EXECUTIVE SUMMARY

This study draws a distinction between the indigenous paradigm and the global paradigm as a way to present a discussion of the various kinds of providers known to and utilized by those seeking health care in the case study province. We examined the reasons customers gave for using or avoiding these providers and we noted the approval they expressed for some providers and the complaints they made about other providers. From these expressions, richly documented in the informants’ own words, we can discern the contours of a concept of “quality” care that is operating in the judgments and preferences of our informants. These underlying values drive the decision-making that is manifested in health seeking behavior.

The indigenous paradigm takes a holistic, multidimensional view of health, illness and healing. The fundamental premise of the paradigm is that social, psychological, spiritual and physical factors work in combination to yield health and illness. Healing is accordingly understood in terms of interventions that attend to all these factors in combination.

The global paradigm centers on a biological view of health, illness and healing. The premise here is that it is useful to separate naturalistic from supernatural elements, physical from mental elements, biological from sociological elements in considering health, illness and healing. The global paradigm utilizes an impersonal, systematic, scientific approach that favors interventions that are narrowly focused on physical, chemical and biological agents that have a known and predictable effect.

The indigenous paradigm is represented in our case study by providers who come from an oral culture or a manuscript tradition of transmitting age-old wisdom, traditional lore, common and customary practices and local knowledge. This knowledge is conveyed to those with a penchant for it who undergo an apprenticeship to a master teacher within a lineage of initiation to the lore and practice.

The global paradigm is represented by providers who come from a literate culture, in which university training and expertise and technical skill is offered to individuals recruited, selected, trained, tested, qualified and graduated by complex social and ideological mechanisms designed to produce the most suitable candidates.

The indigenous paradigm is culturally situated in the rural areas where virtually free herbal remedies abound and where exchanges, in kind, between farmers is an accepted mode of reciprocity.

The global paradigm is culturally situated in urban areas where expensive imported manufactured pharmaceuticals are available and where the expected form of exchange is cash in commercial transactions for goods and services.

Providers in the Global Paradigm

a. Public Sector Providers.

The government providers appear in many ways to be the antithesis of providers in the indigenous paradigm. The complaints our informants voice about public sector providers, taken as a whole, present a model for health care to which our informants are generally averse. The complaints suggest, by contrast, a standard of quality that we find represented in the recurrent practices associated with providers situated in the indigenous paradigm. These complaints about the government health service facilities can be summarized as perceptions of the customers or health seekers and can be expressed as follows:

Perception 1. The government providers are not easily accessible. Government providers are perceived to be poorly paid with the result that they are often seeking alternative income rather than standing by in a public health service facility.

Perception 2. The government facilities do not have medicines and thus cannot cure patients. Desired medicines are available outside the public sector facility in private sector pharmacies. But the required encounter with private sector pharmacists in addition to the government health service provider is viewed with misgivings.

Perception 3. The government facilities require an immediate lump sum payment, which is difficult for a farmer to make. The failure of government facilities to adapt their payment schedules to the agricultural cycle of their customers and the lack of inexpensive credit for large medical expenses creates hardship for many customers.

Perception 4. The staff of the government facility all seems to need a payment on a regular basis to assure that they attend to the customer. The financial management in government facilities gives customers the sense that the facility is in the business of selling goods and services in commercial transactions, in which profit maximization is uppermost.

Perception 5. The government facilities present an intimidating atmosphere where officials are arrogant and rude to relatively powerless petitioners. The perception that poor sick people are treated with contempt and anger in public health facilities threatens the customers’ sense of dignity and autonomy and generates a reluctance to utilize these facilities.

b. Private Sector Providers

The clinic facilities in the private sector (often owned and operated by government providers) present a contrast to the government facilities on a point-by-point basis.

Perception 1. The private facilities are accessible, as they are always open and always have staff standing by.

Perception 2. The private facilities are equipped with staff, equipment and medicines on site.

Perception 3. The private facilities are relatively expensive but they are affordable because they extend credit or delay payment until recovery.

Perception 4. The private facilities are characterized by a home-like atmosphere of caring and attention.

Perception 5. The private clinics compete in the market to attract customers and so they have an incentive to make themselves attractive to health seekers.

Providers in the Indigenous Paradigm

a. The herbalist as a significant provider reflects the importance of self-help and self-medication in Cambodian health seeking behavior. The value in self-medication with herbal remedies is that it preserves the sense of choice and autonomy for the consumer, within a common community lore about natural resources that are free or available at very low cost.

b. The kru khmer as a significant provider reflects the importance of feelings of anxiety, fear and dread that are associated with physical illness and affect Cambodian health seeking behavior. The kru khmer serves as trusted ally to the health seeker when expert help is thought needed to fend off and appease the anger or vengefulness of supernatural beings. The kru’s interventions may accomplish a cure, or may serve as the preparations that are considered necessary to enable other interventions by other providers to be effective.

