public sectors of skilled staffHealth system may collapse under unmanageable

demand

A stable country may bring together all the social groups torespond to the epidemic

Fear, sorrow, deep feeling of inequity can lead to socialunrest

Women voices are the most powerful tool to lead to safesexual patterns

Epidemic burden presses mainly upon women, ascaretakers and household resource providers

Fear of negative country image can lead governments todeny the epidemic

Positive country image is important for activities such astourism and, more generally, for the many relationships

which link a country to the global context.

HIV/AIDS

epidemic

Again, it is essential to fully under-stand the reciprocity of the influencesas shown by the arrows in Diagram 4.A society is, of course, a dynamical

structure. Human development is oneof the most entrenched and demand-ing of the movements at work in anysociety. Achievements in the dimensions


38


The basic idea of Human development – that enriching the lives and freedoms of ordinary people is fundamen-tal – has much in common with the concerns expressed by declarations of human rights. The promotion of humandevelopment and the fulfilment of human rights share, in many ways, a common motivation, and reflect a funda-mental commitment to promoting the freedom, well-being and dignity of individuals in all societies.

Human development and human rights are close enough in motivation and concern to be compatible andcongruous, and they are different enough in strategy and design to supplement each other fruitfully. A moreintegrated approach can thus bring significant rewards, and facilitate in practical ways the shared attempts toadvance the dignity, well-being and freedom of individuals in general.

To have a particular right is to have a claim on other people or institutions that they should help or collaboratein ensuring access to some freedom. This insistence on a claim on others takes us beyond the idea of humandevelopment. Of course, in the human development perspective, social progress of the valued kind is taken to bea very good thing, and this should encourage anyone who can help to do something to preserve and promote it.But the normative connection between laudable goals and reasons for action does not yield specific duties on thepart of other individuals, collectivities or social institutions to bring about human development – or to guaranteethe achievement of any specified level of human development, or of its components.

This is where the human rights approach may offer an additional and very useful perspective for the analysis ofhuman development. It links the human development approach to the idea that others have duties to facilitate andenhance human development.

shown above are inextricably linked,and contribute to the creation of cir-cumstances which the epidemic findseither more or less fertile.

The links between dimensions arenot mechanical: they interact, butprogress—and setbacks - may occurat various paces. This means that evenif general mechanisms can be identified,each society will have a unique patternof development and consequently, asocial issue such as the HIV/AIDS epi-demic has to be understood and ad-dressed within its specific context,while taking into account global les-sons.

Diagram 3 and 4 also highlight an-other important feature. As all socialfields are linked with the epidemic asan issue, so too are the actors who areshaping the response to the HIV/AIDSissue involved in and affected by thesame social dimensions.

Finally, a last distinction will be use-ful to render the above framework op-erational. Readers could easily be con-vinced, when reading the examplegiven for each of the red arrows (pro-viding an illustration of how the con-

text determines the features of the epi-demic) that these belong to two sepa-rate levels of action. Some are directlylinked with the epidemic: sexual prac-tices (for example, negotiating safesex), and better health practices whichwill impact immediately on the spreadof the epidemic. These are the neardeterminants of the infection. The oth-ers, such as poverty alleviation, or im-provements to the level of educationthroughout the entire population, willslowly modify the circumstances inwhich the epidemic in rooted. Theseare the structural determinants. Theyare linked with the near determinants:they determine whether the actionstaken in relation to the near determi-nants are sustainable.

1.3. Human rights implicationsof HIV/AIDS

While the fundamental goals of theHuman Rights approach converge withthose of the Human Development ap-proach, the former does nonethelessemphasise the rights that any humanbeing can demand of the society he/she participates in.

Box 3: Human rights and human development

source: Global Human Development Report 2000, UNDP

39

In accordance with the proposedconceptual framework, the issue of hu-man rights implications of the HIV/AIDS epidemic can be considered byexamining the reciprocal links betweenthe epidemic and the promotion of hu-man rights.

The promotion of Human Rights hasan effect on the dynamics of the HIV/AIDS epidemic. The overall situationhas unfortunately resulted in this situa-tion being illustrated by its negative side,but important examples of a positivelinkage may be found, particularly inPhnom Penh.

! The lack of effective means ofexpression on the part of individualsand communities results in the centraladministration having insufficient infor-mation about the status and the possi-ble progress of the epidemic.

Enabling the voice of concerned in-dividuals, families and communities tobe expressed is a basic duty. It is also apowerful tool for monitoring the epi-demic. In no country is this declarationeasily put into effect. For example, ac-tivists from the homosexual communi-ties in Europe and in the USA strug-gled to make their voices heard. Theglobal experiment nevertheless pro-vides important evidence about the ef-fectiveness of this approach.! The lack of effective means of

expression on the part of individualsand communities results in there beingfewer demands for a public safety net.Thus the burden of the epidemic remainsmainly with the concerned households,undermining their contribution to andbenefit from the wider economicachievements and threatening topolarise this impoverished group fromthe wider society.

Sharing the burden of the epidemicby mobilising public support is the firstof a society’s duties on behalf of theaffected part of its population. Assum-

ing this responsibility is also part andparcel of maintaining and continuingwith strategies to address entrenchedpoverty and implement effective devel-opment strategies.

Conversely, the epidemic accentu-ates the negative aspects of the Hu-man Rights situation.! Fear from infection leads to dis-

crimination; no moral conviction canovercome the refusal to endanger one-self or a near relative. As long as thisfear exists, no clear understandingabout the circumstances of people liv-ing with HIV/AIDS can be reached.! The stigmatisation associated with

seropositive status (which is worse forthose with AIDS) silences most of theaffected people. In turn this silencelengthens the time taken to createawareness in the remainder of thepopulation.

One essential contribution of theHuman Rights approach is that itmakes explicit the legitimacy of the callfor support. The practical implicationsof this perspective are both demand-ing and highly effective in terms ofshaping a response to the epidemic.The outputs of this framework can beappreciated by raising the controver-sial question of access to Anti-Retroviral therapies (ART). The pri-mary right of each human being is tostay alive: demand for access to ARTtherapies, which inhibit HIV from be-coming AIDS, ensue, therefore, as anelementary right. It is the duty of acountry to mobilise its means to cope,as far as possible, with this demand.

1.4. The HIV/AIDS epidemic inthe Cambodian context: knowledgeand lack of knowledge

1.4.1. Prevalence rate estima-tion: HIV Surveillance Surveys

Quantitative knowledge on HIV/AIDS epidemic relies on data provided


40


by the Sentinel Surveillance systemimplemented by the National Center forHIV/AIDS, Dermatology and STIs, adepartment of the Ministry of Health.These are the only countrywide esti-mations for the sero-prevalence rate,and as such they are essential. Therehave been successive issues of the Sur-veillance Sentinel Surveys since 1992,but these have covered a significant partof the country only since 1997. Thereport relies on the four most recentsurveys of 1997 to 2000. While senti-nel surveys have inherent limitations, as

discussed in this chapter, these surveysprovide in-depth information about thespread of the epidemic within selectedpopulation groups.

The methodology of the SentinelSurveys consists of identifying groupspresenting potentially high-risk sexualbehaviour, and groups likely to be rep-resentative of the national behaviournorm. From these groups, a sample ofvolunteers is tested for the presence ofHIV. The groups chosen during theprevious four years are listed inTable 8.

Table 8: Sentinel groups

1997 (22 provinces)

DCSW1

Male policeANC2

Hospital in-patients3

Tuberculosis patientsMilitary personnel

1998 (19 provinces)

DCSWMale policeMarried women ofreproductive ageHospital in-patients

IDCSW4

1999 (20 provinces)

DCSWMale policeANC

Hospital in-patientsTuberculosis patients

Beer promotersNon-brothel based sexworkers5

Households (generalpopulation)

2000 (21 provinces)

DCSWMale policeANC

Hospital in-patientsTuberculosis patients

IDCSW

1 Female Direct Commercial Sex Workers,2 Pregnant women attending antenatal clinics3 Hospital in-patients were surveyed in only three provinces4 Indirect Commercial Sex Workers. IDCSW includes women beer promoters, women bar workers andwomen working in karaoke lounges and massage parlours.5 ‘Beer promoters’ and ‘non-brothel-based sex workers’ were an attempt to disaggregate the IDCSWgroup.

The 2000 Sentinel Survey Samplingthus encompassed six sentinel groups:1) Female direct commercial sexworkers (DCSW) 2) Female indirectcommercial sex workers (IDCSW) 3)Male police 4) Pregnant women at-tending antenatal clinics (ANCwomen) 5) Tuberculosis patients and6) Hospital in-patients (in 3 provincesonly).

For DCSW, IDCSW and Police(and ANC women and TB patients),the sample covered 21 provinces,

stratified in Provincials capitals and re-maining districts. The sampling framein all the 21 provinces but Battambangcovers the two strata. For hospitals in-patient, the three provinces in which thesurvey takes place are Battambang,Kampong Cham and Phnom Penh.

DCSW, IDCSW and police wererecruited from randomly selected sites,while ANC women, TB patients andhospital in-patients were recruited frompurposely selected sentinel sites. Inprovinces where the total number of

41

Estimates of prevalence rates are essential, as knowledge of the extent of the spread of the epidemic isclearly key information in the organisation of any response to the epidemic. Unfortunately, gathering data toestimate prevalence, in addition to the difficulties common to all measurements of social phenomena describedin Annexes, has specific requirements and features that cause such estimations to be inherently fragile data.

Firstly, estimation of HIV prevalence rates requires blood testing from a representative sample of the popula-tion. This requirement is impossible to meet. An essential feature of HIV testing is that it is voluntary. Accommo-dation of the needs for both voluntary testing and a representative sample requires compromises. The Ethicalconsiderations demand that the requirement that blood testing is voluntary is met in full. Therefore, distortionsinside the surveillance samples have to be accepted.

Secondly, fortunately, within the range of overall prevalence likely to be found in Cambodia (an order of magni-tude of around 3 percent), only a few people in a sample of a few thousand will be HIV positive. For example, thesample of pregnant women attending antenatal clinics (ANC), from which the overall Cambodian prevalence rateis deduced (as explained earlier in the report), included 6,562 women in the 2000 round of sentinel surveillance.Among them, 152 were found HIV positive, unequally spread across the 21 provinces. Thus, by province, therewere between one and 17 women who tested positive. Obviously, small hazard variations will significantly influ-ence any description of such a sub-sample. In other words, any figures deduced from this sub-sample encom-pass a large error bar.

DSCW was not likely to exceed 150,the corresponding sample includes allthe DSCW. In provinces where the to-tal number of DSCW was significantlyhigher than 150, cluster sampling wasdone. IDSCW were sampled from alist of all beer companies that hire beerpromotion women, as well as bars,karaoke lounges and massage houses.

The sampling size, per province,was decided to be 150 people fromeach sample group if prevalence in1999 was higher than 5 percent, and300 people from each sample group ifprevalence was less than 5 percent. Insome provinces it was not possible toachieve these sampling targets, and soas many people as possible were in-cluded in the sample.

The first aim of the HSS is to pro-vide an estimate of the overall preva-lence rate among adults. The figures for2000 have already been described inthe introduction of this report: 2.8% ofCambodian adults were expected tobe HIV positive in 2000.

As already explained, this figure isbased on measuring the prevalence ratein a sample of pregnant volunteers at-tending antenatal clinics. This choicemay be questioned for the followingreasons, but no other choice would have

been any less questionable. First, preg-nant women are likely to be moresexually active than the total group ofadult women. But, and this is the mainlimitation, most Cambodian women donot attend antenatal clinics. Accordingto the 2000 Cambodian Demographicand Health Survey, 89% of the babiesborn in the five years preceding thesurvey were delivered at home. Thusonly about 10% of mothers gave birthin a health facility. Indeed most (55%)had no contact with a health facilityduring pregnancy.

Although attending antenatal clinicsis an urban phenomenon typical of thewealthier groups, it also includeswomen with high-risk pregnancies. Itis not easy to assess how these biasesare likely to distort the measured preva-lence, and even less how they mightchange over time.

When the epidemic is most presentin urban areas, such prevalence as-sessed through these attendance fig-ures might overestimate the overallnational prevalence. When preventionis successful among educated people,the reverse might be true. It results inan underestimation of national preva-lence. Box 4 gives details for someaspects of this discussion.

Box 4: Estimates of prevalence rates are inherently fragile data


42


School attainment will be used here to illustrate the type of distortion resulting from these unavoidable featuresof prevalence measurement. An obvious concern about the choice of the sentinel group of pregnant womenattending ANC to represent Cambodian women of reproductive age is that a very small percentage of Cambodianwomen of reproductive age access ANC. Most pregnant Cambodian women do not attend ANC, and those who doare not likely to be a random sample of pregnant women and are likely to share certain characteristics. Indeed,the sample of pregnant women tested in the 2000 Sentinel Surveillance Survey were found to have a schoolattainment distribution distorted towards a high level.

The same kind of distortion was found in the sample of household men surveyed for the 2000 BehaviouralSentinel Survey. Of the 3,166 men sampled through a multistage sample frame, 6.5 percent reported that theyhad not attended school (8.7 percent of men in rural households and 4.3 percent of men in urban households).The corresponding figures from the 1998 census, for the five provinces surveyed pooled together, are respectively19.1percent (total), 23.68 percent (rural) and 8.84 (urban). School attainment of men from 15 to 49 is not suscep-tible to significant change in a two year time period. The choice of the ANC sample, and the sample fromhousehold sampling exhibit the same feature. Reasons contributing to this same distortion appearing in both thesample of pregnant women attending ANC clinics and the male household survey may include difficulties inconducting the survey deep in the countryside and the greater ease of response and cooperation with the surveyamong more educated people.

Adjusting estimates of prevalence rates in the context of a sample that is unrepresentative of school attain-ment levels is not straightforward. Global trends suggest that the older an epidemic is, the more deeply it isrooted in the poorest part of society. If this trend holds for Cambodia, it could mean that surveillance surveyresults will gradually come to underestimate the actual HIV rate. Such underestimation will have consequencesfor all quantitative assessments deduced from the estimated prevalence rate, including the projected number ofpersons developing AIDS at a given time and the projected number of AIDS-related deaths.

The best way to clarify this ques-tion of prevalence is to crosscheck thissurvey with other types of prevalencesurveys. But there has been, so far, noclear answer. An attempt was made in1998 to substitute the sample ofwomen attending ANCs with a sampleof married women of reproductive age.The corresponding value proved to be

lower than what would have been ex-pected through an interpolation of theresults from ANC attendant women.The three values measured fromwomen attending ANCs are 3.2%,2.6%, 2.3% (for 1997, 1999 and 2000respectively), resulting in an extrapo-late value for 1998 of 2.9%. The meas-ured value from married women in thesame year is 2.4%.

Finally, on the basis of the chosenframework, one has to evaluate the dif-ferential rate of infection between malesand females in order to provide a na-tional estimate. This may be measureddirectly through household testing sur-veys, or deduced from behavioural es-timates. The ratio of infection for malesto females of 1.5:1 comes from theBehavioral Surveillance Survey.

It should be clear to readers that thesteps detailed here do not mean thatCambodian data are less reliable thanother data of this kind. These stepshighlight the Cambodian response to theunavoidable constraints of prevalenceestimates. In one way or another, allcountries have to deal with the same

Figure 8 : HIV seroprevalence among sentinel groups in 2000

Source: NCHADS, Sentinel Survey 2000 dissemination

43

problem. The prevalence data in Cam-bodia are far from being less reliable,and the Surveillance System is consid-ered one of the best in the region. TheCHDR deals with the question of reli-ability in some detail, as fair considera-tion of the level of confidence to begiven to epidemic spreading assessmentis needed to consider the possibly weakground on which epidemic might keepon rooting, if not refuelling.

The second aim of the HSS is tofollow the groups designated as high-risk groups. The HIV seroprevalencefor Sentinel sub-populations in 2000 is

shown in Figure 8.In order to interpret these data, it is

important to produce an estimated rateof variation from one province to an-other.

Sentinel Surveys are not designedto provide data for a discussion on thesituation in each province, but therange of variation is nevertheless a sig-nificant indicator. Table 9 shows that,for each sampled group, the disper-sion across the provinces is very im-portant. The results combine statisti-cal fluctuations with significant localdisparities.

Table 9: Range of HIV prevalences in different provinces (HSS 2000)

Sentinel Group

Direct sex workers

Indirect sex workers

Police

Antenatal clinic attendees

TB patients (20 provinces)

Hospital in-patients(3 provinces)

* N=21 provinces

Lowest Prevalence

7.1%

5.2%

0.7%

0.5%

0.0%

8.1%

Highest Prevalence

58.6%

32.8%

10.7%

5.7%

19.5%

12.1%

The prevalence trends of the epi-demic provide data which are of para-mount importance when assessing theeffectiveness policies already imple-mented and when considering the de-sign of future strategies. In order to un-derstand and qualify the major result,presented in the introduction, that is, thedecreasing prevalence for the past threeyears, it is essential that the evolutionof the prevalence among the surveil-lance high risk groups is also assessed.

Figure 9 confirms the prevalenceresults derived from women attendingantenatal clinics. Among the four highrisk groups, two (DSW and Policemen)clearly have a decreasing trend. Lessclear are the trends for ‘Beer Girls’ and

The Trend of HIV Seroprevalence among Direct Sex Workersby Age group (in 19 provinces)

Figure 9: HIV prevalence in high risk groups decreases


44


The Trend of HIV Seroprevalence among Policemen in Urban Areasby Age Group

The Trend of HIV Seroprevalence among Beer Girls

The Trend of HIV Seroprevalence among TB Patients

TB patients, but, nevertheless, they areat least compatible with a decrease.

1.4.2. Behavioural SurveillanceSurveys

The Sentinel System also includesrepeated behavioural surveys(NCHADS 1997-2000). The Behav-ioural Surveillance Survey is a seriesof repeated cross-sectional surveysconducted at regular intervals on a na-tional or regional scale in target groups.The goal is to monitor and track high-risk sexual behaviours in selected tar-get groups on a regular and systematicbasis.

While HIV Surveillance Surveys areintended to estimate the prevalence ofinfection among chosen surveillancegroups, Behavioural Surveillance Sur-vey (BSS) is intended to assess andfollow over time the sexual behaviourof these groups. BSS methodology iswidely used around the world in rela-tion to various aspects of public health,such as smoking, eating patterns, al-cohol consumption and so on. Annualrounds of BSS have been included inthe Cambodian process for monitor-ing the HIV/AIDS epidemic since1997, in order to monitor high-risksexual behaviours in selected targetgroups on a regular and systematicbasis. Expected uses of BSS are statedto be:

- Targeting prevention programs- Identifying specific behaviour in

need of change- Providing indicators of success

and identifying persistent problem ar-eas

- Serving as an advocacy and policytool.

The population is divided intogroups characterised by three broadcategories of behaviour. Firstly a coregroup, defined as a highly vulnerablegroup of individuals characterised byhigh rates of partner change, long du-

45

ration of STD infection often related topoor access to acceptable health care,and highly efficient transmission of in-fection per exposure. Secondly, bridg-ing groups, as the transmission of STD/HIV beyond core groups into the gen-eral population has been shown to bebased on patterns of mixing by individu-

als who have sexual intercourse withpeople categorised as ‘core group’ and‘general population.’ The ‘generalpopulation’ is assumed to be at lowrisk.

The occupational groups chosen torepresent these three categories and besampled for the surveillance survey are:

Female sex workers (BSS I, II, III)Police/Military (BSS I, II, III) Core groups

Women beer promoters (BSS I, II, III)Moto-taxi drivers (BSS I, II, III) Bridge

Working women (BSS I, II)Vocational students (BSS I, II)Governmental officials (BSS II)Multistage sample of households males (BSS IV) General Population

BSS I: 1997 (sample 4,356), BSS II: 1998 (sample 4,265), BSS III: 1999 (sample 3,400),BSS IV: 2000 (sample 3,166).* In three of the five sites, BSS I relied on GTZ study.

