Cambodia heals its wounds

18 World Health • 49th Year, No.6, November-December 1996 Cambodia heals its wounds Jean·Paul Menu Partnerships were formed to help Cambodian health centres such as this one to operate e ffectively. In October 1991, when the four warring factions of Cambodia finally signed the Paris Agree- ment, the country had its first rea l hope of peace and stability. There had been two decades of continual warfare and violence, including four years of infamous rule by the Khmer Rouge followed by a long period of international isolation. The Agreement provided for a period of transition during which nearly 350 000 refugees would be repatriated and general elections would be organized. All this hap- pened under the supervision of one of the largest-ever United Nations peace-keeping operations, known as the United Nations Transitional Authority in Cambodia (UNTAC). This transitional period, which ended in September 1993 with the promulgation of the Cambodian constitution, gave a completely new purpose to the international presence in Cambodia. In parallel with the massive peace-keeping and electoral operations, a phased programme of recovery, rehabilitation, reconstruc- tion and longer-term development was started in a highly complex situation. The health situation in 1991 When the Khmer Rouge regime fell in January 1979, the country 's eco- nomic and social infrastructure was in ruins. Most of the professional and educated citizens had perished or left the country. Considerable progress took place in the 1980s but in 1991 the country was sti II highly unstable. It was divided between four factions, each controlling its own share of territory. The largest area was the "State of Cambodia". Guerilla war-fare was continuing and, because of the huge number of landmines, many villagers were forced to live in makeshift camps. In nearby Thailand hundreds of thousands of Cambodians had been living for years in camps under the responsibility of the United Nations. The health status of the popula- tion was deficient by any standard. Major health problems included high infant mortality rates, high preva- lence of diarrhoeal diseases , acute respiratory infections, drug-resistant malaria, tuberculosis, dengue haem- orrhagic fever and chronic malnutri- tion. There were also thousands of amputees, children as well as adults. The destruction and trauma of war were present everywhere, most notably in the minds of the people. The State of Cambodia had a comprehensive network of health institutions. However, the lack of the most basic equipment made preven- tive and curative services almost unavailable to the vast majority of the population. A new generation of doctors and nurses had been trained but their salaries were below subsis- tence level. Health care was also provided by each of the other three factions in their own territories. Following a massive humanitar- ian effort in 1979-80, the interna- tional community had enforced an embargo against the State of Cam- bodia. The extent of humanitarian assistance fluctuated through the y~ars . United Nations presence was maintained throughout by UNICEF which made a major contribution to the health sector, together with the International Committee of the Red Cross and some NGOs. By 1991, a liberalized policy allowed more and more NGOs to start health pro- grammes, greatly increasing the provision of curative and preventive care, first in the capital and progres- sively in the provinces. Coordination between agencies was loose, however, and the Cambodian health authorities were not in a position to give direction with regard to priority areas. A strategy for development At the start of the transitional period, the challenge faced by the interna- tional community was to continue meeting very pressing humanitarian needs while at the same time starting to establish the basis for recovery and sustainable development. The opinions of agencies and donors were divided. Some felt that no long-term development should be World Health • 49th Yeor, No.6, November-December 1996 considered before the political situa- tion was normalized. Others argued that, without an overall long-term strategy, growing international assis- tance could result in costly and unsustainable projects. WHO held the latter view and, in partnership with other agencies, decided that the priority for its own limited means should be to restore the capability of the Cambodian health administrations to set their own goals and to coordinate all available resources irrespective of their origin. This approach would provide a rational basis for the fur- ther development of the health sector when the country reunified. The strategy adopted to achieve this goal was based on several princi- ples: • providing strong support to the health authorities of each of the factions, with particular attention to the State of Cambodia since it had the largest population (when- ever feasible, support was also furnished to the health sector in the territories of the other three factions, though with limited success with the party of Democratic Kampuchea- i.e. the Khmer Rouge); • using WHO as an "honest broker" to facilitate exchange of views and joint planning between the factions to prepare for reunifica- tion of the health services and to encourage the process of recon- ciliation; • encouraging NGOs and donor agencies to give priority to the concerns defined by the health authorities; • advising UNTAC on the health component of its own rehabilita- tion programme and fund-raising strategy for Cambodia; • collaborating with UNHCR in meeting the short-term and long- term health needs of the returnees and of the communities in which they would settle; • implementing immediately a limited number of emergency projects. In the State of Cambodia, a coordi- nating committee, popularly known 19 At the start of the transitional period, health facilities lacked even basic equipment as "CoCom", brought together senior Ministry of Health staff with representatives of multilateral and international organizations and NGOs. The committee allowed international organizations and NGOs to participate in policy formu- lation under the leadership of the health authorities. A similar ap- proach was used later with other factions and at provincial level. A true spirit of partnership Based on extensive data collection and analysis, the strategy resulted in the formulation of a series of policy options for the health sector. The interventions proposed were de- signed to improve the health system (for instance, health manpower planning and training, financing of health services, hospital rehabilita- tion, pharmaceutical policy) and to A health worker explains the need for AIDS prevention to a group of young Cambodians. AIDS was targeted as a priority disease. control the most prevalent diseases such as malaria, dengue, tuberculo- sis and AIDS. Using this framework, WHO and other agencies initiated numerous public programmes designed to rehabilitate and reconstruct a unified Cambodian health system. Almost invariably, programmes were based on partnership between several agencies and local authorities. We are convinced that the strategy fostered a spirit of true partnership and discouraged competition among health agencies. However, the most important and durable result was that by the end of the transitional period, the strategy had boosted the capabil- ity of the Cambodian health authori- ties to provide health care to their people. This was the greatest possi- ble reward for all the organizations and individuals who contributed to it. • Dr jean-Paul Menu is Emergency Coordinator, Division of Emergency and Humanitarian Action, World Health Organization, 1 2 1 1 Geneva 27, Switzerland. From 1991 to 1993 he seNed as Special Health Envoy, representing WHO in Cambodia.