c. The yiey mop as a significant provider reflects the importance of emotional needs for long-term, intimate, warm support during the stressful time of pregnancy, delivery and post-partum recovery. The emotional, physical and herbal interventions of the midwife are aimed at restoring the health and strength of the new mother, often over a six-month period. Families expect that the yiey mop may attend each of a woman’s pregnancies and then attend the pregnancies of a woman’s daughters. The value esteemed here is the life-long relation of trust, compassion and expert care that is generated between the midwife and the families she serves.

d. The aspect of quality care that is highlighted by these traditional healers is that they take the performance of their roles as a sacred duty or a vocation or calling, in the spirit of service to a community. The kru khmer and yiey mop represent health care providers that attend not only to the physical, psychological and emotional needs of the health seeker, but also to prevailing socio-cultural expectations. This becomes apparent in the character of the payment to these providers. The payments are made in kind and are postponed until recovery. This creates a condition of mutuality and trust between health seeker and provider, which preserves the autonomy and dignity of the health seeker and the esteem of the health provider.

Providers in an Intermediate Category

These are providers we identify on one hand adapt to many of the values and preferences exemplified in the indigenous paradigm, but on the other hand use the techniques and products of the global paradigm.

a. Drug sellers are often an important private provider who makes pharmaceutical products available but dispense the medicines according to the strong customer preference for self-medication and experimentation.

b. Private local peyt make house calls and seem generally to be the most favored provider of health care in our case study.

Perception 1. These pets dispense injections on demand. They fulfill the strong preference for autonomy, self-medication, especially with substances that give rapid tonic or “feel-good” effects. They administer modern drugs, which are otherwise difficult for an illiterate villager to choose or obtain. By the act of giving successful injections the peyt echoes the highly esteemed work of the kru khmer magician who can withdraw sharp objects from the body and shaman who can obtain the blessings of ancestor spirits for a cure.

Perception 2. These pet are very accessible, and are willing to come to the home of the ill person at any time of day or night. They provide attentive, responsive care in a situation where the customer remains in control, in his or her own home surroundings. In this respect, the peyt resembles the highly esteemed yiey mop in maintaining long-term, respectful relations with the customer.

Perception 3. These peyt accept payment in installments, which makes the treatment very affordable. This provider may defer payment until after the patient’s recovery, following the model of kru khmer and yiey mop in deferring to the judgment of the customer about provider effectiveness.

Perception 4. These peyt present themselves as trusted local neighbors and members of the community who compete with other similar providers to make services available within the customers’ frame of reference for quality. The peyt attempt to build a practice, a network of long-term relations of trust, and appear to follow a business model of offering a professional service rather than a business model of selling goods, which appears in many government facilities.

Recommendations

1. The recognition and empowerment of providers in the indigenous paradigm would improve their ability to function effectively as referral and screening agents for serious ailments, complementing the modern providers.

2. An increase in understanding of the value of a holistic approach to health, healing and quality of life, which is already acknowledged in the most advanced modern approaches to medicine, should become part of the repertoire of all medical providers in Cambodia.

3. A clarification of the excessively broad concept “peyt” should be made through a system of credentialing by testing and retraining and re-qualification, so that customers know exactly what degree of competence they can expect from a provider. Sanctions for malpractice and guarantees of accountability should be a part of any reform effort of this kind.

4. A study of the institutional culture of government facilities could determine why they are not sensitive to competition from private sector providers.

5. A credit scheme that would provide loans for needy patients facing catastrophic illness and huge costs should be considered to avoid driving the poorest patients into landlessness. The success of this initiative would depend on adopting the best and most appropriate practices from the micro credit sector of Cambodian development NGOs.

6. The formation of a health consumers’ protection organization should be considered, operated by an independent NGO, which could advocate for higher quality service and receive and mediate complaints about service and charges in both public and private sectors.

7. The formation of a professional association of peyt should be considered, including both those working in the private and public sectors. The association could foster interchange between providers and could provide the germ for peer assessment and discipline. Such a professional association at the province level could advocate on behalf of provincial health care providers to MOH and International Organizations and donors. A professional association at the national level could serve as a mechanism to assure the accountability of Ministry of Health officials. These associations would be the likely targets for capacity strengthening efforts.

8. Capacity building in the skills and attitudes of the culturally sensitive public service professional might be considered. Technical in-service training offered to practicing medical personnel might be complemented by training that cultivates an understanding of a medical career as a sacred profession of responsible care giving.

9. If a market approach to medical service is adopted in Cambodia, medical service suppliers should become aware of the need to be responsive to customer preferences and demand. Capacity building for health service policy makers in techniques for assessing customer preferences and customer satisfaction might be considered so that appropriate research can be commissioned and interpreted and so that informed policy decisions could be assured.