The BSS are administered in onlyfive provinces, where the five largestcities are found:

Phnom Penh, Sihanoukville,Battambang, Kampong Cham andSiem Reap. Each provincial town issampled, plus three rural districts in eachprovince. BSS collects basic demo-graphic information about the respond-ents (age, marital status, age at firstmarriage, number of children, educa-tional level and, since 1998, monthlyincome, whether the person lives withfamily or not and whether the personhas migrated in the surveyed locationduring the last year). Patterns of sexualbehaviour among the pre-definedgroups are captured by the followingitems:

- Mean age at first sex. BSS I to IIIconsistently found younger values for

the women belonging to the coregroups (17.6 all rounds for female sexworkers13 ) and bridge groups (ap-proximately 18.4 for women beer pro-moters) than for general populationwomen (21 to 22.5 for the two firstrounds for working women). Nothingsimilar is observed for men, with fig-ures running from 21 to 22 withoutdefinite trends.

- Percentage ever had ‘sweetheart’and percentage with a ‘sweetheart’ inthe past year.

- Percentage never married andsexually active

- Number of lifetime sexual part-ners - median (and mean).

Beyond expected broad indications(for example, only a few workingwomen who have never been marriedreport being sexually active, as com-

13 Readers should keep in mind that a large number of female sex workers in Cambodia are forced intosex work. Addressing the trafficking of women is part of a comprehensive response to the HIV/AIDSepidemic.


46


pared to 40-45 percent of beer pro-moters reporting sexual activity), noneof these indicators enable straightfor-ward interpretation. This is due to thefact that they are linked with other char-

acteristics of the respondents, such asage. Readers must to refer to the fourdrafts of the BSS.

Particular attention has been paid tomonitoring condom use. The figure 10

Figure 10: Improvement in consistent condom use

Figure 11: The evolution in commercial sex use

Consistent condom use by risk groups

Men's past month commercial sex use

47

below shows an appreciable improve-ment in consistent condom use.

Attention is also paid to thefrequency of STDs and access to STDtreatment and to HIV testing. Thesuccessive BSS also exhibit a trendtowards less commercial sex use. (Seefigure 11).

Nevertheless, BSS also captures theinexorable progression of the humanconsequences of the HIV/AIDS epi-demic: in one year, between 1998 and1999, the percentage of people know-ing someone sick with AIDS has in-creased 2.5 to 3 fold among the sentinelgroup. The 2000 household male sur-vey found that the lowest proportion ofrespondents knowing someone sick orwho has died from AIDS was nearly onequarter (in Siem Reap), while the high-est proportion was more than half of thesample group (in Phnom Penh).

1.4.3. On a knife’s edge betweensuccess and threat

As shown, the Cambodian epidemicsituation, as assessed by the surveillancesystem, includes contrasting features.However, most importantly, the preva-lence rate, hence the number of personliving with HIV, shows a markeddecrease. (See figure 12).

Nevertheless, decrease in preva-lence does not mean a decrease in thenumber of new infections. People withHIV remain HIV positive as long as theylive. In the context of a steadily increas-ing population size, a decrease in thesero-prevalence rate is synonymouswith a decrease in the number of HIVpositive people. Therefore, a decreasein the number of HIV positive peoplemeans that the number of deaths of HIVpositive people is greater than thenumber of new infections. Thus, de-creasing prevalence may occur in a va-riety of contexts: for example, wherethere is increasing incidence coupledwith a more steeply increasing numberof deaths or where there is decreasingincidence. In the current context of the

Figure 12: The number of persons living with HIV/AIDS decreases

epidemic in Cambodia, the number ofdeaths can only increase. Therefore, itis necessary to mobilise other informa-tion sources in order to interpret thedecrease in the prevalence and deter-mine further steps in a relevant re-sponse to the epidemic.

Currently, the only way to gain in-sight into the gradual lessening of theincidence rate is to consider the preva-lence rate for very young adults (Anew, original effort will be undertakenin 2001 to provide more direct infor-mation. See Box 1). The sub-sampleof pregnant women attending antena-tal clinics cannot be disaggregated byage group, particularly with regard toyounger women because this sub-sam-ple is statistically very weak inside thesample. The sample of direct commer-cial sex workers (DCSW) provides analternative method for estimating inci-dence rate variation. The trend amongthis group shows a significant decrease,from a prevalence rate of 42.6 per-cent in 1998 to 31.5 percent in 2000.The youngest women in this sampleaccount for the largest decrease. Whenthis sample of women is divided intotwo age groups, younger than 20 yearsand older than 20 years, both agegroups exhibit a decline in prevalence.


48


However, while the older group showsa decline of about 10 percent (decreas-ing from 43.4 percent to 33.9 percent),the decline in the younger group is al-most 20 percent (decreasing from 41.8percent to 23.1 percent).

It is difficult to assess whether thisencouraging result reflects a generaltrend in the overall population. How-ever, other features give reason foroptimism, in particular, the steady in-crease in reported consistent condomuse.

Less encouraging is, first, the in-creasing number of AIDS deaths. Whileno direct measurement is available,convergent information supports thisfact. On the basis of the global experi-ment, a ten years period from the firstreported HIV case corresponds to themedian length of survival. The Behav-ioural Surveillance Surveys report asharp increase from 1998 to 1999 inthe proportion of people knowingsomeone “sick with AIDS” (see figure13).

Figure 13: The percentage of people in each surveillance groupknowing someone sick with AIDS

In 2000, 47.8% of the sample ofwomen surveyed for the Demographicand Health Survey answered that theypersonally knew someone who hasAIDS or who had died of AIDS. Thedispersion across provinces is signifi-cant. It ranges from 13% in the northeastern provinces to 76.3% in PhnomPenh.

Secondly, from the societal per-spective, several aspects of Cambo-dian society are highly relevant to theHIV/AIDS epidemic: these includegender norms and relations, and pov-erty that is both widespread and highlyiniquitous, along with personal and so-

cial insecurity. Moreover, is it possibleto infer that the trend towards agradual concentration of the HIV epi-demic in the vulnerable segments of thepopulation is true in the case of Cam-bodia?

The answer will be decisive for de-signing steps for prevention and miti-gation of the epidemic’s consequences.In order to cast some light on a pos-sible answer to this crucial question,Chapter 2 explores the issue of re-ciprocal relations between Human De-velopment achievements and the HIV/AIDS epidemic in the Cambodian con-text.

49

The Human Development perspec-tive, together with critical informationabout the current HIV/AIDS epidemic,provide the CHDR with a conceptualframework to elaborate on the pro-posed approach specific to the Cam-bodian context. A decrease in theprevalence rate represents a first andan important success: the epidemic inSoutheast Asia is at its worst in Cam-bodia, but its spread has been dramati-cally slowed. It is, therefore, particu-larly important to understand and sur-mise how the epidemic may evolve inthe future. Certain questions may beasked in relation to this. Can the de-scending spiral described in chapter 1be activated in Cambodia? A processof development is occurring in Cam-bodia, but which of its main achieve-ments will be threatened by the spreadof the epidemic? Conversely, which fea-tures of the Cambodian society are themost likely to facilitate this spread?

The reader will not find a compre-hensive review of the many related so-cial fields and issues in this report. It isnot within its scope to consider all these.The attached bibliography can be con-sulted for greater detail regarding theissues mentioned, or complementaryresearch. The report focuses as closelyas possible on the Cambodian situation,and the features most relevant to thiscontext. Moreover, it has been decidedthat the report should rely on the find-ings of previous studies where possi-ble, and elaborate on only those issuesconsidered both crucial and currently

2. The Human Developmentperspective and the dynamicof the HIV/AIDS in Cambodia

less examined. Finally, certain impor-tant issues, for example, the safety ofblood products and drug abuse - nodoubt significant problems linked to thespread of the epidemic - have been ex-cluded from this report, because, evenif they play a role in the dynamic of theepidemic, their specificity renders themquestionable and, again, it was notpossible to address them in this report.

Conversely, the aims of this reportare to show the effectiveness of theHuman Development approach toconsiderations of the HIV/AIDS epi-demic as a social issue and to discusswhat light this perspective can cast onthe dynamics of the epidemic.

2.1. Introduction: Link be-tween HIV/AIDS epidemic anddemographic features

Population structure, together withits spatial distribution, is of key impor-tance for social issues such as the HIV/AIDS epidemic. Population structurein Cambodia has been heavily affectedby several decades of war and con-flict. Of particular relevance here is thesignificant lack of births and high infantmortality levels during the KhmerRouge regime of 1975–79 (see Fig-ure 14). This generation – children bornand surviving this period – are nowyoung adults. Already proportionatelysmall in number compared to other agegroups in the population, this genera-tion is likely to be severely affected byAIDS deaths.

50


Figure 14: Cambodian population structure (1998 census)

Figure 14 shows the age structureand the age-specific sex ratio of thepopulation.

Disproportionately small in size andwith an unbalanced sex ratio, theyoungest segment of the working agepopulation is now facing the HIV/AIDS

epidemic. The imbalance of the spatialdistribution of women and men is an-other very significant factor to be takeninto account when considering the pro-jections at national level for the poten-tial spread of the HIV/AIDS epidemic(see Figure 15).

Figure 15: Age and Sex Imbalance

Source: CPS-RUPP 2000

In addition to an imbalance in thenational sex ratio, Figure 15 illustrateshow the sex ratio varies significantly byage between urban and rural areas. Incontrast to the general trend, in the age20 to 40 years age group, the sex ratio

is 100 or higher in urban areas, prob-ably as a result of internal migration forwork. Disaggregation of this informa-tion by province reveals that this gen-eral demographic feature is more pro-nounced for some urban areas than oth-

51

2. The Human Development perspective and the dynamic of the HIV/AIDS in Cambodia

ers and also exists in some semi-ruralareas, again, probably due to the avail-ability of employment opportunities thatattract migrant male workers. Locationssuch as these that attract high levels ofmigration require special attention frompolicy makers.

It is essential to take the dynamicsof the demographic structure of thepopulation into account in an assess-ment of the potential nationwide con-sequences of the HIV/AIDS epidemic.Epidemics are dynamic by nature. It isvital for the public administration to at-tempt to anticipate potential triggers forthe further spread of the epidemic. Theaccuracy of this analysis and the effi-cacy of the action taken in responseimpacts dramatically both on thenumber of people directly affected andthe economic consequences of the epi-demic.

2.2. The HIV/AIDS epidemicthreatens human developmentachievements in Cambodia

After 20 years of the global HIV/AIDS epidemic, its power to ravage anation is all too obvious. Dramatic set-backs in human development are seenin high prevalence regions of the world.Economies are shattered when the epi-demic sweeps through the workforce,as is widely observed in some coun-tries in Sub-Saharan Africa.

Cambodia is not experiencing suchvery high prevalence rates. However,with a prevalence rate of 2.8 percent,the country stands on the edge of adangerous slope. The epidemic is al-ready generalised throughout the popu-lation, beyond the so-called “riskgroups”, but vigorous efforts may beexpected to keep it under control andto mitigate its impact, provided that the2001 surveillance results will confirmthe downward trend suggested by the2000 figures. However, it is necessaryto understand how the epidemic affectssociety, in order to scale up achieve-

ments. Aided by such an understand-ing a relevant response may be de-signed and activated. Moreover, thisunderstanding is necessary becausesetbacks in Human Developmentachievements worsen the social con-text and provide opportunities for theepidemic to resist and develop newroots in the population.

The chapter begins with the indi-vidual perspective, as it is appropriateto stress the main consequences of thecurrent epidemic: household impover-ishment and the consequent vulnerabil-ity of children.

2.2.1. The crucial issue of thedistressed sale of productive assets

As the study of the distribution ofindividual consumption has alreadyshown, the standard of living in Cam-bodia is highly unequal, with a wide partof the population living in impoverishedand precarious situations. The Lorenzcurve of inequality in the consumptiondistribution by household in 1999 (Fig-ure 16) and the quantitative summaryin Table 10 below provide a clear il-lustration.

Figure 16: Lorenz curve for the consumptiondistribution by households (SES 1999)

Source: Computed by National ResearchTeam from SES 1999 data

52


Table 10: Quantitative summary of consumption distribution by household

10% poorest

10% richest

Gini coefficient

Share of foodconsumption

2.97%

24.32%

0.33

Share of non-foodconsumption

0.97%

51.4%

0.63

Share of totalexpenditure

2.26%

34.8%

0.44

Source: Computed by National Research Team from SES 1999 data

Some of the principal characteris-tics of poor households are well-estab-lished, as they have been repeatedlyconfirmed by the successive SES.These surveys confirm common trendsin social stratification:

- Poor households tend to belarger, younger and include proportion-ately more children than richer house-holds.

- The poor are more likely to livein households in which the head of thehousehold is illiterate and has signifi-cantly fewer years of schooling than her/his richer counterparts.

- Human poverty is highest inpoor households in which the head ofthe household is engaged in agriculture.

This profile has to be understood ina context where subsistence farming isthe main occupation for a majority ofthe working age population. The cen-sus for 1998 shows that more than75% of the working age populationwere farmers: that is, 3 out of four em-ployed people over the age of 14worked in the agricultural sector. Thus,an assessment of the consequences ofthe HIV/AIDS epidemic must beginwith an assessment of the consequencesfor rural farming households. With manyamong this vulnerable population livinga precarious existence, the epidemicfeeds the mechanisms by which house-holds become landless. Landlessness isalready widely anticipated to becomean increasingly serious problem over thecoming years. Landlessness in Cambo-

dia is an extremely serious issue due tothe limited range of alternative activi-ties. Farmers forced to sell their pro-ductive land face few options otherthan to sell their labour to other farm-ers or to migrate to towns in search ofwork as labourers. Diagram 5 illustratesthe mechanisms by which people be-come landless.

Land issues are indeed of crucialsignificance for an agricultural countrysuch as Cambodia.

Moreover, the same mechanismslead to asset sale and impoverishmentof households affected by HIV/AIDSregardless of the basis of their liveli-hoods. Mounting health costs (includ-ing high spending on unregulated or in-appropriate biomedicine or traditionalmedicine), the loss of labour of pro-ductive family members and the impactof fear and discrimination on employ-ment and business activities are all fac-tors that trigger sale of land and otherassets, followed by a rapid slide intopoverty and sometimes destitution.

Health cost is a surprisingly com-plex issue in Cambodia. The negativeconsequences of illness on householdmembers often feature in the stories offamilies who have fallen into social dis-tress. On the other hand, as will beshown in the second part of this chap-ter, the safety net of public healthcenters is active, and staff claim, at leastoutside the towns, that services areprovided free—the fee-based systembeing inappropriate, due to the extent

53


Diagram 5: Mechanisms by which people become landless

Factors related to landlessness in Cambodia

Sources: Sik (2000), Kato (1999), O’Brien (2000), Biddulph (2000),Vonn et al. (2000), Ramamurthy et al. (2001), Figueiredo et al. (2001).Analysis by National Research Team

Unwantedland

Returnees

Authoritiestake over land

Businessfailure

Insecurity andabsence of legal

land tenure papers

Some NGOcredit projects

LandlessnessInappropriate landdistribution system

Distressedsale

Expensivecredit

PopulationGrowth

Ceremony

Lack of healthservices

Lack of ruralcredit

Illness/accident

Land grabbing bypowerful people

Newly marriedcouples

NaturalDisaster

of poverty. An exploratory qualitativesurvey taken in the agricultural provincewith the highest population density14 ,where landlessness is currently the mainthreat to households, illustrates thecomplexities of the relationshipbetween the health care system and thepeople. Every household surveyedclaimed to need more land, butdeclared that the hope of buying suchland was dependent on none of itsnumber becoming ill. Only the pooresthousehold stated that health care wasprovided free in the public facility.

The Demographic and Health Sur-vey findings also reflect this inconsist-ency. Households were asked aboutseeking treatment for members ill orinjured in the 30 days before the sur-vey. Of these, for a first treatment, 35%sought care in the non-medical sector,33% in the private sector, and 19% inthe public sector. The mean total ex-penditure for this first treatment accord-ing the source is displayed in figure 17,and it shows that public sector was themost expensive of the three sources(the category “Others” can be ex-

14 Takeo province

54


Figure 17: Mean expenditure (in US dollars) for a first treatment

Source: Cambodia DHS - 2000

will, in turn, provide increasingly fertileground for the spread of the epidemic.A descending spiral that rapidly gathersmomentum could thus be initiated,becoming ever more difficult to halt.Therefore, enabling households toavoid distressed sales of productiveassets should be a key focus for publicintervention.

2.2.2. AIDS deaths and the vul-nerability of children

In addition to the loss of livelihoodthrough the sale of productive assets,households affected by HIV/AIDSface the illness and death of familymembers. The welfare of children or-phaned by AIDS is a major concernfrom both the household and nationalperspective. In the current conditions,the vast majority of people with HIVwill eventually die from AIDS. Anti-retroviral therapy is available only to asmall, affluent minority. A projection ofdeaths per year was done in 1999,using three different scenarios forepidemic spreading, by Bunna andMyers (see 2.2.4 below).

Two years after their study, the pro-jections they derived from Epimodelsoftware may be retained as an orderof magnitude. Although their projec-tions concerning the pressure on thehealth system seem, at the present time,not to have come to pass in rural ar-eas, the conclusion that ‘the benefits ofaggressive prevention are clear’ re-mains relevant to the current situation.

The 2000 Surveillance Survey esti-mates the number of adults (aged 15-49 years) living with HIV to be near170,000.15 According to the ratio ofdeath to the number of people withHIV provided by the projections ofBunna and Myers (1999), an order ofmagnitude of the estimated number ofcumulative deaths is around 10,000.

cluded, as it may represent those whowent to another country such as Thai-land or Vietnam, or who used special-ist services).

As these mechanisms cause increas-ing numbers of households affected byHIV/AIDS to slide into deep poverty,the expansion of the segment of thepopulation living far below the povertyline in severe and entrenched poverty

Figure 18: Epimodel projection for cumulative number of AIDS deaths

Source: Estimated Economic Impacts of AIDS in Cambodia,Bunna and Myers (UNDP, 1999)

15 The 2000 sentinel surveillance gives a figure of 169,000 adults (aged 15-49) living with HIV. A computation, based on linear interpolationbetween 1998 census data and the NIS projection (2000), for the estimation of the number of adults (15-49 years old) in 2000, gives a figureof 170,000 adults living with HIV.

55

Box 5: HIV/AIDS and the vulnerability of children

This text is taken from ‘Children Affected by HIV/AIDS: Appraisal of Needs and Resources in Cambodia’,published by the Khmer HIV/AIDS NGO Alliance (Khana (2000) (Phnom Penh)).

Many factors make children vulnerable in Cambodia. These are nearly all related to poverty and are morepronounced for girls than for boys. The most vulnerable ages are between 7 and 12 years, and the most vulnerablechildren overall are orphans from poor families. Children affected by HIV/AIDS are exposed to increased factors ofvulnerability through high levels of psychosocial stress and stigma. The impacts of having a parent with HIV-related illness are multiple and serious. Families can slide into poverty quickly. Children take on new roles ascarers and income generators. Some may have to leave home. After the death of a parent, children can becheated of land, housing and other assets. Some may have to work or beg to pay back their parents’ debts.Siblings are often split up and are unable to look after one another.

There are limitations to all the options for the care of orphans. Grandparents are often old and poor and thedemographics show proportionately few people of grandparent age. Other relatives may treat fostered children asservants, monks have limited resources, children prefer family life to orphanages and life on the street can bedangerous and unhealthy. Adoption and fostering practices are largely unregulated.

The psychosocial impact on children affected by AIDS is very high. Caring for sick parents, coping with grief,relocation too unfamiliar surroundings, separation from siblings and other support networks can all be traumaticfor children. Children may worry that they themselves are infected, that their parents have done something bad, oreven feel that they themselves are responsible for what has happened. They may be actively discouraged fromtalking about a situation where the death of parents is associated with sex. They may be made fun of by otherchildren, or isolated from playing with other children by adults who are misinformed about HIV transmission.Often, children in distress behave in ways that may be interpreted as misbehaviour.

Children with HIV are at risk of being denied their basic rights. Poverty and misinformation can result infamilies thinking that it is not worth treating a child with HIV or sending them to school. There is little experienceamongst health workers of treating children with HIV/AIDS in Cambodia and drugs are either expensive or notavailable.

Figure 18 shows how the cumulativenumber of deaths could rise at an in-creasing rate over time.

