Innovative Approaches to Increasing the Access to Health Care: The Cambodian Example

On a visit to Cambodia in March of this year, I was fortunate enough take a tour of its premier teaching hospital – Angkor Children’s Hospital (“Angkor”).  During the visit, the hospital staff provided me with extensive information about the health needs of the community, and the programs the hospital has implemented to improve the access to health care in Cambodia.  Functioning as a safety net hospital which never turns away patients for inability to pay, the institution is funded by the Friends Without a Border NGO.  Angkor was started by Japanese photographer Kenro Izu after a child died in front of him when he was visiting the historic temple complexes in the area.  My visit to the hospital was a real lesson in how much can be done with so little, and left me with the question of how some of the innovative programs at Angkor could be remodeled and implemented in America and elsewhere.

Cambodia has unique causes of social and health problems hospitals such as Angkor must address.  These include the ongoing loss of life and limb from the still prevalent land mines; the unbalanced population of predominantly young people after the Khmer Rouge genocide nearly eliminated the older generation; the fact that many Cambodians survive on less than $1 per day; and the fact that 85% of Cambodians live in rural areas.

Angkor has treated over 1,000,000 children since it opened in 1999, and provided nearly 3,000 home visits for chronic care patients in 2011 alone.  Patients treated at Angkor routinely must travel 100 miles or more to reach the hospital.  More children die on their way to the hospital than at the hospital, and the ailments they suffer from are frequently both preventable (with education) and easily treatable (if the children can receive care before their condition severely deteriorates).  The most common reasons for admission to the hospital are: pneumonia; dengue and hemorrhagic fever; diarrhea; sepsis; malaria, HIV and malnutrition.

There are many transportation barriers to accessing quality healthcare for many Cambodians.  Many people earn only a $7 weekly wage, and high costs of transportation make trips to a facility like Angkor difficult or impossible.  It is not uncommon for a family to sell a cow, or even their home, to try to get their children to the hospital.  Even if they can raise the money for the trip, it still can take several days or more to arrive at the hospital.  The child may die en route, or arrive too late to be effectively treated.

While the hospital is home to a 24 hour emergency room, upon arrival, some outpatient cases may be asked to return for treatment the following day.  On any given night, you may see those who’ve traveled the furthest distances pitching mosquito nets outside the hospital where they sleep until morning.

In response to the transportation barriers like these, Angkor has focused heavily on not only staffing its hospital – but also capacity building – to achieve sustainable impact. The hospital provides extensive medical training for doctors and nurses in local communities.  Angkor has piloted programs which send doctors and nurses who have been highly trained at Angkor into local neighborhoods to both treat people in rural areas, and to provide additional training to local medical practitioners.  Less than $1 million funds the hospital for a year thanks to their innovative measures to keep costs down and increase effectiveness.  Its focus on outreach has reduced the number of deaths that occur in children en route to the hospital (which can be a long and treacherous journey in rural areas with poor infrastructure).  By providing better training to the staff at 40 regional hospitals in Cambodia, Angkor attempts to provide the highest quality care in the most effective and cost efficient manner possible.   Angkor employees and volunteers teach individuals in rural areas about basic health, nutrition, and hygiene, helping to prevent many incidences of disease which could otherwise become serious.  Home visits are also provided through the Angkor home care program, since returning to the hospital is often too expensive for patients needing preventative care.  At the same time, providing home visits rather than treating these patients in the hospital is more cost effective.

While there are key differences that cannot be overlooked, there are also many things America’s public clinics and safety net hospitals can learn from this institution’s success.  Over the course of the next several weeks, through a series of blog postings, I plan to take a cursory look at the issues that are present at a variety of public access clinics and hospitals in the U.S. and abroad, identifying the key issues, notable successes, and similarities in the different institutions and approaches to the challenge of providing accessible and affordable health care.  I hope to include information about the following: availability and ease of access to care for the poor/uninsuredquality of care provided; types of diseases/injuries most often requiring treatment by the patients; education and outreach programs; costs of running such programs; and social framework which created or contributed to the failures of the health system among particular populations.

Heather Mullins-Owens, J.D. is an M.A. candidate at Indiana University where she studies bioethics. She is also the Director of Global Health at HERO Network LLC, a team of interdisciplinary researchers using collaboration to inspire innovations in health policy, to increase access to healthcare, and to decrease health disparities in diverse populations internationally.  Follow her on Twitter @HLMullinsOwens, and @HeroNetwork.


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