Situation. People with disabilities in Cambodia face multiple barriers when accessing health services. The public health system has limited capacity to prevent, detect and treat impairments that can be disabling.
Approach. German Development Cooperation has followed a ‘twintrack approach’ to promoting the inclusion of persons with disabilities. In addition to mainstreaming a focus on disability into on-going work on health financing, health system governance and health service delivery,
the projects also supported interventions which built awareness of disability and the rights of persons with disabilities and strengthened the early detection of impairments among newborns and children in two provinces.
Results. There is greater understanding of need for inclusion of persons with disabilities in the health sector among partner institutions, local authorities and communities, and at the political level.
Lessons learned. In contexts where inclusion is not an established concept, it takes long-term commitment, partnerships with a range of stakeholders, and a flexible approach to testing and refining interventions in order to create and sustain the momentum and ownership for changes that result in a more inclusive health system.
This case study describes how technical cooperation projects funded by Germany’s Federal Ministry for Economic Cooperation and Development (BMZ) and implemented in cooperation with the Royal Government of Cambodia have systematically fostered the inclusion of persons with disabilities in the health sector in Cambodia.
According to the 2009 Cambodian Socio-Economic Survey, 6.3% of Cambodians live with a disability, although actual disability prevalence is likely to be higher. Many of the impairments associated with disability are preventable and are exacerbated by poverty and poor access to health services, clean water and sanitation.
Cambodia’s public health system is not well equipped to meet the needs of persons with disabilities, or to diagnose and treat impairments which could become disabling. Barriers encountered by persons with disabilities when accessing care include high direct and indirect costs, the physical inaccessibility of health facilities, communication barriers, and negative attitudes on the part of health care workers. There is no institutionalised screening for impairments among newborns, infants and children. Few specialised health services are available at the local level, coordination between service providers is inadequate, and there is not a functional referral system to support a continuum of care.
In line with the BMZ’s Action Plan for the Inclusion of Persons with Disabilities, the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH has systematically introduced a cross-cutting focus on the needs of persons with disabilities into two technical cooperation projects which are implemented on behalf of BMZ in cooperation with the Ministry of Health of Cambodia.
Together with provincial health departments and non-governmental organisations such as Handicap International and Epic Arts, the Social Health Protection project and the Rights-Based Family Planning and Maternal Health project designed and implemented a package of measures aimed at improving the accessibility and utilisation of health care services by persons with disabilities, making the health system itself more inclusive, and preventing impairments that can result in disability. The twin-track approach pursued by GIZ involves both ‘mainstreaming’ a focus on inclusion into the projects’ core work and providing specific support to persons with disabilities, their families and disabled people’s organisations (DPOs).
In Kampot and Kampong Thom provinces, the projects built awareness about disability and the rights of persons with disabilities through workshops, trainings and community events reaching more than 6,000 representatives of commune councils, Village Health Support Groups, health officials and health workers, religious leaders, parents, and other community members. More than 5,000 people watched modern dance performances, created by a troupe of young deaf and disabled artists from Epic Arts, aimed at combatting stigma and discrimination against persons with disabilities.
The projects supported measures aimed at improving the early detection of impairments and the prevention of disability among children. These included developing a set of screening tools, training health workers in their use, creating service directories, making screening available to more than 17,000 children, and supporting detected children to receive follow-up consultations.
DPOs participated in community forums and participatory planning processes aimed at making the health system more responsive to citizen needs. A voucher mechanism which reimburses the transportation costs incurred by persons with disabilities when travelling to local health centres has been developed and piloted; evidence about the high health expenditures incurred by persons with disabilities is also being brought into national-level policy discussions on the expansion of social health protection schemes.
This case study, unlike those which have preceded it in the German Health Practice Collection, documents the early experiences of an important new approach, rather than the outcomes of an established development intervention.
Efforts to promote the inclusion of persons with disabilities in the health sector have yielded some preliminary results, although these are difficult to measure. There is now greater awareness of disability and of the need for inclusion of persons with disabilities among partner institutions, in communities where the projects work, and at a political level. The projects’ investments in the development of tools and procedures for screening children for impairments have opened up the prospect that early detection could eventually become institutionalised in the health system. Work with commune councils and DPOs has led to DPOs’ involvement in routine planning meetings, bringing the concerns of persons with disabilities into health-related governance processes.
Among the key learnings to date:
- Introducing a focus on inclusion into a complex development intervention requires strong leadership, commitment across the project team, and an investment of both time and resources. This case from Cambodia provides a positive example of how a systematic approach to promoting inclusion can be pursued, from collecting evidence on the challenge and identifying entry points within project frameworks, to consulting with partners, identifying appropriate collaborators, and integrating new approaches into project cycles.
- Inclusion lends itself to sectoral mainstreaming approaches, but broader partnerships are required to tackle structural obstacles. Structural challenges within the health system go beyond what can be addressed by projects through a mainstreaming approach, while social and economic factors with roots outside the health sector also constrain persons with disabilities from using health services. Cooperation beyond the health sector, in areas such as education and employment, might unlock new opportunities.
- The early and active involvement of DPOs in designing, planning and implementing inclusion measures can encourage more persons with disabilities, and their families, to claim their rights. DPO participation significantly changes the perception of disability in society and promotes understanding about the diversity of individual capacities.
- A long-term commitment and a focus on building alliances are important to help create political ownership for inclusion. It is possible to catalyse momentum around inclusion of persons with disabilities by leveraging existing relationships with government partners and by joining forces with key players, including local disability organisations. However for positive changes in the lives of persons with disabilities to be sustained, political ownership is essential.