The majority of deaths now occur-ring are the result of infection in the earlyyears of the epidemic. Spouses, par-ticularly women, remain highly vulner-able to infection from one another. Theinfection and eventual death of bothparents results in growing numbers oforphaned children. With limited com-munity resources and options for pro-

viding adequate care and support forthese children, they are particularly vul-nerable to poverty and extreme depri-vation that is additionally fuelled by fearand discrimination. From the nationalperspective, the growth of such a seri-ously deprived sub-group within thepopulation will undermine other devel-opment achievements.

Of particular concern is the prob-lem of school drop-out rates. Theseare high in Cambodia, especially for

girls over the age of 12 (see Introduc-tion). Specific solutions are needed ur-gently, and they should be another keyfocus for public intervention, possiblyin partnership with the NGOs alreadyinvolved.

The input of sufficient resources toprovide support for children affected byAIDS - for example, enabling them tocontinue their education and remain intheir home communities - is essential ifthe huge social costs of allowing them

to suffer extreme poverty and depri-vation are to be avoided. The resourcesrequired to provide support for chil-dren affected by AIDS will grow con-tinuously over the next decade as ex-isting HIV infections lead to deathsfrom AIDS. Such scenarios raise le-gitimate questions about the possibil-ity of preventing mortality among peo-ple infected with HIV. The medicaltechnology to achieve this exists. Thekey question is whether or not Cam-


56


bodia can mobilise the resources andcapacity required to make this technol-ogy available and effective for peoplewith HIV (see next session).

2.2.3. Setbacks in human rightsachievements

Human development achievementsare fragile, particularly in the field ofhuman rights. The presence of HIV/AIDS can have a shattering effect onthe very concept of human rights. Thefirst right of any human being is to live.This basic right requires acknowledge-ment in all fields of human activities, andHIV/AIDS leads to setbacks in allthese.

- Respect for the person.Firstly, with regard to respect for

persons with HIV, a significant effort isbeing made in Cambodia to facilitaterespect for people with HIV by inclu-sion of the subject in communicationabout HIV/AIDS at community level,in information campaigns16 and in train-ing for staff involved in HIV/AIDSwork. The negative impact of discrimi-natory behaviour and attitudes is statedand discussed. However, the overallsituation in the country differs from therequirements. It is frequent to still en-counter a persistent disregard for themost elementary rights of people withHIV especially those with AIDS. Fearis a powerful motive for discrimination:a lack of clear information and under-standing about HIV transmission is animportant factor in the continued exist-ence of discriminatory practices.

HIV/AIDS prevention and carecannot be separated from one another.Discrimination is an important issue inthe availability of a continuum of carefor people with HIV/AIDS. In PhnomPenh and in the few other areas whereit is implemented at the current time,

the joint government-NGO home-based care programmes have beensuccessful in reducing fear and discrimi-nation within the household and localcommunity, and in establishing effec-tive referral systems for hospital care.Elsewhere it is possible to witness ap-palling situations. It is vital for discrimi-nation to continue to be actively ad-dressed at each step along the con-tinuum. Discrimination, often based onfear, remains a dominant issue amongpeople involved in the care of peoplewith HIV and AIDS. For example, al-though staff in one referral hospitalstated that people with AIDS were notrefused admission to the hospital, pa-tients with end-stage AIDS were ac-commodated in an extremely small andpoorly maintained building away fromthe main wards.

Unfortunately, discrimination - anda failure to acknowledge a person’sbasic right for respect - may also befuelled by prevention campaigns. Forexample, efforts to implement effectivemeasures to reduce transmission of HIVthrough commercial sex can quicklylead to discriminatory practices againstwomen working in the commercial sexindustry.

- Equitable access to the benefitsof scientific progress

The needs of AIDS patients andtheir families are universal: medicineand scientific progress are the com-mon property of all humankind.(UNAIDS 2001a)

People have a right to receive thehighest level of technical support thattheir society is able to provide at a giventime. Discussion of what Cambodiansociety is able to provide at the presenttime has, so far, been limited to a circleof experts. From the perspective thatthe HIV/AIDS epidemic is a human

16 Such as the video “With Hope and Help: Cambodia” (funded and co-ordinated by UNICEF East Asia and Pacific Regional office and UNICEFCambodia, with support from UNAIDS, produced by Living Films, 2001), which was televised in part. This gives a voice to people livingwith HIV

57

development issue and needs to beaddressed through a rights based ap-proach, it is suggested that it is now timeto open up this debate for people di-rectly affected by HIV/AIDS and so-ciety in general.

The CHDR wants to emphasis theneed to overcome obstacles and con-sider enabling anti-retroviral therapy(ART) on a rights based strategy. Atthe present time, there is no cure forHIV/AIDS. Without specific treatment(ART) there is 100 percent mortalityfrom AIDS. After a long asymptomaticperiod (the global median period ofsurvival from HIV infection to death isestimated at 10 years), with episodicopportunistic diseases, a brief sympto-matic period (estimated at severalmonths to more than one year) withsteeply declining health status, is fol-lowed by death. With ART, this lastperiod can be postponed, and optimaltreatment may enable people to have anearly normal life expectancy, althoughthis is not a cure for HIV.

The year 2001 is an importantbenchmark in debate of the issue ofART, as the formerly insurmountablebarrier of the costs of ART has beenovercome. Nevertheless, there are stillmajor difficulties in enabling widespreadaccess to ART:

- ART requires adequately trainedmedical personnel and adequate facili-ties. Key issues in the provision of ARTinclude beginning therapy at the appro-priate time and ensuring correct dos-age. Failure to do so results in the rapiddevelopment of virus resistance to drugsand consequently, in very poor prog-nosis

- ART has serious side-effects (forexample, on liver function). In a coun-try where the average level of health ispoor, side effects of the drugs may bean insoluble problem.

- ART is extremely demanding onthe patient, requiring a quasi perfectadherence to the drug regime. The ef-

fectiveness of the therapy declines verysteeply without strict adherence to theregime

- In the present conditions ), ARVdrugs are rare goods. A market existsfor the re-sale of many drugs, and thisis likely to be particularly significant forARV drugs. A failure to effectively ad-dress this situation will result in therapid enrichment by a few tradersrather than a significant mitigation of theconsequences of the epidemic

However, these difficulties have tobe considered in the context of thesocial cost of the deaths of the vastmajority of people with HIV. Assess-ments of the social costs must take intoaccount both the direct and indirectconsequences of AIDS mortality. Di-rect consequences include orphanedchildren, impoverishment of house-holds and impact on the working agepopulation. Indirect consequences in-clude the weakening of social links andcooperation resulting from increasinginequity and the limited involvement ofpeople with HIV in efforts to developan effective response to epidemic.

Open and informed debate on thisissue of access to ART, involving allsectors of society is urgently needed.International assistance, particularlyfrom the UN system may inform thisdebate with global experience.

Notwithstanding that this will be adifficult debate, discussion which ena-bles the informed participation of peo-ple with HIV and people affected byHIV/AIDS will enable their voice tobe heard in the public sphere. Opendiscussion about access to treatmentis also intrinsically linked to the facili-tation of access to voluntary counsel-ling and testing.

An open and informed debateabout access to treatment will also fa-cilitate the sharing of accurate informa-tion about HIV/AIDS. Knowledgeabout HIV/AIDS and about treatmentfor HIV/AIDS exists, in a context of


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vast amounts of conflicting and inac-curate information17 . Facilitating thesharing of accurate information not onlyempowers people to make informedchoices about their lives, but also dra-matically reduces discrimination againstpeople with HIV, based on fear. Clearknowledge about HIV transmissionenables carers to support people withHIV without fear that they are placingthemselves at risk of infection. Clearinformation about HIV reduces rejec-tion – by families, communities and in-stitutions – of people who have a basichuman right to live with dignity and re-spect and to receive the best treatment,care and support that society is able toprovide.

2.2.4. An example of assessingthe national impact of the HIV/AIDS epidemic

Combined, two reasons render dif-ficult any tentative assessment of themacro consequences at a national level.The first is the scale of the epidemic:within a range of a few percent, socialconsequences are pointed at the com-munity level, but quantitative consoli-dation of these findings at the nationallevel is reliable only for very limitedactivity domains. The second reason isthe specific features of Cambodian so-ciety. These encompass in particularthe weak social sector, various levelsof monetisation and the feeble enforce-ment of the existing labour code. Asummary of an assessment of the eco-nomic consequences of the HIV/AIDSepidemic by Bunna and Myers (1999)nevertheless allows certain assump-tions to be made about the magnitudeof its impact. The methodology theyused to assess economic impacts ofHIV/AIDS states that:

Studies of the economic costs ofillness and death typically distin-

guish ‘direct costs’ and ‘indirectcosts’. The ‘direct costs’ of HIV/AIDSinclude the public and private costsof treatment and care, the costs ofcaring for AIDS orphans, the costsof funerals, the public and privatecosts of prevention, and the costs ofpreparing the health care system todeal with the growing epidemic. Themost important ‘indirect costs’ ofAIDS are the private losses to house-holds, extended families and commu-nities due to the premature death ofyoung adults of prime working age.What is lost is the income theseadults would have earned, the prod-uct they would have produced.(Bunna and Myers 1999)

Bunna and Myers explore the con-sequences of three possible scenariosfor the evolution of the HIV/AIDS epi-demic in Cambodia. The first scenariois that the epidemic had alreadypeaked in 1998, the second is that thepeak will occur in 2002, and the thirdscenario is that the epidemic will peakin 2006. The authors attempted tocompute, for each of the threescenarios, direct and indirect costs ofthe epidemic: that is, the costs of illnessand death resulting from HIV/AIDS.

1) Direct costs include the publicand private costs of treatment and care,the cost of caring for children orphanedby AIDS, the cost of funerals, publicand private costs of prevention and thecosts of preparing the health system tocope with the growing epidemic.

Of those, only public costs of treat-ment, for both inpatients and outpa-tients, were priced. Lack of informa-tion prevented quantitative assessmentof the following items:

- Cost of prevention (public andprivate, including expenditure byNGOs)

- Household costs (expenditure on

17 For example, so-called Tai-Sheng capsules were being offered by medical staff as Anti-retrovirus medication in a large provincial town.The composition of these capsules is, in fact, plant extracts (Radix ginseng, Radix angelicae, Sinensis, Fructus lycii) and by no means dothey constitute ARV medication.

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healthcare and funerals)- Public health system costs other

than the cost of treatment (e.g., man-aging blood supplies and HIV testing)

Costs of treatment were priced asfollows:

Inpatient care:- Estimate the number of hospitali-

sation episodes: number of people withHIV who will use public health facili-ties multiplied by the number of timesthey will use them.

- Estimate the average length of onehospitalisation episode, in days.

- Estimate the average cost per hos-pitalisation episode (cost per inpatientday plus and average drug cost perepisode).

Outpatient care:Assessed by the same method as

above (number of outpatient episodesper person with HIV and average costper episodes).

These assumptions are time depend-ent and based on the current situationof Cambodia’s main public hospitalsand experience in Thailand. Inparticular, the authors assume that thewidespread availability of home-basedcare will gradually be achieved.

2) Indirect costs are computed asthe loss of earnings of adults dying fromAIDS. The authors argue that it is pos-sible to compute this loss using the av-

erage per capita product ($300), witha decrease over time (to $250) due tothe probable concentration of the epi-demic among urban poor and ruralhouseholds

3) The impact on households ismainly the result of expenditure onhealth services (direct costs and meansof financing payment of health costs).One consequence is that children areleft very vulnerable for example to mal-nutrition and school dropout. The au-thors stress the vulnerability of mostCambodian households to illness andthe costs of illness even before theHIV/AIDS epidemic.

For calculation of points 1) and 2)above, the key data is the estimationof the number of people with HIV, thenumber of people with AIDS and thenumber of deaths from AIDS in eachsuccessive year. This is done throughEpimodel software (Chin and Lwanga1990, 1995), using data available atthe time of the paper, for the three sce-narios described above. Figure 6 in thisCHDR report is based on projectionsfor the ‘best’ scenario (the peak of theepidemic in 1998), which possibly bestrepresents the current situation.

Bunna and Myers’ cost estimationfor 1999 within scenario 1 (epidemicpeak in 1998) is given below as anexample of the outputs of this methodof quantitative assessment of the eco-nomic consequences of the HIV/AIDSepidemic (Table 11)

Estimation of 1999 situation (scenario 1)- Number of new AIDS cases:- Cumulative total number of AIDS cases:- Number of AIDS-related deaths occurring this year:

Direct costs (in USD)- Inpatient cost estimates:- Outpatient cost estimates:- Total:

Indirect costs: (in USD)

5,33611,2166,610

1,152,575400,200

1,552,776

23,131,560

Table 11: Estimation of 1999 HIV/AIDS epidemic cost


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2.3. Poverty in Cambodia fuelsthe HIV/AIDS epidemic

One specific result of the HumanDevelopment perspective is that it helpsto understand the social mechanismsstimulating the epidemic. Global ineq-uity according to the capability to re-spond to the epidemic has been dis-cussed in the Introduction. Obviouslythe multi-faceted problems of humanpoverty are highly conducive to thespread of the epidemic. In order forthis statement to result in effectivepolicy design, the main mechanismsleading to it have to be identified.

2.3.1. Gender inequality feedsHIV/AIDS epidemic

· Strict division of roles betweenmen and women inside society and in-side the family

At the current time, Cambodia ischaracterised by a strict division of rolesbetween men and women inside soci-ety and inside the family. Combinedwith strong social hierarchies, this leadsto rigid stratification. To continue withthe example of the important issue ofschooling, gender differentials are evi-dent from childhood: girls drop out fromschool younger and more often thanboys. This is not a rural feature: eventhe capital town, with its high school-ing rates, follows the drop out patternexplained earlier in the report (see Fig-ure 19).

Figure 19: Gender differential in school drop-out rates(population census 1998 data)

Source: CPS-RUPP Research Team 2000

· Parallel life educationCambodian society is not tolerant

to mixed sex youth activities and doesnot countenance premarital sex be-tween young people. This parallel lifeeducation is ground for socially toler-ated commercial sex consumption byyoung men. This is enhanced by a highsingulate mean age at marriage: Cen-

sus-1998 data give the ages of 24.2years for men and 22.5 years forwomen, respectively. There is evidenceof a present lower value for women,but no known trend for men.

Gender inequality contributes tocommercial sex consumption by youngmen and the vulnerability of marriedwomen to infection from their husbands,

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preparing the ground for the spread ofthe epidemic in the general population.Gender issues are actively addressedby a number of organisations, bothCambodian and international. There issome evidence of changing behaviourin urban areas. However, sustainableimprovement in gender-relatedvulnerabilities requires structuralchanges towards a new balance. Ob-viously, this new balance cannot beconceived of without significant povertyalleviation.

2.3.2. Poverty and low human de-velopment deprive society from theability to act upon itself.

· Social link, public sector andgovernance issue

Low social and economic develop-ment not only contributes to the spreadof the epidemic, but also renders thenecessary response at national level dif-ficult to achieve.

The full power and authority ofthe state needs to be brought to bearon the crisis, ensuring optimal allo-cation or resources and the mobili-sation of all sectors and levels ofgovernment around a result-orientednational strategy. This is the govern-ance challenge of HIV/AIDS.(UNAIDS 2001a)

In Cambodia, the national authori-ties are responding to the epidemic (seechapter three). However, these effortsare hindered, and possibly renderedineffective, by the weakness of the so-cial sector.

A multi-sectoral response is essen-tial to reduce vulnerability to infection,as well as to mitigate the impact of theepidemic at all levels. For example,action by the education sector is clearlyneeded. As described above, it is par-ticularly important for young people tobe targeted for HIV prevention.Knowledge of the social and biologicalmechanisms by which HIV is transmit-

ted as, or before, young people enterinto sexual relationships may be ex-pected to lead to a significant drop inthe HIV incidence rate. The classroomis one of the few places where girls andboys gather together. Even if schoolattendance rates are proportionatelylower for girls in the high grades, theschool provides an opportunity to dis-cuss openly both the HIV/AIDS dis-ease and the underlying mechanismsthat facilitate its spread, particularlygender inequality.

Equally important is the responsefrom the health sector. Following thereform of the health system, a networkof health centres is in place throughoutCambodia. These health centres arethe basic tool for implementation ofeffective public health surveillance.Among its responsibilities are the pro-motion of reproductive health throughSTI treatment and antenatal care andthe immunisation of children. Eachhealth centre is linked to a referral hos-pital, to which it refers patients need-ing hospitalisation or whose illness re-quires more sophisticated medical in-tervention.

An assessment of the effectivenessof the public sector is needed in orderto evaluate the means actually avail-able to the authorities to implementprogrammes for HIV/AIDS informa-tion, prevention and care. Effectivenessof the public sector is not an internalquestion for the public services, but aquestion of the relationship between thelocal facilities and local population.

· The case of the health sectorThe National Research Team un-

dertook fieldworks to collect informa-tion about the level to which the popu-lation can and do make use of publicfacilities. A short timeframe meant thatthe team had to focus their researchon selected aspects of this question.The health sector was chosen as ex-ample of the public sector and four


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provinces were selected. However, theresults of the field study hold for otherfields of public intervention and otherprovinces as well: careful study of spe-cific cases sheds light on how the levelof human development in Cambodia isundermined by public action.

The four provinces visited wereKompong Cham, Pailin, Koh Kong,and Mondulkiri. Kompong Cham is acentral province and the provincialcapital is accessible by river and by agood road from Phnom Penh. Pailinand Koh Kong are both along the bor-der with Thailand, in the west and south-west of Cambodia respectively.Mondulkiri, the largest province inCambodia on the eastern border withVietnam, is a plateau with an elevationof 800 meters. It is particularly difficultto reach from Phnom Penh due to theabysmal road access. The situation inthe province is evidence of the poorestachievements in human development.

In these four contrasted situations,observation of the everyday life of peo-ple involved in responding to the HIV/AIDS epidemic and those infected ordirectly affected by HIV/AIDS helpsto assess consequences of the epi-demic for basic economic activities.This assessment will inform recommen-dations for an effective response. Thesefour examples enable a number of gen-eralisations to be made:

The Cambodian population liveswith endemic diseases, which contrib-ute to the precariousness of life. Ma-laria is widespread. In each of the fourlocations surveyed, campaigns for mos-quito nets are implemented periodically,including the distribution of mosquitonets supplied by the Ministry of Healthor with help from NGOs. Neverthe-less, malaria kills in Cambodia. InPailin, medical staff reported that new-comers were particularly likely to suf-fer serious episodes of malaria, whilethe local population tends to have lessacute episodes. In Mondulkiri, it is es-

timated that up to 70% of the popula-tion is infected by malaria. Tuberculo-sis is very widespread, as are acuterespiratory infections. Health staff alsoreported significant incidence ofdiarrhoeal disease and dermatitis. Lep-rosy is not yet eradicated. There areperiodic dengue epidemics, particularlyin urban or more densely populatedareas, resulting in child deaths. InKompong Cham, at the time of thestudy, health staff were distributing in-secticide for the water containers inresponse to an outbreak. Although den-gue outbreaks are generally more com-mon during the rainy season, dengue isa dry season problem in Koh Kong.The HIV/AIDS epidemic is takingplace in a population already fightingagainst and/or living with endemic com-municable diseases.

The network of health centres is in-tended to address the day-to-dayhealth needs of the population and toidentify patients who need to be re-ferred to hospital. This network is rea-sonably dense, despite an unequalspread. The study found a high aware-ness of the HIV/AIDS epidemic at alllevels of the health system as well asmotivated health staff.

This renders even more striking themajor finding of the fieldwork. Thehealth system addresses, at least par-tially, the HIV/AIDS epidemic. How-ever, the epidemic, rather than exert-ing pressure on the health system, isnearly invisible at each of the differentlevels of the system.

For example, commercial sex is tar-geted for prevention activities by Pro-vincial AIDS Offices. One hundredpercent condom campaigns are inplace, conducted through the Opera-tional Districts and sometimes sup-ported by NGOs. The 100 percentcondom campaigns are implementeddifferently in different locations (seeBox 9). For example, in KompongCham the campaign largely employs

63

strategies of education, including peereducation. Elsewhere, measures aremore coercive, including the relocationof all brothel-based commercial sex toa single location outside the town andcontrol of individual sex workers atProvincial Health Department levelthrough the holding of personal data.At the local level, all the health centressurveyed were willing to include infor-mation on HIV/AIDS in their outreachactivities. Prevention work with indirectsex workers is also undertaken in someplaces, for example, through a pro-gramme of peer education in KompongCham.

Yet, demands on the health systemfrom people directly affected by HIV/AIDS are very low. This lack of de-mand is a reflection of extremely lowrates of utilisation of health facilities forall healthcare needs. For example, whilethe standard of facilities and equipmentlevels vary at the four referral hospi-tals, they share (with the notable ex-ception of Sean Monorom RH inMondulkiri) a low to very low rate ofoccupancy of their medical wards.Occupancy rates are low or minimaleven in the referral hospital in KompongCham provincial town, which is one ofthe largest and has an advantage interms of trained staff, since it was for-merly the provincial hospital. The‘Communicable Diseases Ward’ has acapacity of 20 beds, which are desig-nated for patients with a range of dis-eases including HIV/AIDS, and hasbeen newly repaired and repainted.During our visit only four beds wereoccupied.

Medical staff at all levels are cat-egorical: only poor people make use ofthe public health system, and clients are

often the poorest among the poor. Thisresults in under-activity for the healthcentres. The health centres visited areresponsible for providing services tobetween 10 and 15 villages.18 Thenumber of reported outpatient consul-tations ranged between 100 to 500 forthe month of July 2001, which givesan average of 16 per day. It is not neg-ligible, but it is out of proportion withthe expected healthcare needs of thecatchment area populations.

The clinical skills of health staff areclearly not a factor in this under-utili-sation of the health system by the bet-ter off. The private clinics used by betteroff people are usually run by staff fromthe public clinics. This under-utilisationmay be accounted for by three mainreasons, both of which are closelylinked to development issues.

The first reason is the limited avail-ability of the health staff, which in turnis directly linked to the issue of sala-ries. Health staff members receive asalary that meets the family needs onlyfor a few days of each month. Theytherefore have no choice but to under-take other activities, such as runningprivate clinics or cultivating chamcar.19

The time available for fulfilling theirduties in the public health services istherefore, what remains after they havemet their family’s expenses. Cambo-dia urgently needs a more effectivesystem, but the health staff are pres-ently able to secure only a small partof their livelihood through work in thehealth system. Lack of national re-sources creates a significant discrep-ancy between the organigram of thehealth system and reality, and it facili-tates the spread of the HIV/AIDS epi-demic.

18 Exceptions can be found in remote areas. For example, staff at the Sala Krau HC in Pailin reported that the HC was responsible for providingservices to four communes, a total of 32 villages. Staff noted that difficulty of travel to the referral hospital demands an inpatient facility in theHC that does not currently exist.

19 Chamcar is land used for cultivation other than rice.


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The reported salaries of government staff range from 30,000 to 60,000 riels permonth (between approximately US$ 8 to US$15), depending on the family sizeand position. This does not provide a living wage for an individual, let alone afamily. Well aware of this fact, the government has implemented a policy of salaryincentives for staff but these are currently available only in a small number of workcontexts, for example, for health staff working with tuberculosis patients. Thegovernment is in the process of building partnerships to support the implementa-tion of this policy of staff incentives. International assistance also plays an impor-tant role in the implementation of projects that would otherwise be unaffordable.However, this assistance has the potential to create significant imbalances inhealth service provision, through patchy geographic coverage and time-limitedsupport.

Low salaries coupled with this incentive system result in incentive-driven ac-tivity. This may not permit staff to identify and follow their own clinical prioritiesthat can be highly frustrating and discouraging to the staff.

How far do health staff salaries fall short of providing a basic acceptable stand-ard of living? Health centre staff in Koh Kong made a rapid calculation, based onthe basic needs of a family (rice, food, electricity, water). These needs amount toUS$345.

Box 6: The salary issue

Insufficient state resources result ina poor public sector. A poor publicsector deprives government of themeans for effective action. This situa-tion provides fertile ground for thespread of the HIV/AIDS epidemic andincreases its impact.

The second reason for the under-utilisation of public health facilities is thepoor state of the infrastructure in Cam-bodia. Health centres, without electric-ity, result in difficult conditions (for ex-ample, babies born at night are deliv-ered by candlelight). Travel is difficultfor healthy people; it can be traumaticand dangerous for ill people.

Another important reason for therestricted utilisation of public health fa-cilities is linked to the availability ofmedicines. Firstly the list of essentialdrugs available at public health facili-ties appears to be too limited. Sec-ondly, periodic shortages in essentialproducts undermine the efforts by healthcare staff in the areas of prevention andeducation. For example, while STIs arethought to be a serious public healthissue, and knowing that they can facili-tate the transmission of HIV, a lack of

appropriate basic medicine (such asvaginal suppositories) was found ineach of the surveyed public facilities inall provinces visited. In Mondulkiri, atthe end of the 2001 rainy season, thecontraceptive pill was no longer avail-able, and it was not known when thenext supply would arrive. Hence, theassessment by the population is thatpublic health facilities have limited use-fulness.

· The two aspects of the infra-structure issue.

Cambodia has limited and poorlymaintained infrastructure. Poor qualityroads and limited alternative transportoptions make travel to many parts ofthe country difficult and time-consum-ing. For example, until the upgradingof Route 42 is completed, Phnom Penhis accessible from Koh Kong by atwice-weekly plane or by sea followedby road. Weather conditions, especiallyin the rainy season, sometimes preventboth these modes of transport. Theroad north to Pursat is also very poorand impassable in the rainy season.There has, however, been reported sig-

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nificant migration and mobility betweenKoh Kong and the bordering provinceof Klong Yai in Thailand. Similarly, itrequires half a day to travel from Pailinto Battambang, the provincial capital,a distance of 75 kilometres. And, againdepending on the season and the con-dition of the roads, at least twelve tosixteen hours are needed to reachMondulkiri from Phnom Penh.

HIV/AIDS prevalence rates differbetween provinces and within prov-inces.

These differences may be partiallyaccounted for by limited populationmobility in some areas, which is itselfpartly due to poor transport infrastruc-

ture. Improvements in the road net-work have the potential to fuel thespread of HIVÁIDS, and, ironically,avoiding this possibility will be an im-portant challenge of the coming years(Lee-Nah Hsu 2001).

2.3.3. Poverty fuels mobility andmigration

Mobility and migration are wide-spread in Cambodia, for economic andhistorical reasons. The population cen-sus of 1998 found that 10.4 percentof the population had changed theirresidence within the last five years, withthis rate being much higher in someprovinces and lower in others.

Map 2: Percentage of persons declaring a previous residence less than 6 years ago.


Source: Census 1998

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The highest rates of immigrationfound by the 1998 census are in PhnomPenh, Koh Kong and Pailin, with thefigure for Pailin approximately 40 per-cent. These statistics were one of thereasons for selecting these provincesas fieldwork sites. Superimposing Map2 onto a corresponding map for the sexratio shows that migrants to Koh Kongand Pailin tend to be male workers.These different migratory patterns arean important determinant of vulnerabil-ity.

Mobility and migration are brieflydiscussed here as this report aims tocover societal aspects of the HIV/AIDS epidemic comprehensively.However, in view of the significance ofmobility and migration to the epidemic,a separate study is required in order toprovide comprehensive, in-depth un-derstanding of current patterns of mi-gration and mobility and to enable fu-ture patterns to be anticipated alongwith their potential consequences forthe HIV/AIDS epidemic.

2.3.4. Poverty disempowers thepoor from claiming their rights

Another reason for the failure of theepidemic to exert noticeable pressureon the health system is deeply rootedin the social context of widespreadpoverty: poverty disempowers the poorfrom claiming their rights. The Directorof the Kompong Cham referral hospi-tal gave a striking example of thisdisempowerment. He stated that peo-ple with HIV/AIDS admitted to thehospital are among the poorest of thepoor. However, these patients did notapproach the hospital independently,but are brought to the hospital by anNGO.

The HIV/AIDS epidemic in Cam-bodia is characterised by the public si-lence of those affected. The conse-

quences of infection are a private af-fair, a statement supported by the factthat there is no visible demand on ei-ther the health system or the local au-thority. The burden of HIV/AIDS isbeing felt at household level. Only inPhnom Penh is the health system un-der some pressure. So, unexpectedly,for a country whose sero-prevalencerate (2.8 percent) indicates that theepidemic is already generalisedthroughout the population, researchersfind themselves in search of the epi-demic in the public sphere.

2.4. ConclusionThis section briefly reviews four key

issues raised in this chapter.Firstly, fieldwork undertaken for this

study suggested that substantial humanresources are available to respond tosituations arising as a result of the HIV/AIDS epidemic, but the effective de-ployment of human resources is under-mined by a lack of material resources.

Secundly, at the current time, dueto characteristics of social and eco-nomic development in Cambodia, it ispossible that the epidemic has alreadyhad dramatic consequences for largesectors of the population without thisimpact being reflected by standardeconomic indicators. Cambodia ischaracterised by a very small salariedsector, limited monetisation of the in-formal sector20 and transition to a mar-ket economy that is still recent. Themajority of the population is occupiedin subsistence farming. In such a con-text, standard economic indicators arenot well-adapted to capture even sig-nificant changes because such indica-tors are all based on monetary calcu-lations.

Thirdly, inequitable shares in devel-opment achievements are a seriousconcern for attempts to respond effec-

2 0 For example, calculations using the 1998 census data show that 41 percent of the population aged14 or above are ‘unpaid family workers’. For women this rate is 62%.

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tively to the HIV/AIDS epidemic. Eco-nomic development will not automati-cally reduce social and economic ineq-uity: indeed certain paths of economicdevelopment contribute to an increasein GDP while widening income gaps andpromoting de-skilling. Some investmentis directly exploitative and contributesto an increase in other forms of ineq-uity, specifically gender inequity. Anexample of this is the growth of thecommercial sex industry.

Finally, society is constructed froma set of relationships encompassingbalances of power, gender, knowledgeand economic status. These relation-ships are tightly interdependent. It is notpossible to bring about sustainablechange in one area of social relationswithout altering the balance in anotherarea. Similarly, one area cannot be ad-dressed without addressing all areas ofsocial relations. For example, it is notpossible to bring about change in gen-der relations without directly address-

ing relations of power, knowledge andeconomic status.

These findings point out the gov-ernance challenge as playing a key rolefor scaling up the response given sofar to the epidemic.

HIV/AIDS is a governance chal-lenge of great complexity. In otherwords, success in tackling the epi-demic will depend on how well theoverall national response is gov-erned, managed and coordinated,through strong leadership at all lev-els, dynamic interaction betweengovernment and civil society, andsociety-wide mobilization behindthe common goal of containing thisepidemic (UNAIDS June 2001)

Cambodia is facing this challengewith strong will and involved humanresources, together with poor meansof action. Chapter 3 reviews theachievements already reached in thiscontext, and proposes orientation toovercome this essential inconstancy.


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69

3.1. Governmental and publicsector involvement

3.1.1. The HIV/AIDS task forceChapter two discussed the social

context within which the HIV/AIDSepidemic is developing. This context ofpoverty, inequality, mobility and weakpublic sector services and infrastructureprovides fertile ground for the epidemic.The situation in Cambodia in 2001 in-cludes a range of obstacles to HIV/AIDS prevention, care and impact miti-gation. These include: widespread pov-erty, low human development achieve-ments, and weakness in means of gov-ernance. Conversely, there have been

important achievements in the responseto the epidemic that, it is hoped, willenable Cambodia to join the very smallnumber of countries that have de-creased their sero-prevalence rates.

The government indeed respondedquickly to the emerging HIV/AIDSepidemic in Cambodia. In cooperationwith UN agencies, an HIV/AIDStaskforce was constituted andoperationalised in stages. Table 12describes key milestones in the gov-ernment response to the HIV/AIDSepidemic (UNAIDS 2001c).

The National AIDS Authority(NAA) plays a key coordinating rolein the government response to the HIV/

3. Achievements and Challenges

Table 12: Key milestones in the government response to the HIV/AIDS epidemic

1991

1994

1998

January 1999

2000

2001

Mid 2001

National AIDS Programme established

Provincial AIDS Committees (PAC) and Provincial AIDS Secretariats (PAS)established

Establishment of the National Centre for HIV/AIDS, Dermatology and STDs (NCHADS)within the Ministry of Health

Establishment of the National AIDS Authority (NAA)

Strategic Plan for HIV/AIDS and STI Prevention and Care 2001-05, developed byMinistry of Health

Review of the National AIDS Response

Development of the National Strategic Plan 2001-05

AIDS epidemic. Key tasks includemaking recommendations for policyand for action at national level and en-suring information exchange and com-munication. Identified challenges foraction include:

To ensure that all government struc-tures can work together within the stra-tegic framework.

To develop the capacity and ca-

pabilities of the NAA (includingmember ministries) as well as Pro-vincial AIDS Committees to ensuretimely response and implementationof the National Strategic Plan and(future) Provincial Strategic Plans.(UNAIDS 2001c)

The National Centre for HIV/AIDS, Dermatology and STDs(NCHADS) is another pillar of the

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Administratively a province is divided into districts. Following health sectorreform, a province is also divided into health districts, known as Operational Dis-tricts (OD). One OD often covers more than one administrative district. The OD isthe administrative office in charge of planning, supplying, monitoring and evaluat-ing the health services and structures.

Each OD has one Referral Hospital (RH) and several Health Centres (HCs). Inordinary conditions, the RH provides only inpatient services, while HCs provideexclusively outpatient services. In areas where transportation is very difficult, aHC may provide inpatient services.

In order to respond to the HIV/AIDS epidemic, three working groups are estab-lished by the Provincial Health Department together with the Provincial Authority:the Provincial AIDS Committee (PAC), Provincial AIDS Secretariat (PAS) andProvincial AIDS Office (PAO).

- PAC is a policy-making body, headed by the first deputy governor of theprovince. Its membership consists of the heads of all the departments within theprovince, such as the department of health, department of women’s affairs and soforth.

- PAS is a coordinating body, which is headed by the provincial health direc-tor. Members are officers working in HIV/AIDS prevention in different departmentswithin the province. For example, the member from police department is respon-sible for HIV/AIDS prevention activities in all police stations within the province,such as the recruitment and training of peer educators within the police force.

- PAO is the team of the health staff who work in the HIV/AIDS section of theprovincial health department. They are permanent members of the PAS, whichmeans that they play an important role in implementing HIV/AIDS preventionactivities in the health sector. In addition, they assist other members of the PASin the implementation of HIV/AIDS prevention activities in the different depart-ments.

government response. NCHADS is incharge of the sentinel surveillance sys-tem, it develops, in line with the Stra-tegic Plan for HIV/AIDS and STI Pre-vention and Care 2001-05, strategiesbased on three concepts:

- that a series of high risk situationsfor HIV transmission exists in the coun-try; these situations arise from the be-haviour of a large number of both mar-ried and single men who continue tobuy large amounts of commercial sex

- that the HIV prevalence ratesamong men throughout the country arealready sufficiently high that the spread,via their wives and girlfriends, into thegeneral population, and eventually intochildren, is already taking place

- that sufficient numbers of HIVinfections already exist in the coun-

try to make a significant burden ofincreased morbidity and mortalityinevitable (quoted in UNAIDS2001c)

The Ministry of Health is a key ac-tor and is part of the Priority ActionProgramme. Involvement of other min-istries is also required, through trainingof staff and through specific actions.For example, the Ministry of NationalDefence organises peer educationprogrammes. Guidelines for alternativecare of children affected by HIV/AIDSin formal or non-formal institutions havebeen produced by the Ministry of So-cial Affairs, Labour, Vocational Train-ing and Youth Rehabilitation in coop-eration with UNICEF.

In addition to an HIV/AIDStaskforce and the effective collection

Box 7: The provincial HIV/AIDS taskforce

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Calmette HospitalCalmette hospital has a ward named ‘Medecine B’ with a capacity of 55 beds. Of the 26 staff assigned to this

ward, 6 are medical doctors and 3 are medical assistants. The bed occupancy rate is almost 100 percent. At thetime of writing, 60 percent of the 55 patients were people with HIV-related conditions. The majority of thesepatients were hospitalised with opportunistic infections. The hospital does not provide anti-retroviral drugs (ARVs).However, ARVs are available through private stockists in Phnom Penh and the doctors will prescribe them if thepatient can afford them.

In addition, the hospital has an outpatient department that provides services for people with HIV-related ill-nesses. On average, the department sees about 30 patients a day.

Preah Norodom Sihanouk HospitalThis hospital there is a ward called ‘Medecine infectieuses ward’ with a capacity of 60 beds. Of the 30 staff

assigned to this ward, 6 are medical doctors and 2 are medical assistants. In cooperation with MSF France, theward provides treatment for opportunistic infections as well as providing ARVs to people with HIV.

Centre of Hope/ Sihanouk hospitalThe Centre of Hope is a hospital run by a Christian NGO, providing general outpatient services on Mondays to

Fridays. An average of 10 patients with HIV-related illnesses are seen each day. ARVs are not provided.

Maternal and Child Health CentreA pilot project providing ARV drugs to HIV positive pregnant women and their babies after delivery is currently

in the training phase.

Box 8: Phnom Penh hospital services for people with HIV/AIDS

3.1.2 The ‘National StrategicFramework for a Comprehensiveand Multi-Sectoral Response toHIV/AIDS, 2001-2005’ developedby the National AIDS Authority

The conceptual framework designedby the NAA for the period 2001-2005advocates a shift in paradigm. NAAvision relies on the observation that twocomplementary approaches in supportof decreasing the vulnerability to HIV/AIDS at the individual, community andsocietal level have emerged, accordingto the review of the current situation andthe analysis of obstacles and opportu-nities for change.

The first approach concentrates oninfluencing individuals to understand thatsafe behavior is a more attractive op-

tion, whereas the second strategy fo-cuses on changing aspects of the ex-isting socio-economic context to sup-port individuals to protect themselvesfrom HIV infection and to cope withthe consequences of HIV/AIDS.

Therefore, the NAA strategy callsfor a change to the existing paradigmfor HIV/AIDS actions from a seg-mented, health centered, and top-down approach to a more holistic de-velopment approach that is gender sen-sitive and people-centered with a fo-cus on empowering individuals, com-munities and society.

The guiding principles of this para-digm shift are:

! Holistic> Multi-sectoral and interdiscipli-


of data, advanced medical services forHIV/AIDS exist in Phnom Penh, animportant vanguard in the provision ofmedical technology with which to ad-

dress HIV/AIDS prevention and care.Efforts are now underway to link HIV/AIDS services with other existing serv-ices, particularly TB services.

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nary involvement is essential for build-ing an adequate response to the HIVepidemic.

! Empowerment> People and groups should be em-

powered to protect themselves againstHIV infection

> The plan endorses the GIPA(Greater Involvement of People Livingwith or Affected by HIV/AIDS) prin-ciple as an overriding principle of thenational response

! Community involvement

! Gender equality> Resources allocated must take

into consideration the vulnerability ofthe various affected groups and com-munities

! Human rights based> Equal access to basic care and

services must be guaranteed for all peo-ple infected and affected by HIV/AIDS

> The individual rights and respon-sibilities of people infected and affectedby HIV/AIDS must be upheld, in par-ticular the right to confidentiality

> HIV testing must be voluntary withguaranteed confidentiality and adequatepre- and post-counselling both in thepublic and private sectors

> Adequate health care and supportservices must be easily accessible toall persons infected and affected byHIV/AIDS

The goals for the national responseare set as:

! To reduce new infections ofHIV

! To provide care and supportto those people living with and affectedby HIV/AIDS

! To alleviate the socio-eco-

nomic and human impact of AIDS onthe individual, the family, communityand society

Within this framework and accord-ing to the above goals, seven strate-gies have been designed by NAA

! Strategy 1: Empowering the in-dividual, the family and community inpreventing HIV and dealing with theconsequences of HIV/AIDS throughthe promotion of a social, cultural andeconomic environment that is condu-cive to the prevention, care and miti-gation of HIV/AIDS

! Strategy 2: Enhancing legislativemeasures and policy development

! Strategy 3: Strengthening themanagerial structures, processes andmechanisms to increase the capacity forcoordinating, monitoring, and imple-menting HIV/AIDS actions, and en-hance cooperation with stakeholders atnational and international levels

! Strategy 4: Strengthening and ex-panding preventive measures whichhave proved to be effective and pilotingother interventions

! Strategy 5: Strengthening and ex-panding effective actions for care andsupport which have proved to be ef-fective and piloting ‘new’ interventions

! Strategy 6: Strengthening nationalcapacity for monitoring, evaluation andresearch

! Strategy 7: Mobilising resourcesto ensure adequate human capacity andfunding at all levels.

3.2 Successful partnerships

3.2.1 The United Nation Coun-try Team (UNCT)

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This National Task Force is sup-ported by UN agencies active in Cam-bodia. The United Nation CountryTeam (UNCT) developed a CommonStrategy 2001–05 for the work of theUnited Nations Country Team in sup-port of the national response to the HIVepidemic in Cambodia’ in May 2001.

Within this conceptual framework,the UNCT has articulated a set of prin-ciples for its individual and collectivesupport to the national response to theHIV epidemic. It has decided that itsapproach should be: holistic and devel-opment linked; human rights based;people centred and gender sensitive;based on the mobilisation of the socialand moral resources of Cambodiansociety, and synergistic.

The element of the common strat-egy are: A unified country presence;Leadership dialogue; An advocacystrategy; National capacity building foran integrated and holistic approach;National capacity building for aid co-ordination; Collaborative programming;Review and assessment mechanism.United Nations agencies in Cambodiawill support almost 60 HIV/AIDS ac-tivities costing a total of $2.9 million in2001.

3.2.2 Local and internationalNGOs

Local and international NGOs work-ing on HIV/AIDS in Cambodiacoordinate their work through thePhnom Penh-based HIV/AIDS Coor-dinating Committee (HACC). HACCcurrently has 49 member organisations,many of which in turn provide technicaland funding support to partner NGOsand CBOs in order to build the capac-ity of the local NGO sector to addressthe HIV/AIDS epidemic. NGO strat-egies for HIV/AIDS prevention com-monly include: awareness-raising: con-dom promotion and normalisation andimproving access to condoms; support-ing access to health services and, where

available, voluntary counselling andtesting; intensive work with targetedgroups of men and women to buildknowledge and skills that assist themto reduce their vulnerability; work atcommunity-level to address the socialcontext of vulnerability; mobilising thesupport of local authorities, commu-nity and religious leaders, and workwith peer educators and communityvolunteers.

As the epidemic has become morevisible in Cambodia, and communitiesare experiencing increasing numbers ofdeaths from AIDS, many NGOs andCBOs have begun to provide care andsupport for people affected by HIV orAIDS, their families and carers, andto develop initiatives for impact miti-gation. Key activities include the pro-vision of psycho-social support, ma-terial support and basic medical careas well as referral to clinical and otherservices. Many care and support ini-tiatives have drawn lessons from thejoint government-NGO Home Careprogramme, and importance is at-tached to building partnerships in or-der to provide effective linkages be-tween services. At community level, thesynergy between prevention and careinitiatives are obvious – for example,in reducing discrimination against peo-ple with HIV.

Some NGOs are working in theprovision of medical care for peoplewith HIV or AIDS, either directly orthrough capacity building and fundingsupport for public services. Improvingaccess to treatment is a key challengeand in Phnom Penh, pilot projects pro-viding ART are underway (see Box 8).NGOs also have a key role in advo-cating for the rights of people with HIV,at local and national level. The recentformation of the first network of peo-ple living with HIV in Cambodia re-ceives crucial technical and financialsupport from NGOs and is a key stepin enabling the involvement of people


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with HIV at both programming andpolicy level (see Box 11).

NGOs work in all provinces of thecountry and in the capital. However,geographic coverage is uneven andmany needs remain unmet. NGOs havea vital role to play in enabling effectivelocal and national responses to the HIV/AIDS epidemic. Much has beenachieved, but the need to scale up bothdepth and coverage of activities, incoordination with government servicesand activities, remains a significant chal-lenge.

3.3. AchievementsIn order to assess achievements of

the response to the HIV/AIDS epi-demic, the process of the epidemic can

be divided into five components. First,the context in which the epidemic de-velops: the key concept here is socialvulnerability. Second, the near deter-minants of infection: responses hereoften attempt to target people consid-ered most likely to adopt risky behav-iour. A third component is the issue ofvoluntary counselling and testing (VCT)facilities. Fourth, the issue of peopleaffected with HIV. Fifth, the issue ofpeople dying of AIDS.

This division is only methodologi-cal. It is devised from the natural pro-gression of the disease, rather than bythe relative significance to the societyor as a chronological order for the so-cial response. Clearly, these five com-ponents are intrinsically linked at many

Figure 20 : Knowledge of HIV/AIDS

Source: Cambodia Demographic and Health Survey, 2000

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Regulations on 100 percent condom use in Koh Kong province, July 2001As we know, HIV/AIDS is a savage disease that is continuing to spread through the population across all the

provinces of Cambodia. At the same time. there is an increasing rate of deaths caused by this disease which isof growing concern

In order to suppress and reduce this death rate due to AIDS, and to ensure the welfare of the population theprovincial authority has issued regulations for compulsory 100 percent condom use as follows:

1. The Provincial AIDS Committee, Provincial Health Department and Provincial AIDS Secretariat must stronglyencourage education and dissemination to all the general population in order to avoid the transmission of HIVthrough condom use every time they have sex outside marriage. This measure is to guarantee safety during sex.

2. 100 percent condom use is compulsory throughout the province, to make sure that the people are clear intheir minds that they have no danger in having sex with all kinds of sex workers, in brothels, hotels, guest housesor any other places.

3. Administrative measures will be used to enable active collaboration with concerned organisations to imple-ment this regulation in order to achieve success such as closing down the establishments and sanctioningpeople who do not comply with the regulation.

4. People who make their living from commercial sex must implement and participate in the 100 percentcondom use campaign very actively.

5. The authorities at all levels must participate actively with the 100 percent condom use monitoring commit-tee.

6. The 100 percent condom use campaign must be implemented from the date of issue of this regulationonwards. The 100 percent condom use monitoring committee must provide a written report every month to theprovincial authorities and solve all problems that occur in commercial sex and entertainment establishmentswithin the province in order to achieve a positive result.

(unofficial translation)

21 2000 Behavioural Surveillance Survey found a proportion of 13% of men having ever beentested.

levels. Each component constitutes thecontext of the others and acts directlyon them.

For example, greater availability ofVCT has been widely shown to enablepeople to make more informed assess-ments of risk.21 Therefore, available andaccessible VCT services can be ex-pected to influence the two first com-ponents. Public disclosure of HIV sta-tus by significant number of people withHIV, compared to the present situationwhere the disclosure is exceptional,would deeply modify both the contextof the epidemic and near determinantsof infection, through the power of thevoice of people with HIV and throughthe social response to advocacy for therights of people with HIV.

Along this methodological division,two components have been the currentfoci of responses to the epidemic todate: near determinants of infection and,to a lesser extent, care and support forpeople with AIDS.

3.3.1. Impressive levelof awarenessCambodia is characterised by a

good level of awareness of the HIV/AIDS epidemic: this is both a conse-quence of the achievements mentionedabove and a factor that is conduciveto the strengthening and developmentof such achievements. Throughout thefieldwork undertaken for this report,both the knowledge and active involve-ment of staff at all levels of the provin-cial governmental structures were ob-vious. Opportunistic mini-surveys onmarkets consistently found awarenessof the epidemic and of the main meansof preventing HIV transmission.

The CDHS-2000 Survey confirmsthe same result for women, with a slightimprovement according to age (seefigure 20).

3.3.2 Resolute campaign forsafer commercial sex

Among the achievements contrib-

Box 9: The 100 percent condom use campaign


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Norea Peaceful Children

Norea Peaceful Children (NPC) is an NGO launched and headed by the Venerable Muny Vansaveth, at Noreapagoda, near Battambang. It was begun as an orphanage for children whose parents died as a result of civilconflict, in order to help them to escape a future of continued deprivation: the alternative for these children is oftena life limited by lack of education, lack of food supply and lack of health care.

By 1997, the Ven. Muny Vansaveth realised that a new disaster was causing many children to becomeorphans – namely, the AIDS disease. NPC decided to launch an HIV prevention and care programme. NPCcontinued to provide shelter for orphans from war and AIDS, for street children, and began to provide care andsupport for people living with HIV/AIDS who do not have relatives to care for them.

In 1998, the Ven. Muny Vansaveth believed that he was caring for most of the local orphans needing hissupport (there are presently 61 living inside Norea Pagoda), and began to visit neighbouring villages in order todevelop an education programme about AIDS. Four houses have been built to provide shelter to people living withHIV, in different villages. During visits to villages, the Ven. Muny Vansaveth tries to encourage people living withHIV and to provide information to relatives, mostly wives, about taking care of an HIV infected person.

The Ven. Muny Vansaveth believes that pagodas should and can play an important role in the fight againstHIV/AIDS. There is a high level of respect for monks among Cambodian people and their religious teaching isinfluential. Nowadays, he raises these ideas as widely as possible: two other pagodas now care for orphans, buthave not yet joined the HIV/AIDS programme.

The key message advocated by Ven. Muny Vansaveth is that the role of the pagoda is precisely to help.Moreover, the AIDS epidemic is different from other communicable diseases, such as tuberculosis which can betransmitted through everyday contact. He believes that it is both important and possible to help HIV infectedpeople. Monks should educate monks. In accordance with this, NPC try to train other monks. NPC also co-operates with the Provincial AIDS Office, particularly in order to share training material, in order to increasesupport to infected people.

This support includes encouragement for people, but also explaining and teaching in the community. For Ven.Muny Vansaveth, it is important to involve both traditional healers in dealing with opportunistic infections and thegovernment in implementing a for policy enabling low price modern drugs. Gathering all human resources is hisessential message: if one could achieve an actual co-operation between government, pagodas, and NGOs, a lotcould be done!

This impressive example of involvement of a religious institution in the fight against the HIV/AIDS epidemic isalso an example of lone man’s courage: minimal support is given to Norea Pagoda (so far, the only contributionhas been a supply of rice from the World Food Programme). In order to ensure sustainable support for the 61orphans gathered there, and to try to reduce the number of children orphaned by AIDS in the future. NPC isdeveloping three programmes: agriculture (to help meet food needs), care for the children, and the HIV/AIDSprogramme. NPC urgently needs food supplies and equipment.

uting to this stabilisation of the preva-lence rate is the campaign for safercommercial sex. This approach aims totarget particular contexts of risky be-haviour and has been vigorously de-veloped. The campaign focuses on 100percent condom use (see Box 9). Dif-ferent provinces and teams are vari-ously adopting more education-basedor more control-based approaches. Itis not yet fully deployed, and is just be-ginning in some places, but its potentialimportance should be recognised withinthe context of a clear understanding ofthe dynamics of commercial sex inCambodia.

3.3.3 Care and support for peo-ple with AIDS

Care and support for people withAIDS assume different forms. At leastin Phnom Penh one find Hospices, thatprovide palliative care to terminal stageAIDS patients, such as pain relief, ac-cessory medical care like wounddressing, education on hygiene, nutri-tion, sanitation and food providing:

1. Missionaries of charity (Home ofPeace ) located in Chaom Chao com-mune, Phnom Penh, has a capacity of24 beds, 12 for men and 12 for women.

Box 10: An example of grassroots action in response to the epidemic

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2. Maryknoll provides hospice careas part of its HIV/AIDS programme,with 12 beds available at a hospice inChakangre Krom commune. The aimof the hospice is to provide care for‘those who have no family’. Maryknollalso supports two group homes for atotal of 20 people who are able to takecare of their personal needs.

Pagoda Involvement are an issue offirst importance, as one finds inBattambang (Wat Norea) together withthe NGO, named Salvation Centre forCambodia. They provide food to pa-tients, advise patients to meditate, andcare for orphans (see Box 10)

Finally, home-based care is a mostpromising approach to effective, re-spectful care and support. This impor-tant achievement has been developedmainly in Phnom Penh, but provincialteams are also active in a few locations.Home-based care teams succeed ingathering medical and non-medicalcarers and ensuring their effective co-operation. They integrate the three fol-lowing important actions:

1. The provision of basic treatmentfor symptoms

2. The provision of counselling andadvice and information on condom useand HIV/AIDS

3. The provision of welfare fund forneeds such as transportation to medi-cal services and testing facilities, foodand house repairs.

The present numbers of Home CareTeams are:

- Phnom Penh 10 teams- Battambang 2 teams- Siem Reap 2 teams- Kandal 2 teams- Kompong Cham 1 team- Along national road # 1 and # 4

Related to this issue of care and sup-port for people with HIV/AIDS, theirfamilies and carers, but applying morewidely, is the co-operation between

governmental sector and NGOs, bothnational and international. Despite ob-stacles in some areas, the achieve-ments resulting from this co-operationare encouraging.

3.4. Challenges

3.4.1 The heterogeneous natureof the epidemic in Cambodia

An important challenge is the het-erogeneous nature of the epidemic inCambodia. Pockets of high prevalencerates and of low prevalence rates existfor all surveyed groups, at provincialand - presumably - local level (seechapter 1). Evidence exists for geo-graphic differences in development ofthe epidemic. For example, some ar-eas, such as Pailin, exhibit features ofa more recent epidemic than elsewherein the country, except the north east-ern provinces (Mondulkiri andRatanakiri, which have been so faronly marginally struck). The comingyears will also bring increased nationaland international traffic, through theupgrading of the national road network(Lee-Nah Hsu 2001). Future chal-lenges may include the need to respondto multiple epidemics, thus multiplyingand diversifying the need for accurateinformation and effective means of ac-tion.

3.4.2. A people-centred approachThe key message of this study of

the societal and individual aspects ofthe HIV/AIDS epidemic is that themost effective means of ensuring aneffective and holistic response is toadopt a people-centred approach. Asshown in the report, making the presentachievements sustainable and takingfurther steps towards reducing thespread of the epidemic and mitigatingits impact, requires significant changesin the relations between different so-cial actors. For example, changing thebalance of gender norms and relations


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will be of key importance in develop-ing a fully effective response to the HIV/AIDS epidemic. Other factors are per-haps circumstantial rather than deeplyrooted in society, but are so closelylinked to the national and internationalenvironment that effecting changepresents a difficult challenge. Measuresto improve the effectiveness of the pub-lic sector, such as addressing the issueof civil servants’ salaries are an exam-ple of this.

An effective response to suchsocietal challenges is to adopt a reso-lutely people-centred approach, ena-bling local communities to assess thesituation and local needs in relation toHIV/AIDS, and to enable linkages andinformation-sharing between local ini-tiatives which will be invaluable in in-forming, influencing and strengtheningthe response to the epidemic at nationallevel. Key principles that inform such apeople-centred approach include:

! Giving voice to people.At present, the people most directly

affected by HIV/AIDS, including thepeople living with HIV and the peoplesuffering from AIDS, are largely silentoutside their family and immediate so-cial context. This silence has had a verynegative impact on both the responseto the epidemic and the situation of theaffected persons. On the one hand, thissilence deprives the wider populationof knowledge and an understanding ofthe epidemic, which are vital for theireducation and as a source of informa-tion. Conversely, when they are ableto voice their situation, people directlyaffected by HIV/AIDS are eager toshare their knowledge and are efficientin raising public awareness. For exam-ple, an important testimony is pre-sented to the public in “Cipy heritage”,a video produced by NCHADS in1999. Cipy, who contracted HIV, in-fected his wife and watched her death,knows that he will leave his children

without any parents. He hopes that ifothers, at least, know the circum-stances of his family tragedy, then thatmay help them avoid the same. As heexplains,

“This is the tragedy that my fam-ily is experiencing. I would like totell the true story of my family forthe whole of Cambodian society tolearn from it. I hope there must be achange in behavior to stop the trans-mission of HIV, otherwise this trag-edy will hurt you. I hope that AIDSwill be away from Cambodia fromnow on.”(NCHADS 1999)

On the other hand, for the thou-sands like Cipy with HIV or AIDS andothers affected by HIV/AIDS, silencedeprives them of the chance to claimtheir rights and benefit from the avail-able social help and medical support.An immediate priority is to enable thevoice of people affected by HIV/AIDS, as well as that of grassrootscommunities and civil society actors, tobe heard. The Cambodian network ofpeople living with HIV will be essentialin achieving this goal (see Box 11).

! Ensuring respect for the rights ofpeople with HIV/AIDS through im-proved knowledge of HIV/AIDS.

“My feeling is that I don’t wantanyone to look down on me; I’m ahuman being, just like everyoneelse…I am not afraid of showing myface to you, because it is not onlyme who has this disease, but thou-sands of other people as well…I liketo tell people who have HIV like me,to try not to be upset but to stayhealthy as I do. You may not believethat I have been infected for 7-8years. But I’m telling the truth, Ihave HIV, and I’ve had it since 1993.So far, I am still healthy because Itake care of myselfl. I don’t let thevirus bring me down.” (UNICEF2001)

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The voice of people living with HIV is now beginning to be heard. Support groups and CBOs run by, and for,people with HIV have played an important part in establishing opportunities for advocacy. Recently, these groupsand organisations have come together to form CPN+, the first network of people with HIV in Cambodia. Thecreation of CPN+ is a vital step in enabling the voice of people with HIV to be heard in public discussion about HIV/AIDS and in all levels of policy-making. The member groups and organisations that make up the network currentlyhave a total membership of approximately 800 people.

The objectives of CPN+ include advocacy for the rights of people with HIV and ensuring that they achieve andmaintain a visible public face, and the expansion of the network beyond its strong base in Phnom Penh and thethree provinces where it is currently active. CPN+ is focusing attention on the need to build capacity in order toimplement its activities with maximum effectiveness. Strong and important links with the regional network, APN+,are already established. CPN+ has also attracted the active support of government and non-governmental organi-sations in Cambodia, including KHANA, UNAIDS, HACC, NAA and the Home Care Network Group.

CPN’s member groups undertake many vital activities in addition to advocacy. For example, the CBO, VitheyChiwit, has established strong links with public health services that facilitate referrals to, and from, the organisa-tion. Practical and psycho-social support is provided, including counselling, support for children affected by AIDS,home support visits, a telephone hotline and practical support for funerals.

Box 11: Cambodian Network of People Living with HIV

The people living with HIV whoappear in the UNICEF video “WithHope and Help” send a message thatlinks their requirement for complete re-spect of their dignity with explanationsof their fight to cope with the diseaseand the possibility of going on with anactive life. A clear understanding of thesituation of people living with HIV/AIDS is indeed essential for them tobe respected and supported. Above allwhat is needed is an understanding thatHIV/AIDS cannot be transmittedthrough daily acts:

“We can have meals together, canrest together, can wear each other’sclothes. Therefore, we should not bescared to live with people with HIV.

Instead, we should encourage them,help them to feel comfortablearound their family and friends.Mental support like this helps themto regain their spirit, it gives themthe hope to survive and instils inthem the courage to live in society”(Dr Ph. Cheang Sun Kaing, UNICEF2001). The NAA, for its part, has pro-posed a Charter for Persons withHIV/AIDS in Cambodia. The chartergives examples how to defend and re-spect the rights of people with HIV/AIDS. One of the objectives in writ-ing the charter was to create a basefrom which a national discussion couldspring to produce a law enforcing theserights (see box 12).

Box 12 Rights and responsibilities of people with HIV/AIDS

Charter for Persons with HIV/AIDS in Cambodia

by National AIDS Authority

Considering:- the existing discrimination against persons with HIV or AIDS and their partners, their families, their care-

givers,- danger that the rapid growth of the epidemic in Cambodia, will lead to an unfair and/or irrational attitude

towards HIV infected people and AIDS sufferers,- the imperative necessity for the population to be more aware and better informed about the HIV/AIDS

epidemic and its consequences,- the necessity to undertake common action within the whole country to stop the progression of HIV/AIDS,This charter stipulates the fundamental and basic rights and duties of all citizens with regard to the HIV/AIDS

epidemic.


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1 Liberty, Autonomy, Security of the Person and Freedom of Circulation! The persons with HIV or AIDS are entitled to have the same rights to assure their autonomy, the security of

their person and their freedom of circulation as the rest of the population,! No restriction concerning their movements within the national borders as well as abroad should be imposed

upon the persons with HIV or AIDS,! Segregation, isolation or quarantine of persons with HIV or AIDS in prisons, hospitals or elsewhere is totally

unacceptable,! Persons with HIV or AIDS have rights in decisions regarding marriage and child-bearing, although counselling

about the consequences of these decisions should be provided.

2 Confidentiality and Privacy! Persons with HIV or AIDS are entitled to confidentiality and privacy concerning their health and HIV status,! Information regarding a person’s HIV or AIDS status must not be given without that person’s consent. After

his/her death, this information must not be given without the consent of this or her partner or his/her familyexcept if this information is legally requested or could prevent other people’s lives from being endangered orthreatened.

3 HIV Test! The HIV test must occur only with free and informed consent,! The voluntary and anonymous test must be preceded and followed by a medical examination available to all

the people,! Any HIV positive person shall have access to medical services and to medical, psychological and social

support within the provisions and capabilities of the state.

4 Education on HIV and AIDS! All people are entitled to receive adequate education on HIV and AIDS and to have access to information

concerning preventive methods,! Information to the general public shall be widespread in order to prevent discrimination against persons with

HIV or AIDS

5 Employment! The HIV test shall not be part of an employment test,! Being HIV positive shall not, by itself, be grounds for cancellation of an employment contract, nor for down-

grading or relocating an employee or discrimination in the work place,! No information concerning an employee who is HIV positive or has AIDS shall be given by any employer,! No justification whatsoever shall be given to have an employee get an HIV test,! Information and education about HIV and AIDS as well as access to medical visits shall be organised at the

workplace.

6 Health and Support Services! Persons with HIV or AIDS have rights to housing, food, medical assistance and welfare equal to all other

citizens,! Reasonable accommodation in public services and facilities should be provided for persons with HIV and

AIDS,! Persons with HIV or AIDS shall not be denied access to medical aid funds and to medical services.

7 Media! Persons with HIV or AIDS have the rights to fair treatment by the media and to observance of their rights to

privacy and confidentially,! The public is entitled to receive comprehensive and detailed information about HIV and AIDS in order to guide

their behaviour.

8 Insurance! Persons with HIV or AIDS and those suspected to be at risk of having HIV or AIDS, should be protected from

arbitrary discrimination in insurance,

9 Gender and Sexual Partners! Any person has the right to insist that they or their sexual partners take appropriate precautionary measures

to prevent transmission of HIV,

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! The particular vulnerability of women and children shall be recognised and taken into account.

10 Prisoners! Prisoners shall have access to education, information and preventive measures just like the rest of the

population,! HIV infected prisoners shall have access to the same level of care and treatment as available to all prisoners! Prisoners with AIDS shall have access to treatment that is equivalent to that given to prisoners suffering

from long and other chronic and serious diseases

11 Equal Protection of the Law and Access to Public Benefits! Persons with HIV or AIDS shall have equal access to public benefits and opportunities and the HIV test shall

not be demanded! Public measures shall be taken to protect persons with HIV or AIDS from discrimination in employment,

housing, education and medical and social welfare

12 Duties of Persons with HIV or AIDS! Persons with HIV or AIDS shall respect the rights, the health and physical integrity of others. They shall

take the appropriate measures to ensure this where necessary.

The Cambodian Network of Peo-ple Living with HIV and the NAA char-ter are very important. Neverthelesstheir existence and efforts have yet tochange the realities of those living withHIV/AIDS throughout Cambodia. Themain challenge is to succeed in provid-ing sufficient, accurate and understand-able information. The root of rejectionof people with HIV or AIDS is fear,resulting from misinformation and inac-curate knowledge about HIV/AIDS.For example, the symptoms of AIDSis often extremely distressing, with hugeloss of weight and diarrhea. In order tosupport and care for a person sick withAIDS without fear for their personalsafety, carers need clear and accurateinformation about communicable dis-eases in general and HIV in particular.As long as misplaced fear of infectionpersists, the rights of people with HIVor AIDS cannot be respected.

! Addressing social inequity in or-der to mobilise all social groups effec-tively

Giving voice to people and ensuringaccurate knowledge about HIV/AIDSare crucial strategies. Establishing open

and informed debate will enable theparticipation of vulnerable populationsin initiatives intended to benefit themand this will greatly enhance the effec-tiveness of such initiatives. Such de-bate will, in turn, inevitably lead to dis-cussion of issues of equity. For exam-ple, at present:

- Access to the full range of treat-ments available in Cambodia and thecapacity to mitigate the impact of HIVare directly related to individual wealth,education and power

- Families and carers of the poorlack resources to care and support fortheir relatives

An illustration of dialogue betweenactors and civil society groups at com-munity level and national authorities isprovided by Botswana. The BotswanaHuman Development Report (BHDR)of 2000 was entitled Towards anAIDS Free Generation (UNDP2000). Widespread dissemination ofthe BHDR throughout Botswana en-hanced mobilisation of society, includ-ing people with HIV, in response to theepidemic.22 In Botswana, this led todebate about access to treatment (inparticular, anti-retroviral drugs) which

22 Botswana has one of the highest sero-prevalence rates in the world.


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allows HIV positive people to managethe infection, substantially prolonginglife. Botswanan authorities are re-sponding to this issue.

3.5. Summary: Breaking the vi-cious cycle

The human development perspec-tive is effective when developing a co-herent understanding of the epidem-ic’s dynamics. Poverty and inequalityfuel the HIV/AIDS epidemic, which inturn feeds deepening poverty and in-equality and leads to setbacks in hu-man development achievements. Pov-

erty and inequality enhance vulnerabil-ity: the essential mechanism of this vi-cious cycle. In order to break this vi-cious cycle, its context of gender andsocial inequalities in development mustbe addressed. It is also essential toaddress the specific mechanisms of thisvicious cycle, at least at two levels: themechanism by which poverty leads toinfection (thus leading to a decrease inthe sero-prevalence rate) and themechanism by which infection leads todeath (this mitigating the consequencesof the epidemic). Diagram 6 summa-rises this analysis.

Diagram 6: Breaking the vicious cycle

Prevention:decreasingincidence rate

Support and care for peopleliving with HIV: mitigatingepidemic consequences

Support and carefor people dyingfrom AIDS: fulfillingfundamentalhuman rights

antibody

HIV

CD4

Key concept:Vulnerability. Callsfor the balance ofsociety to change:Gender inequality,

social iniquity.Response:

mobilisation of allsegments of the

society through opendialogue.

Key concept:give voice to people.Calls for bold policy.Response: household

protection against loss ofassets, equity in the shareof medical care, includingART, avoiding HIV leading

inevitably to death fromAIDS.

Key concept: HumanRights.

Calls for knowledge.Response: informationand education, HomeBased Care involvingas much as possible

communities.

Key concept:Risk. Calls for

information andeducation.Response:

Community-basedapproach, peereducation, VCT.

83

It is essential to understand that thefour parts of Diagram 6 are intrinsicallylinked with one another, each being thecontext, cause and consequence of theothers. Addressing one aspect requiresthat all are considered and acted upon.

Prevention is essential if the incidenceof HIV/AIDS is to be controlled. Ascan be understood from Diagram 6 (seethe two left inserted text boxes), pre-vention necessarily involves both thestructural and the near determinants ofthe infection. While the near determi-nants may be addressed with immedi-ate actions, and they will respond rap-idly (a good example in Cambodia isthe 100% condom campaign for com-mercial sex workers), addressing thestructural determinants is essential forsustainable progress to be made inmanaging and eventually halting the epi-demic. Calling for fundamental changesto the main social balances (such as thegender imbalance) involves all sectorsof the society and cannot be consid-ered without first considering the fullimplications for each from the centralto the grassroots levels.

Mitigating the consequences of theepidemic (in Diagram 6 the third tex-tual box from the left) is a social chal-lenge of great importance for Cambo-dia. Although significant difficulties havebeen encountered when attempting toalleviate widespread poverty, no further

steps towards economic and humandevelopment may be considered with-out this alleviation first taking effect.Poverty alleviation is crucial in helpinghouseholds avoid the consequent im-poverishment of HIV/AIDS. This is callfor both a social safety net and deter-mined efforts to keep alive and activepeople infected by HIV.

Dignified support and care for thosewith HIV/AIDS (the fourth of the textboxes in Diagram 6) is not only a ba-sic duty of the society. This mobilisa-tion of communities through initiativessuch as home-based care structures isin return invaluable information, whichwill contribute to prevention strategies.

Both the graph and textual parts ofDiagram 6 show that effective govern-ance is called for.

The Cambodian government hasshown strong political will and shapedan effective tool to design and imple-ment a truly multi-sectoral strategicresponse to the HIV/AIDS epidemicin its creation of the National AIDSAuthority. But, other governance as-pects such as the creation of the ca-pacity to mobilise civil society or theability to bring the response to the lo-cal level, are being undermined by theineffectual social sector and wide-spread poverty. Shortcuts have to befound, whose common features will beenabling people initiative.


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85

Cambodia has attained an importantfirst stage in the response to the HIV/AIDS epidemic. Key achievements todate, which are expected to be condu-cive to continued success in develop-ing an effective response to the epi-demic, may be summarised as follows:

- While it is too early to claim thatthe epidemic is under control, evidenceexists that the national prevalence ratemay have stabilised and is, perhaps,decreasing.

- The presence of the epidemic, itskey characteristics and the challengesit poses for society are well-known andare addressed by the staff of central andlocal administrations.

- Cooperation between central andlocal administrations, the UN agenciesand international and national NGOsexists and plays a significant role in ad-dressing various aspects of the epi-demic.

However, global experience of HIV/AIDS shows that a mature epidemiccan become concentrated in vulnerablesectors of society, where there is al-ready significant social deprivation. Thisleads to the worsening social and eco-nomic situation of the most vulnerablepeople in society and the underminingof poverty alleviation efforts. Such con-centration of the epidemic among thepoor and vulnerable also serves tomaintain levels of infection which havethe potential to refuel the spread of theepidemic. Cambodian society mightexperience such a situation because:

- There is widespread social depri-vation.

- The central administration is largelydeprived of the means to conduct ef-fective action, due to unrealistic salaryprovision for public servants and suchpoor infrastructure that a number ofareas remain effectively isolated fromthe rest of the country.

Therefore, in addition to continuingto implement strategies that have beenfound to be effective, the response tothe epidemic needs to move to a newstage. The first key message of thisreport is the importance of building onachievements to date through theadoption of a broad people-centredapproach. An effective people-cen-tred approach means the mobilisa-tion of communities together withsufficiently strong civil links insidesociety to organise the circulationof resources and suggestions be-tween communities and central ad-ministration.

· Towards a new stage in the re-sponse to the epidemic

Such mobilisation is possible, as aformal public structure exists, withhighly skilled leaders, informed and in-volved staff, with coordination with UNsystem and with the NGO network.This structure may link community levelinitiatives with governmental action,enable community expression to beheard by policy makers and facilitatethe sharing of information.

Such mobilisation is urgentlyneeded, as the inequalities in Cambo-dian society, together with the differ-ential prevalence rates found in differ-ent locations are likely to be condu-cive to the further spread of the epi-demic.

Poverty has long been a centralconcern of the Cambodian authorities.An effective response to the HIV/AIDS epidemic calls for a rapid andeffective poverty alleviation process,together with the strengthening of par-ticipation of all social actors in the de-velopment and implementation of so-cial policies. Such effective processesare possible only if the following issuesare addressed.

4. Conclusion

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- The weakness of the public sec-tor. A significant factor in this weak-ness is the low salary levels that fall farshort of providing a decent standardof living. Developing and implementingsustainable policy will be very difficultas long as this sector remains incapaci-tated by salary levels that necessitatecivil servants making their living byother means.

- The vulnerability of households,particularly poor rural householdswhich account for the majority of thepopulation, to crisis and emergency.Legal and supportive measures to pre-vent the distress sale of productive as-sets are urgently needed, if a growingcore of deep and intractable povertyinside Cambodian society is to beavoided.

- The low socio-economic status ofwomen, which is a serious obstacle toaddressing gender issues, a vital stepin reducing the spread of the epidemic.Key areas of concern include the traf-ficking of women, gender-based vio-lence and the vulnerability of marriedwomen.

- The limited opportunities for in-formation, demands and ideas to cir-culate openly, particularly from thegrassroots level of communities andother groups to the higher authoritiesand policy makers. Increased commu-nication flows from ‘bottom to top’ re-quire mechanisms of policy making thatare able to incorporate suggestions,analysis and demands from the variouscommunities.

The human and economic conse-quences of the HIV/AIDS epidemic inCambodia will depend on the direc-tion that is now taken in the responseto the epidemic. For example, the in-ternational road network currently un-der construction is a potential catalystfor the further spread of the epidemic.The extent to which such catalysts areforeseen and addressed in a timelymanner are key determinants of theconsequences of the epidemic for

Cambodia. Another example is the ex-tent to which access to treatment isenabled, which substantially decreasesthe number of people with HIV whodevelop AIDS in the future. The ac-cessibility of effective treatment forpeople with HIV will determine thenumber of households devastated byAIDS through asset sale and the lossof the productive labour of family mem-bers, and the number of children or-phaned by AIDS.

This report has detailed the avail-ability of data and analysis related tothe HIV/AIDS epidemic in Cambodia.The contribution that quantitative stud-ies make to the understanding of thedynamics of the epidemic has beennoted, along with some of the inherentfragility of such data. It will be impor-tant to ensure that the current surveil-lance systems receive adequate sup-port for continued effective implemen-tation. However, there is now substan-tial information existing, as well as awealth of documentation of global ex-perience of the epidemic that can in-form the Cambodian response to theepidemic. While gaps in understandingremain, and it will be important to learnand document lessons specific to theCambodian experience, the next stageof the response cannot be delayed. Theurgent need is for coordinated and con-certed action.

The following recommendations areoffered as a contribution to this coor-dinated and concerted action:

· Action on HIV incidence:- Effective strategies for reducing

the rate of new infections are alreadyin place and should receive continuedand adequate support.

The partnership between PACstructures and NGOs has proved to behighly effective. Cooperation betweenrelevant administrations, local authori-ties and the PAC needs to be contin-ued and enhanced.

- Enabling sharing of information,

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open discussion and the developmentof strategies for coping with the epi-demic for all groups in society. Part ofan effective strategy for achieving thismay include extending networks of peereducators within professional and vo-cational bodies. Peer educators havebeen found, internationally, to be an in-valuable resource for enabling an envi-ronment of informed discussion andsupport

The different line ministries are keystructures to scale up peer educationprogrammes. Of particular importanceshould be the involvement of the Min-istry of Social Affairs, Labor, VocationalTraining, and Youth and Rehabilitation(MoSALVY), in partnership with thecorporate sector. Within the corporatesector prime responsibility rests with thetransport and garment industries. Thelatter being concentrated in the suburbsof Phnom Penh and employing thou-sands of young women.

- Opening up communication chan-nels within communities, between com-munities and between community andnational levels, will enable the epidemic,and its impact, to be better understoodand will ensure that the views and needsof people at community level are heardby people responsible for coordinatingthe response to the epidemic at nationallevel. At village level, the existing sys-tem of local administration provides akey opportunity for the sharing of in-formation and understanding betweendifferent stakeholders.

The communal elections, to takeplace in early 2002, will place at thehead of each commune their firstelected commune leaders. Communalcandidates should interact with theNGO networks, and the Ministry ofInterior should facilitate the raising ofHIV/AIDS concerns during the elec-toral campaign.

- Mobilising the support of influen-tial people in the community is a keyaspect of an effective response to theepidemic. The pagoda, and religious

leaders, remains a focal point for manycommunities. Active support from thepagoda and religious leaders has a keyrole to play in raising awareness andreducing discrimination.

A people-based approach relies onthe involvement of a variety of keycommunity members. This groupshould include monks, Achars, andmore generally those well-versed inBuddhism, as well as teachers andolder educated men. All these commu-nity members command respect. Theyare a part of a series of integrated so-cial links. Their participation in the ef-fective implementation of a people-based strategy will be very valuable,provided support is given, at all levels,for accurate information circulation andopen debate.

- Women face specificvulnerabilities, both to HIV and to theimpact of HIV. Women are also largelyunrepresented in the local administra-tion systems. Enabling the voice ofwomen to be heard at local and na-tional level, and providing full supportfor action undertaken by women toreduce vulnerability and impact are keycomponents of a response to the epi-demic.

The Ministry of Women and Veter-ans Affairs has developed awarenesscampaigns about the need for wom-en’s participation in civil, professionaland political life. However, the devel-opment of women’s associations isprimarily an urban phenomenon andmostly limited to the affluent in PhnomPenh. Nevertheless these associationsare important and some have radio,electronic and printed communications,examples of which are the CambodianWomen Media and the KhmerWomen Voice Magazine.

- Protecting the different social seg-ments by understanding their differ-ences is very important. This type ofunderstanding is especially needed inthe design and implementation of strat-egies aimed at Cambodia’s youth.

Conclusion

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Steps towards a future without AIDSmust include vigorous youth-orientedprevention programmes in order toachieve what Botswana’s HDR hascalled “an AIDS free generation”. Asexplained in the report, Cambodiansociety is characterised by a strict di-vision of gender roles and the markedseparation of males and females dur-ing their youth. These social and physi-cal demarcations provide an incentivefor traditional male behaviour particu-larly in relation to the consumption ofcommercial sex. Integrating safe sexcampaigns within wider reflections ongender, responsible sexuality and fam-ily life will be essential if their programsare to shape the values of those on thecusp of adulthood.

In these campaigns the Ministry ofEducation incorporating the Depart-ment of Informal Education, is a keyinstitution as many young Cambodiansno longer attend school in their teen-age years. Both HIV prevention pro-grams and programs addressing dis-crimination and stigmatisation should bein the curricula. Where possible thecontents of these programs should bedetermined and designed in collabora-tion with relevant NGOs and commu-nity associations.

· Action on the impact of the epi-demic:

- Improving access to quality VCTis essential if the incidence and impactof HIV/AIDS are to be affected. Cur-rently there is a serious lack of nation-ally approved VCT facilities. Multiply-ing Family Health Clinics with appro-priate resources and trained staff isneeded. Increasing the level of accessto VCT facilities also calls for co-op-

eration between the private and publichealth sectors.

- Increasing access to effectivetreatment for opportunistic infectionswill improve the health status of peo-ple with HIV and enable them to con-tinue to play an active and productiverole in the family and in the wider soci-ety. This requires that sufficient re-sources, in terms of drugs, equipment23

and salaries are made available to pub-lic health facilities and steps are takento ensure that treatment is accessiblefor people with HIV.

- An informed debate aboutantiretroviral therapy is needed at alllevels of society in order to assess thepossibility of making this therapy widelyavailable and effective for people withHIV throughout Cambodia. Recentglobal reductions in the cost ofantiretroviral drugs24 and lessonslearned from the implementation of pi-lot projects in Phnom Penh provide abasis for serious debate of this issue.Such a debate may be expected tohave an immediate benefit in that it willcounter the current climate of misinfor-mation about ‘AIDS cures’ availablein Cambodia and internationally. Thepossibility of requesting technical sup-port from the Accelerating Access ini-tiative of the UNAIDS Secretariatcould be considered during such a de-bate.

The Ministry of Health has an im-portant role in the provision of infor-mation about the technical aspects ofthe ART issue, but it is also recom-mended that a tripartite co-operation(involving the key informants, peopleliving with HIV and health centre staff)be established at the grassroots level

- Continued support for the exist-

23 Health centres surveyed during this study had staff with laboratory technician skills but lackedequipment with which to put these skills to use. For example, the only equipment available in most ofthe health centres was a microscope.24 An Indian pharmaceutical company is offering generic drugs to Medicins sans Frontieres at a cost ofUS$ 350 per person per year, in contrast average costs in the US of US$10,000 per person per year.The same drugs have been offered to governments at a cost of US$500-600 per person per year(Colebunders 2001).

89

ing networks of people with HIV andplanned expansions should be providedby the relevant bodies in order tostrengthen the capacity and scale-up ofthese networks.

- The burden of care for people withHIV or AIDS is felt at household level.Action is needed to lessen this burden.For example, the strengthening of ex-isting social safety nets and the crea-tion of additional appropriate legal andsocial systems will enable families andhouseholds to avoid distress sales ofassets which lead to impoverishmentand destitution of family members, in-cluding children.

Based on the findings from experi-ments in Cambodia (for example thoseconducted by NGOs dealing withcredit systems) and outside Cambodia(for example the Thai system of co-operation between referral hospitalsand communities), the Village Develop-ment Committees could assume lead-ership of a co-operative relationshipbetween the Ministry of Rural Affairsand local and international NGOs.

- The provision of home-based carethrough joint government-NGO initia-tives is one of the achievements to datein the response to the epidemic.

However, scale-up is urgentlyneeded and sufficient financial and tech-nical support should be provided toenable this. It will be important to en-sure that home care teams are part ofan active and effective network at pro-vincial level.

- The vulnerabilities of childrenaffected by AIDS will be addressed,at least in part, by the actions detailedabove. Children orphaned by AIDShave a specific need for appropriatecare-givers to be identified. Interna-tional and Cambodian experienceshows that children usually prefer toremain with family members and in theirhome communities where this is pos-sible. Support should be made avail-able to initiatives that promote andsupport care for orphaned children byappropriate people within their homecommunity. Local institutions, such asthe pagoda, may also be in a positionto provide valuable support for or-phaned children.

Actions on incidence and action in-tended to mitigate the impact of theHIV/AIDS epidemic are intrinsicallylinked on many levels. International ex-perience shows that the most effectiveresponses to the epidemic are thosewhich address both HIV preventionand HIV care and impact mitigationsimultaneously.

Cambodia has made great stridesin a short space of time towards apeaceful society. Building on theseachievements, Cambodia may nowadopt a people-centred approach forthe mobilisation of all its resources inits efforts to reduce the spread of theHIV/AIDS epidemic, joining the ranksof the small minority of countries thathave reduced their prevalence rate, andto mitigate its impact.

Conclusion

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91

The goal of this capacity buildingprocess is national capacity to produceHuman Development Reports, througha body of skilled government and non-government researchers, drawn from anumber of relevant Cambodian minis-terial and academic institutions. Thisgoal is in line with the concept of Hu-man Development and with the globalUNDP principles underlying the pro-duction of Human Development Re-ports (UNDP 2001b), including:

- National ownership- Independence of analysis- Quality in analysis- Participatory and inclusive prepa-

ration- Flexibility and creativity in pres-

entation- Sustained follow-upThe capacity building is currently in

pilot phase, which has involved the re-cruitment of a National Research Teamof nine members, with a Research Di-rector appointed by an independentresearch institution, Cambodia Devel-opment Resource Institute (CDRI).Four institutions are involved, Ministryof Planning (MoP), Royal University ofPhnom Penh (RUPP), National AIDSAuthority (NAA), and National Cen-tre for HIV/AIDS, Dermatology andSTDs (NCHADS), the two last in viewof the fact that the 2001 CHDR focuseson the HIV/AIDS epidemic. This teamhas been responsible for the prepara-tion and the production of the CHDR2001, with technical support fromCDRI and under the overall leadershipof Ministry of Planning.

The capacity building project isguided by three principles:

1. Capacity building is a proc-ess over time

Learning is a complex process. It iswell known that there exists a gap be-tween a first stage of familiarity, whichis sometimes assessed through the ac-quired capacity to repeat definitionsand stereotyped procedures, and fullownership of a field of knowledge,which implies an understanding of thecontext of knowledge and analysis ofinformation. Such full ownership ena-bles autonomy in conducting researchand producing hypotheses and findings.Capacity building programmes areaimed at supporting processes of learn-ing to this latter stage, which alone canlead to sustainable intellectual and na-tional autonomy.

2. On-the-job training: an effec-tive but demanding approach

An effective method of learning,and one which is well-suited to adultswith existing professional experience,is on-the-job training, enabling train-ees to ‘learn by doing’. The presentphase of the UNDP project CapacityDevelopment for the Preparation of theCambodia Human Development Re-ports is utilising this approach fully, asthe National Research Team recruitedin 2001 is responsible for preparingand producing the 2001 CHDR re-port.

In the field of human development,where the conceptual framework mustbe informed by quantitative assess-ments, a broad training programme isrecommended. Ownership of the re-port’s content implies the capacity tounderstand and undertake the entireprocess from raw data to analysis andthe drawing of conclusions. This re-

Annex A

Capacity building for national ownership on Human De-velopment perspective

Annex A. Capacity building for national ownership on Human Development perspective

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quires a good knowledge of up-to-datecomputer data analysis procedures, aswell as the ability to contribute fully tothe discussion of the necessary adjust-ments that influence the final value at-tributed to indicators. This final steprequires a researcher to draw on abroad range of skills and knowledge.It also requires access to discussionsheld among international experts:‘Learning by doing’ is possible only inclose synergy between trainees and thatbody of international expertise.

3. Medium of communicationAt the present time, English language

is the international language of science

and communication. No high-levelwork in the human sciences can beachieved without access to this medium.English language is needed to acquirefamiliarity with international resourcesand to participate in scientific ex-changes.

In parallel with this requirement, theworking language used by the NationalResearch Team is Khmer. This is typi-cal of research practices around theworld. Working in the national languageand mother-tongue of the researchersserves to ensure both full understand-ing and communication among the re-searchers and effective disseminationto a broader audience in Cambodia.

1) General Population Census –1998

The National Institute of Statistics(in the Ministry of Planning) conducteda General Population Census in 1998.Based upon a de facto population, the1998 census collected informationabout household facilities, and indi-vidual demographic, educational, em-ployment, and recent fecundity data.Thus it provides a robust descriptionof the country.

The National Institute of Statisticstook particular care when disseminat-ing the results, both in the form of sev-eral reports, including the main tables,and as a database, thus allowing re-searchers to undertake further analy-ses. The census database is availablein the following three presentations:

- aggregation at the village level,which can be handled by any statisticalpackage (NIS Cdrom n°2).

- the above village database is in-corporated in a software package be-longing to the SIG family, PopMap

(NIS Cdrom n°3)- the data for individuals is only

available through the software WinR+,ensuring no misuse of this informationis possible (NIS Cdrom n°4).

2) The Socio-Economic SurveysThese sample surveys include a very

detailed questionnaire, covering themain aspects of social life (education,activity, health, income and expendi-ture). The table 13 shows the keycharacteristics of the Socio-economicSurvey in Cambodia

3) Demographic and Health Sur-vey

The Cambodian Demographic andHealth survey was conducted in 2000by the National Institute of Statistics(Ministry of Planning) and the Direc-torate General for Health (Ministry ofHealth), with technical assistance fromMacro International through itsMEASURE DHS+ program. 12236households were interviewed (1817

Annex BLarge surveys in Cambodia: a wealth of invaluablequantitative data.

93

Sample size

Sample coverage

Survey timing

Consumption recall

SESC 1993-94

498 villages5,578 households32,079 pers.

Rural 68.0%Urban 95.2%15 Provinces3 strata

October-September

177 food items266 non-food items

CSES 1997

474 villages6,010 households


June


CSES 1999

600 villages6,000 households


January-MarchJune- August


Adapted from ‘A Poverty Profile of Cambodia’ (Gibson 1999).

1) Poverty is a multidimensionalconcept

The concept of poverty is appliedto situations at both individual (orhousehold) and country levels. Fromboth these perspectives, poverty is amultidimensional concept. Box 13 de-scribes the concept of poverty from anindividual (or household) perspective.At the country level, poverty is linkedto the capacity of the economy to pro-vide a central administration with suffi-cient resources to develop infrastruc-tures, organise public services and im-

in urban areas and 10419 in rural ar-eas), from which the correspondingnumber of eligible women, those be-tween the ages of 15 and 49, inter-viewed was 15351 (2627 in urban ar-eas and 12724 in rural areas).

The DHS asked for descriptions ofthe household population, housing char-acteristics and the respondents’ char-acteristics and status, together with thequestions about the following 12 top-ics:

- Health status and the utilisation ofhealth services

- Fertility- Abortion practices- Fertility regulation and other

proximate determinants of fertility- Fertility preference- Adult and maternal mortality- Infant and child mortality- Maternal and child health- Maternal and child nutrition- HIV/AIDS and other sexually

transmitted infections- Women’s status and empower-

ment- Domestic violence.

plement development programmes.Key economic factors that determinethis capacity include: the level of eco-nomic activity, the state of the interna-tional market, and the currency ex-change rate. While the first of thesethree factors can be directly affectedby policy at national level, the latter twoare closely related to the global eco-nomic context. In addition, social fac-tors are also key determinants of thecapacity of the economy to provideadequate resources to the central ad-ministration.

Annex CMeasuring poverty

Annex B. Large surveys in Cambodia: a wealth of invaluable quantitative data.

Table 13: Key characteristics of the socio-economique survey in Cambodia

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Poverty at the individual or household level is a complex concept. It affects individual or household capacity toachieve an acceptable quality of life. These capacities can be characterised as follows:

- The capacity to meet the basic needs of the individualOne obvious dimension of poverty is the inability of the household to provide each of its members with suffi-

cient food and shelter: meeting the basic needs of its members is one of the most immediate concerns of poorhouseholds. In a cash economy, the ability to meet the basic needs of the members of a household is determinedby the balance between income and essential expenditure. In rural village life – where 84 percent of the Cambo-dian population live (1998 population census) – subsistence farming or the exchange of goods form an importantpart of the rural economy. Therefore, the possession of even the simplest of productive assets, including labour,is often a significant factor in enabling households to meet the basic needs of their members.

- The capacity to cope with emergenciesPoverty is the lack of minimum security in the face of unforeseen events and crisis. For example, a health

crisis is a common factor in triggering a decline into poverty or worsening poverty at the individual and householdlevels. Medical costs or the loss of the labour of a productive member of the household often lead to debt ordistress sales of productive assets, even when basic needs were met on a day to day basis under normalcircumstances.

- The capacity to mobilise a support networkThe capacity to mobilise support in the face of shortages or crisis reduces vulnerability to poverty or worsening

poverty. Such a support network often includes extended family and kinship ties as well as other alliances.Poverty is the lack of a network that can provide such support in time of need.

- The capacity to benefit from opportunitySocio-economic changes, inherent to every society, may lead to disaster at an individual and household level

– for example, through the collapse of agricultural prices or the loss of traditional sources of income. Suchchanges also provide opportunities for advancement, such as the opportunity for employment or business. Pov-erty is the lack of resources to seize such opportunities, including economic and human resources; for example,the lack of resources to respond to a business or employment opportunity.

- The capacity to promote children out of povertyPoverty is also an inheritance. Simply meeting the basic needs of children does not reduce their vulnerability

to crisis or enable them to break free of the cycle of poverty. Poverty is the lack of capacity of families to enablechildren to grow out of poverty. Access to appropriate education and training is a key factor in raising children outof poverty

Box 13: Poverty is a multidimensional concept

Links between poverty at householdlevel and poverty at country level arecomplex: positive economic growthrate (measured, for example, as an in-crease in per capita GDP) may be ac-companied by impoverishment of par-ticular sub-populations. Such vulner-able groups often include workers mi-grating from rural areas in search ofeconomic opportunities in the cities,where they often make a precariousliving at the margin of urban develop-ment. Industrial activity requiring largeamounts of cheap labour may gener-ate appreciable taxes and incomes fromexport while workers receive lowwages with limited job security and lit-tle negotiating power.

Despite the complexity of the con-cept of poverty, it is essential for policymakers and social actors in general tohave access to a quantitative assess-ment of the poverty situation. Quanti-tative knowledge is required both tofollow changes over time (in order tomonitor the impact of policy implemen-tation) and to compare with the situa-tion in other countries. In Cambodia,substantial efforts have been made overthe last decade, both by the centraladministration and by the internationalcommunity, to collect informationcountrywide about a range of demo-graphic and socio-economic variables.

Measuring poverty, as with all meas-urement of social issues, necessarily

95

requires simplification. Many of the di-mensions of poverty described aboveare difficult – or impossible – to quan-tify. Even for those features that seempossible to measure, summarising vari-ous dimensions in a single index is highlychallenging. In order to provide a meas-ure of poverty it is necessary to makechoices, leading to a simplification ofthe concept of poverty.

However, measurement of povertyis necessary in order to provide essen-tial information for all programmes thataim to reduce poverty. For example,the World Bank discussion paper, APoverty Profile of Cambodia, states,

Better and up-to-date informationabout the poor is essential to assist

the government in designing effec-tive policies for attacking poverty.Who are the poor? How many poorare there? Where do they live? Whatare their sources of income? Poli-cies intended to help the poor can-not succeed unless the Governmentknows who the poor are and howthey are likely to respond to publicinterventions. (Prescott and Pradham1997)

Therefore, we must simplify. Twoaspects of poverty are more easilyquantified than others and can be usedas a basis for poverty assessment – in-dividual income and consumptionvalues.25 In Cambodia, consumptionvalues have been selected as the basis

25 Consumption data is collected at household level. Individual consumption values are calculated bydividing the household value by the size of the household (Knowles 1998).

Box 14: The food poverty line

The consumption level that separates the poor from the rest of the population is called the poverty line. Turningfirst to food consumption, the food poverty line has been calculated using data from the SES 1993–94 andupdated with data from the subsequent SES surveys. Data were collected by asking respondents to report thequantity1 consumed in the past week of a given list of food items and the value of this consumption. Where valuesare given in-kind rather than in cash terms, value is assessed using the market price. The steps for calculating thefood poverty line from this data are as follows:

1) Nutrition is itself a complex subject. Diet must fulfil a wide range of nutritional needs, such as protein,energy and many micro-nutrients. Again, measurement requires simplification. The choice made here is to sim-plify by focusing only on energy intake, measured in terms of calories. The benchmark adopted is a 2,100calories minimum energy requirement per person per day. This is a low value; for example, the WorldHealth Organisation (1985) states that the daily calorie requirement for a subsistence farmer (a large part ofCambodian population) is 2,780.

2) There are many possible ways to provide 2,100 calories per day. However, typical consumption patternscan be identified for broad categories of population in a given country at a given date. SES 1993–94 providesdetailed data on quantities of food consumption, from which consumption patterns may be drawn. The popula-tion group chosen to derive the model composition of food consumption is the third quintile for totalconsumption distribution.2 A reference food basket is constructed by taking average values of the reportedquantities consumed of each food item by this population group. It is important to notice that in this basket morethan two-thirds (69 percent) of the calories obtained are from cereals, especially rice. The reference food basketderived in this way actually corresponds to a calorie content of 2,298. Thus, all quantities are scaled down by thesame factor in order to achieve a reference food basket with a calorie content of 2,100.3

3) Cost of this reference basket has now to be determined. This is done using market prices. SES makes useof pre-stratification of areas (see Annex A). SES 1993–94 defined three strata: Phnom Penh, other urban areas,and rural areas. Separate price estimates were obtained for each of the three strata, leading to three different foodpoverty lines.

1 At least for SES 1993-94. SES 1997 and 1999 did not provide quantities, but only values, leading to a complicated update method.2 The median quintile is the 20 percent of the population whose total consumption is mid-way between the poorest and the richestquintiles.3 Dividing 2,100 by 2,298 gives a factor of 0.9138

Annex C. Measuring poverty

96


for attempts to quantify poverty. Themain reason for selecting consumptionrather than income as a basis for apoverty index is that discrepancies areoften observed between declaredincome and declared consumption,with the declared income beingsignificantly lower than declaredconsumption. Another reason is thatthere is more information available onconsumption than income as the socio-economic surveys (SES) of 1993-94and 1997 focus on consumptionassessment. Consumption data areusually more reliable than those ofincome. The first countrywide surveyto provide information on income wasthe 1999 SES.

2) Poverty linesThe first step in calculating a con-

sumption-based index is to assess alevel of consumption below which an

individual will be defined as poor: theso-called poverty line. It is well knownthat if consumption is divided into twocategories, food consumption and non-food consumption, the poorer peopleare, the higher the proportion of theiroverall consumption that is accountedfor by food consumption. In determin-ing consumption levels that can be usedto separate the poor from the non-poor, food consumption is the most sig-nificant measure. Thus, a food povertyline (a minimum level of food consump-tion) is first calculated (see Box 14). Anon-food minimum allowance is thencalculated (see Box 15) and added tothe food poverty line to provide the totalpoverty line.

The non-food allowance estimationrelies on regression model. Let us re-call that the minimal allowance for non-food goods is based on the typical non-food spending of those who can justafford the reference food requirement.

Box 15: Total poverty line.

To incorporate non-food expenditure into the construction of the poverty line, a minimum allowance for non-food goods was computed, based on the typical non-food spending of those who can just afford the reference foodbasket and are therefore just on the food poverty line. If people who are just on the food poverty line allocateexpenditure to non-food items, it can be assumed that the welfare derived from this amount of non-food is higherthan welfare derived from the food expenditure that this requires them to forgo. It can thus be considered aminimum allowance for non-food spending.

It is not easy to calculate the cost of this minimum non-food allowance, and consequently the overall povertyline, because no unit value for non-food items were recorded in any of the SES surveys. SES 1997 used a differentmethod for calculating the cost of this allowance to that employed in SES 1993-94 and SES 1999.

The method used in 1993-94 and 1999 was to estimate a regression equation. Given the individual totalexpenditure and the poverty line value, one can estimate an equation for the individual food share to be a functionof these two values. The value of this estimated food share for those just reaching the poverty line (total expendi-ture equal to poverty line) enables the non-food allowance to be calculated, and then the overall poverty line (seeannex B for detailed model).

The method used in SES 1997 is closer to the steps used to estimate the food poverty line and is an updateof the non-food allowance calculation from the 1993-94 data. The non-food consumption of individuals whose totalconsumption was within 10 percent above or below the value of the food poverty line was used to form a set ofweights (share in total consumption) for ten groups of non-food items. To overcome the fact that data on unit pricewere not collected, the Phnom Penh Consumer Price Index was used to obtain an estimate of the change in thecost of the non-food allowance between July-September 1994 and June 1997. The main drawback of this methodis that it assumes that price movement in the Phnom Penh strata is a good approximation for the rural and otherurban areas strata. This is unlikely, as it is not the case for food prices.

97

26 y is a linear function of x if the dependence of y from x takes the form : y = a + b*x. a andb are two parameters, the first one called intercept (or constant), the second one calledslope.

The resulting values for the poverty lines are presented in the table below:

Poverty lines, in riels per person per day

1993-94

1997

1999

Phnom Penh

Other Urban

Rural

Phnom Penh

Other Urban

Rural

Phnom Penh

Other Urban

Rural

Food Poverty line

1,185

995

881

1,378

1,102

940

1,737

1,583

1,379

Average foodshare* (%)

0.67

0.73

0.73

0.68

0.72

0.71

0.58

0.68

0.71

Non-food allowance

393

269

236

441

305

270

733

510

398

*for those just reaching the poverty line

The regression approach follows the following steps: * In order to compute the non food allowance for those just capable of reach-

ing the food poverty line, one build a food demand function for each strata j (PhnomPenh, Other Urban areas, Rural areas), which compute the food share for eachhousehold (food share for household i in strata j = si

j) as a linear function26 of thelog of the value of total spending (total spending for household i = xi) relative to thefood poverty line (food poverty line for strata j = zj

f )

sij = aj + b log (xi / zj

f ) (1)

In this equation, we know the food share, the total expenditure and the foodpoverty line. We use (1) to compute the constant aj and the slope b by bestadjustment on the data.

* using the such determined coefficients aj and b, we compute a non-foodallowance (we compute a food share, so we deduce a non-food allowance) foreach strata for those just reaching the poverty line. For these households indeed,xi = zj

f , so the ratio equal 1, and consequently the log equal 0: Thus the food sharefor those just reaching the poverty line is given by aj .

* We compute an overall poverty line by adding the non-food allowance to thefood poverty line for each stratum. As aj is the food share for those just reachingthe poverty line, their non-food share is given by (1- aj ), and thus the non foodallowance is (1- aj )* zj

f . Then the overall poverty line is:

z j = zjf + (1- aj )* zj

f

z j = zjf *(1 + 1 - aj )

z j = zjf (2- aj )

Poverty Line

1,578

1,264

1,117

1,819

1,407

1,201

2,470

2,093

1,777


Annex C. Measuring poverty

98


3) Poverty indices

When individual consumption is compared with the corresponding poverty linevalue, classified as poor are those whose level of consumption is below the pov-erty line. A series of indexes may be derived for the purpose of describing andcomparing situations. The indicator most often used is the head count index, whichgives the percentage of the population classified as poor. It is this index which isused in the body of the report (see Table 4). It belongs to the family of indicesderived from the Foster, Greer and Thorbecke equation. This equation reads:

Pλ = (1/n)* qj=1 (gj / z) λ

where z is the poverty line, xj the value of expenditure of person j, gj = z - xj isthe poverty gap for individual j, n the total population size, and q the number ofpoor.

The sum runs over all poor (from 1 to q), and λ is a parameter which runs from0 to whatever wanted (one seldom goes after 2).

If the parameter λ is set to zero, each term of the sum become 1, as a anynumber rise to the power 0 gives 1. A sum of q terms each equal to 1 gives q: theequation reduce to:

P0 = q/n , which is the head-count index: proportion of person whose expendi-ture level is under the poverty line.

If parameter λ is set to one, the equation becomes:

P1 = (1/n)* qj=1 (gj / z) , which is the poverty gap index: mean of the gapsbetween poor peoples’ standard of living and the poverty line.

If parameter λ is set to two, the equation becomes:

P2 = (1/n)* qj=1 (gj / z) 2. This is the Poverty Severity index, which is sensitive

to the distribution of living standards among the poor. Even if its absolute value hasno intuitive interpretation, this index is thought to provide relevant ranking amongcountries, as it takes into account the variations in distribution of welfare amongstthe poor.

99

Annex D. Poverty temporal comparison issues

The difficulty in comparing socio-economic data collected at differenttimes since 1993 (see for example Ta-ble 3) has sometimes led to disappoint-ment, if not impatience. The fact thatno straightforward trend could be com-puted seemed discouraging, but itshould be remembered that the popu-lation census of 1998 and the set ofcountrywide sample socio-economicsurveys provide invaluable sources ofdata. Nonetheless, the lengthy processof developing high level knowledge andskill in administrative and research ori-ented statistics apparatus is stillunderway. In addition, quantitative sur-veys have inherent and inescapable limi-tations: data provided by surveys areunavoidably tainted by the methods andcontext of their collection, at best pro-viding only approximate figures. Themain pitfalls in attempts to measure so-cial phenomena are briefly reviewedbelow.

1) Measuring social phenom-ena: main pitfalls

Social phenomena are inherently dif-ficult to measure. For example, count-ing the number of people in a given lo-cation, region or country may appearto be a simple task, although there arepractical difficulties. However, concep-tual difficulties arise as soon as any moreprecise description is attempted. Ageis a good example of a notion that atfirst glance seems to be particularly suit-able for quantitative treatment untilcloser examination reveals how it isrooted in the socio-cultural context.Developed countries have long reliedon exhaustive civil records, resulting inconstant use of age data and a preciseknowledge of this characteristic by in-dividuals. However, in most develop-ing countries no precise record orknowledge of their age is familiar to the

people. Instead approximate agegroups are used by individuals. Isolat-ing age data from the social context inwhich it was collected leads to demo-graphic charts where round ages (fin-ishing in 0 or 5) are disproportionatelymore numerous than the other values,creating peaks where the analyst waslegitimately expecting smooth varia-tion.

Similarly, particular circumstancesmay add to the complexity of handlinginformation about age. For example,in a context where there is no formalage record system but there are ad-ministrative requirements, such asmaximum age for school applicationsor recruitment, necessity often leadspeople to declare an official ageyounger than the biological one and tomake use of this official age in every-day life. All such sources of impreci-sion will be reflected in the quantita-tive data. As soon as attempts are madeto measure more complex character-istics than age, misunderstandings, con-fusions and lack of trust will increaseoccasions of mis-recording.

Therefore, the first thing to bear inmind when making use of quantitativeinformation is that it necessarily comesfrom measures which embody errorsand, consequently, has to be under-stood as probable – rather than pre-cise – values. This is the case regard-less of the quality of the survey used tocollect information: a perfectly de-signed and implemented survey willreduce the imprecision, but never pro-vide an exact figure. For conceptualreasons, exact figures are unattainableby measurements of social phenomena.

A second aspect of measurementis worth recalling before turning to thequantitative information of this report.The sources of imprecision describedabove apply even in the case of an ex-

Annex DPoverty temporal comparison issues

100


haustive survey, such as a census. Butmost of the social information collecteddoes not come from census but fromsample surveys. Sampling can causeanother type of imprecision. Again,excellent sampling techniques can re-duce the uncertainty, but cannot reduceit to zero.

The main practical consequence ofthese structural aspects of all measuresof social phenomena can be summa-rised by the following empirical rule: assoon as the sub-population studied istoo small (one often chooses a thresh-old of 60 cases), no conclusions shouldbe drawn from measured characteris-tics. This is why general population sur-veys are not intended to provide reli-able information about specific smallsub-populations and why disaggrega-tion of data cannot be pursued too far.

2) Comparing SES dataThe problems in comparing data

from the different SES outlined abovecan be grouped into two categories.The first category relates to conjecturalissues, mainly arising from the failureto maintain a consistent methodologyacross the successive surveys. The sec-ond category is structural: this refers tothe difficulties inherent in social issuemeasurements, which are unavoidable.

Concerning the SES series, the maincomparison issue is that consumptionquantities were collected only duringthe first survey (1993–94). Therefore,the only option is to use the data fromthe subsequent SES to update povertyline calculations based on the 1993–94 data, as no independent poverty linecalculations can be made. In addition,even updating these calculations willrequire a good deal of approximationdue to variation in the items retained inthe food basket and the non-food al-

lowance.The 1993–94 food basket contains

155 items.27

No consumption quantities werecollected in 1997 and, moreover, thevillage survey provides the prices foronly 36 food items of which only 22are comparable with the food basketitems. These 22 items correspond toless than 50 percent of the cost of thereference food basket. The followingsteps were therefore necessary in or-der to update the poverty line:! The Consumer Price Index for

Phnom Penh was used to calculateprice changes for 75 items in order tocalculate changes in the cost of living.(The result showed a 16.2 percent in-crease.)! The prices for 22 items collected

in the 1997 village survey were com-pared with the prices for those itemscollected in 1993-94, in order to esti-mate increases in the cost of living inthe three strata. The increase in OtherUrban areas was found to be 10.7 per-cent - two-thirds of the increase inPhnom Penh. The increase for Ruralareas was calculated at 6.7 percent,only 40 percent of the increase in costof living in Phnom Penh.

In 1999, the proportion of the ref-erence food basket for which prices areavailable rises by more than 20 per-cent, enabling 70 percent of the costof the bundle to be priced. This datawas used to update the poverty line asfollows:! 46 items of the reference food

basket were priced! The sub-total cost of these 46

items was then calculated! The cost of the same 46 items was

calculated using 1993-94 values, in or-der to find their share of the total costof the reference food basket. (The re-

27 In fact, it contained 177 items, but 22 items happened to have a weighting of zero for the thirdconsumption quintile population.

101

sults were: 67.4 percent share of thetotal cost for Phnom Penh, 68.1 per-cent for Other Urban areas and 70.1percent for Rural areas.)! This cost share is then used to

calculate the cost of the whole basketTherefore, the updated values of the

poverty line rely on a series of assump-tions and approximations. In addition,the three poverty lines, and the reliabil-ity of their comparison, rely heavily onthe quality of the data collection. In re-sponse to the demand for precision, aninnovation was made in the 1999 SES,which has provided a benchmark fordata reliability. The survey was admin-istered in two rounds, one in the dryseason (January-March) and one in therainy season (June-August). A methodof interpenetrating sub-samples wasemployed, ensuring each sub-samplewas nationally representative, in orderto capture the impact of seasonality (orother temporal changes) without thedata being spoiled by variations in thecomposition of the samples.

Unexpectedly, major differencesappeared between the volume of con-sumption estimates, inequality estimates,and some features of cross-sectionalprofiling, in the two rounds of data col-lected. These differences were eithernot consistent with previous evidenceabout seasonality, or were too large tobe accepted as valid. Several organi-sational factors were identified whichhelped explain this outcome, but thesefactors cast doubt on the data quality.

In order to mitigate justifiable dis-appointment, let us point out again someinherent difficulties in the measurementof social phenomena. One is the inverserelationship between the depth of the

study and quality of the record; a verylong and complex questionnaire will in-crease the proportion of mistakes andinconsistencies. A difficult balance hasto be struck between eagerness forcompleteness and precision on the onehand and the actual manageability ofthe questionnaire administration on theother hand.

Another inherent difficulty is thatmeasures of social phenomena, evenmore than other measures, are imper-fect. The figures obtained have to beunderstood not as exact figures but asthe centre of an error bar. The size ofthis error bar depends on the contextof the survey and while it may be large,it is never a null set. This error bar en-compasses well known statistical phe-nomena such as sample fluctuations, aswell as issues related to the measure-ment tool – in this case, the question-naire and its context. When looking fortemporal change, conclusions shouldbe drawn not from comparing the cen-tres of these bars, but from the shapeof the band formed between the edgesof each error bar.

Nevertheless, the two rounds ofSES 1999 revealed unacceptable in-coherence. The fact that SES 1997was administered in one round avoidsthis question does not in itself provehigher quality of data. In addition,changes in the questionnaire forced agood deal of approximations duringupdating poverty line measurements.Moreover, sample coverage greatlyimproves along the series of SES. Thesedifficulties should not discourage ex-amination of the series of results, butshould be taken into account whileconsidering the data.

Annex D. Poverty temporal comparison issues

102


Annex EFieldwork methodology

1) Fieldwork selectionOne striking feature of the HIV Surveillance Surveys is the wide dispersion

across provinces (see Table 9). Part of this dispersion can be accounted for bystatistical fluctuations, as the study deals with fairly small samples. This feature ofdispersion is the reason why the Surveillance System cannot be used as a validtool for drawing local conclusions. Nevertheless, provided care is taken in inter-preting the data, comparing the specific provincial circumstances with the level ofHIV prevalence may be expected to provide some understanding of the epidem-ic’s dynamics. Moreover, the differences between the provinces are expected tobe critical in the possible refuelling of the epidemic. On this basis, the principalcriterion of the fieldwork was to cover the contrasts from both the epidemic andhuman development points of view. A second criterion was added privileging re-mote areas. The reason for these choices relied mainly on the analysis that anessential challenge to the epidemic must ensure that a capability to respond isbrought to the local level. This two criteria led to the choice of the four followingprovinces: Kampong Cham, Pailin, Koh Kong and Mondolkiri.

Kompong Cham is an agricultural province, with substantial fishing opportuni-ties, large rubber plantations, and fruit growing. There are two towns with busi-ness activities. However, in some districts, landlessness is becoming a problemsince land plots are too small to accommodate the new generation, or of littleagricultural value; as a result, some in the workforce, mainly young adults, migrateto the provincial capital and to Phnom Penh. A mobile sub-population is thusemerging.

Kompong Cham: Key statisticsDemographic indicators in 1998:Population: 1,608,914Sex ratio28 : 93.1 (93.0)Percentage of population under 15 years old: 42.1 (42.8)Percentage of working age population engaged in agricultural activities: 85.4Percentage of working age population engaged in industrial activities: 2.8Percentage of persons with a previous residence outside the province during

the last 5 years: 6.8HIV prevalence rate 2000:

- Direct female sex workers: 29.3 (31.1)- Indirect female sex workers: 15.1 (16.1)- Policemen: 2.0 (3.1)- TB patients: 4.6 (6.0)- Pregnant women attending antenatal care clinics: 1.0 (2.3)

Trends in prevalence rate:- Direct female sex workers 28.0 (1998) 41.7 (1999)- Policemen 1.8 (1997) 3.3 (1998) 3.0 (1999)- Pregnant women attending antenatal care clinics 1.5 (1997)

Health equipment:

28 The figures contained in brackets are the corresponding countrywide statistics.Sources for provinces description: Population census 1998; NCHADS 2001; National Research Teamprimary research

103

- Referral Hospitals: 10- Health centres: 128 (of which 93 fulfil Minimal Package of Activities)- Medical staff: 1,403 (of which 132 are medical doctors)

Main disease in the population:- Tuberculosis- Malaria in the north of the province

Pailin is a remote province, isolated from the main activity centres of the coun-try, mostly as a result of very poor road access rather than geographical obstacles.Pailin is a recently established administrative division, separated from Battambangprovince in 1996, after prolonged conflict. Land mines remain a serious issue, andsections of the population remain in fragile settlements. There has been a surge ofnewcomers hoping to take advantage of the economic opportunities emergingsince the reconciliation.

Pailin: Key statisticsDemographic indicators in 1998:Population: 22,906Sex ratio: 117.9 (93.0)Percentage of population under 15 years old: 40.3 (42.8)Percentage of working age population engaged in agricultural activities: 50.5Percentage of working age population engaged in industrial activities: 8.6Percentage of persons with a previous residence outside the province during

the 5 last year: 39.6HIV prevalence rate:

- Direct female sex workers: 37.9 (31.1)- Indirect female sex workers: 8.6 (16.1)- Policemen: 6.6 (3.1)- TB patients: not tested (6.0)- Pregnant women attending antenatal care clinics: 0.5 (2.3)

Trend in prevalence rate:- Direct female sex workers 10.9 (1999)- Policemen 5.6 (1999)

Health equipment:- Referral hospitals: 1- Health centres: 3- Medical staff: 149 (of which 11 are medical doctors)

Main disease in the population:- Malaria

Koh Kong is characterised by a quasi-absence of agricultural land. Only 10percent of the area of the province is suitable for cultivation, between a mountain-ous landscape covered by forest and a wide mangrove swamp bordered by thesea. At present, Koh Kong is usually accessible only by boat or plane. Koh Konghad a very small population at the end of the Khmer Rouge period (some wit-nesses report a population of 3,000 inhabitants in 1979). The province has sinceattracted many immigrants, especially in the early 1990s, when there were lucra-

Annex E. Fieldwork methodology

104


tive opportunities for logging, smuggling, marijuana growing and fishing. Of theseactivities, only fishing now remains. The logging ban became effective only in 1999,but it has had a huge effect on the population, as the cessation of logging wasfollowed by large-scale emigration from the province. The repair of the road thatlinks Koh Kong with the rest of the country is now near completion, and appearslikely to have a significant impact on the province.

Koh Kong: Key StatisticsDemographic indicators in 1998:Population: 132,106Sex ratio: 105.1 (93.0)Percentage of population under 15 years old: 40.7 (42.8)Percentage of working age population engaged in agricultural activities: 53.2Percentage of working age population engaged in industrial activities: 7.4Percentage of persons with a previous residence outside the province during

the last 5 years: 31.2HIV prevalence rate:

- Direct female sex workers: 53.6 (31.1)- Indirect female sex workers: 15.7 (16.1)- Policemen: 10.7 (3.1)- TB patients: 16.7 (6.0)- Pregnant women attending antenatal care clinics: 5.0 (2.3)

Trend in prevalence rate:- Direct female sex workers 52.0 (1997) 41.0 (1998) 41.7 (1999)- Policemen 21.0 (1997) 25.9 (25.9) 24 (1999)- Pregnant women attending antenatal care clinics 19.5 (1997)

Health equipment:- Referral hospitals: 2- Health centres: 8- Medical staff: 132 (of which 29 are medical doctors)

Main disease in the population:- Malaria

Mondolkiri is a high plateau. It is very lush during the rainy season, but dry forthe remainder of the year. One of the main characteristics of the population in thisprovince is the predominance of other-than-Khmer ethnic groups. The provincialnorm of severe poverty in all dimensions of human development and the recentdegradation of the means of transport (there are no more scheduled flights and thecondition of the roads is ever-worsening) limit the population’s contact with therest of the country.

Mondolkiri: Key StatisticsDemographic indicators in 1998:Population: 32 407Sex ratio: 102.2 (93.0)Percentage of population under 15 years old: 43.8% (42.8)Percentage of working age population engaged in agricultural activities: 75.6%Percentage of working age population engaged in industrial activities: 5%Percentage of persons with a previous residence outside the province during

the last 5 years: 13.7%

105

HIV prevalence rate: Mondolkiri is not covered by the Surveillance SystemHealth equipment:

- Referral hospitals: 1- Health centres: 6- Medical staff: 133 (5 of which are medical doctors)

Main disease in the population:- Malaria (a prevalence rate of up to 70%)

2) The SurveyThe daily activity of the local health centers was the beginning point for the

study. Firstly, because it could be expected that the health system would feel thepresence of the epidemic earlier than most other parts of the population. Sec-ondly, because it is a reasonable place to observe the general relationship be-tween local population and the public administration.

The Provincial Health Director and at least one District Operational Officerwere first interviewed. Then the referral hospital in the provincial capital was vis-ited. Finally, medical staff from several Health Centers, outside the provincial capital,were interviewed. Where possible, simple opportunistic surveys were performedin some private health facilities, and with the local population in the market places.

The following is an outline of the respondents’ roles and the various issues theywere asked about:

• Provincial Health Department:

• Health issue in the province:-the presence of major health diseases in the province.- the current major concerns.- the health body: size, training, origin of the staff.

• The organisation of the HIV/AIDS task force in the province: chart,number of persons involved.• The NGOs in the province involved with the HIV/AIDS issue.• The assessment of those responsible concerning their knowledge andthe involvement of the medical body of the province vis-a-vis the HIV/AIDS issue.• The supply of medication

- general organisation of supply- specific HIV/AIDS needs

- the availability of antiretroviral drugs• Suggestions for efficient action against HIV/AIDS.

• Referral Hospital Headquarters:

• The HIV/AIDS section: its organisation, number of persons, origin ofthe staff.• Daily organisation of the hospital

- a description of the weekly schedule.- issues related to the supply of medications

• An assessment of the HIV/AIDS situation in the province:- trends observed- the sub-populations at risk

Annex E. Fieldwork methodology

106


• Suggestions:- unmet needs- further suggestions

• Health Centres:

• Daily organisation of the centre:- schedules- the number of person involved- the main diseases treated

• Specific HIV/AIDS related activities:- the intensity, frequency and level of demands- the main characteristics of HIV/AIDS patients- usual behaviour of HIV/AIDS patients- availability of medication

• An assessment of the epidemic situation in the district- trends observed- the sub-populations at risk

• Suggestions:- unmet needs- further suggestions

107

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UNAIDS (2001c), The HIV/AIDS/STD situation and the national responsein the Kingdom of Cambodia, 4th edition, Phnom Penh

UNAIDS and WHO (2000), AIDS epidemic update December 2000, http://www.unaids.org

UNAIDS and WHO (2000), Epidemiological Fact Sheets 2000 Updatefor Thailand, Vietnam, Laos, Indonesia, Malaysia, http://www.unaids.org

UNDP (2000), Human Development Report 2000: Human Rights andHuman Development, New York

UNDP (2001a), Human Development Report 2001: Making NewTechnologies Work for Human Development, New York

UNDP (2001b), UNDP Corporate Policy on NHDRs, New York

Vonn, V., S Than, S. Pen, C. Kao, Y. Khan, B Booy and W. Gum (2000),“All Our Livelihoods are Dead”: Landlessness and Aquatic Resources inBattambang Province, OXFAM GB, Phnom Penh

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Videos

“Cipy heritage”, product of National center for HIV/AIDS, STDs andDermatology, with National Center for Health Promotion and Cambodi HeamthDevelopment Project of Ministry of Health, Kingdom of Cambodia, November1999.

“With Hope and Help: Cambodia”, funded and coordinated by UNICEFEast Asia and Pacific Regional office and UNICEF Cambodia, with support fromUNAIDS, produced by Living Films, 2001.

UNDP is the UN’s global development network, advocating for...

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