EXECUTIVE SUMMARY.. 2

TABLE OF CONTENTS. 7

Health Seeking Behavior in Kampong Chhnang... 8

Introduction.. 8

Research Design. 9

Research Methodology. 9

Study Findings. 12

Introduction.. 12

I. Global paradigm... 15

A. Drug Sellers. 15

B. Peyt, Private and Public. 17

1. Private peyt who make house calls. 18

2. Public peyt working privately. 21

C. Health Care Facilities. 23

1. Private health care facilities. 23

2. Public sector health care facilities. 27

II. INDIGENOUS PARADIGM... 40

A. Herbal Healing. 41

1. Self-help. 41

2. Itinerant medicine sellers. 42

3. Kru Khmer. 43

B. Spiritual Healing. 45

1. Self-help. 46

2. Kru Khmer. 46

C. Physical Healing. 53

III. Conclusions and recommendations. 58

A. Conclusions. 58

1. Approach of the study. 58

2. Global Paradigm. 59

3. Indigenous Paradigm. 61

4. The Intermediate Category. 63

B. Recommendations. 64

ANNEX.. 66

MEDICAL PRACTITIONERS AND TRADITIONAL HEALERS:

Health Seeking Behavior in Kampong Chhnang

William Collins, Ph.D.

Introduction

The government of Cambodia has initiated several reforms to produce health services of better quality and lower cost. In order to identify strategies that might increase utilization of public sector health services, it was recognized that information was needed on customer behavior. This information would clarify the choices and decisions underlying the current use of different providers in the medical market.

A qualitative study of consumers’ health seeking behavior was contracted to the Center for Advanced Study to investigate the decisions and choices made by families when seeking health care. The terms of reference indicated that the study should explore customer opinions about the quality of services available and obtained and to elicit customer expectations and perceptions of quality and affordability that drives decision and choice making. The research was to use Kampong Chhnang as a case study site. It was considered advisable to investigate any differences in health seeking behavior by location in the province and by socio-economic level and to include both men and women across all adult age categories.

The terms of reference for this study emphasized three related objectives.

1. To examine health seeking behavior of households, in terms of provider choice and expenditures incurred in the purchase of priority services, such as curative care for minor and major illness, antenatal care, delivery, immunization, birth spacing, etc.

We asked where people sought treatment that they needed, what costs were involved and why they chose that provider.

2. To report the opinions of customers regarding their satisfaction, expectations and reactions to services they received from health service providers.

We asked what people felt about the providers and treatments available and what they felt about the treatments they obtained from the providers they consulted.

3. To examine the customers’ concept of quality of services.

We asked people to tell us about any virtues and advantages or complaints and misgivings they felt about providers or services. We asked if the interviewees would return to particular providers again and why, or why not.

Progress in implementing reforms in health financing at public sector facilities is at different stages in the case study province. Our study did not attempt to target the catchment communities of particular facilities to assess customer opinion about the reforms or schemes utilized at those specific facilities. Our study provides a more general picture of customer preferences and expectations through out the province.

On the basis of this general picture, planners of health service reform can better determine the options for improving the quality of service in the public sector to meet customer expectations and preferences that our study uncovers. With these insights, policy makers and planners can decide on successful marketing strategies for their reformed services more effectively.

The results of this study, in accord with the terms of reference, provide insights into the socio-cultural dimensions of customer decision making. These insights can inform health service reform planners about the underlying values, beliefs, attitudes and preferences that prevail among the consumer population in the province. These insights will be valuable in identifying realistic options to improve public sector service delivery that lowers cultural barriers to access.

Research Design

Our study sought sample households on a purposive basis in Kampong Chhnang. We sought informants from the different regions of the province to identify broad ecological factors that could contribute to consumer needs and preferences.

1. We surveyed the flood zone including districts of Chul Kiri, Boribo and Kampong Leng, on the East of the Tonle Sap.

2. We surveyed the hill zone West of the national highway and the railroad line, including the districts of Tuk Phos and Samaki Meanchey.

3. We surveyed communities located along the National Highway, in the urban area in and around Kampong Chhnang town, in rural and urban settings north along the road to Baribo and Rolea Bier and south along the road to Kampong Tralach.

Our sample was designed to include households where house type and possessions suggested that they might fall roughly into poor, medium and rich socio-economic categories. We sought informants from each category to identify economic factors that might contribute to consumer preferences and choices.

We sought out a full spectrum of age groups of both genders in the various ecological and socio-economic settings in order to obtain as wide a representation possible of the consumer public in the case study site for our qualitative purposes. Whenever possible, our researchers sought out pregnant women or mothers with small infants to include in the sample. These informants enabled us to include questions about ante and post natal care and delivery as well as birth spacing knowledge and awareness.

We conducted a total of 122 household interviews with a total of 149 informants. The large majority of informants were Khmer. However, we also included seven Cham families and three Vietnamese families.

Tables that show the distribution of household types in our sample, gender representation in the sample and age distribution of the sample are included in an Annex to the paper.

Research Methodology

In this research, semi-structured interviewing was based on an interview guide developed before the fieldwork began. [The guide can also be found in the Annex to this report]. The interview guide indicated the questions and issues that had to be covered, although the order of the coverage of topics was left to the individual interviewer. The purpose of the interview guides was to have each team of interviewers cover the same issues in more or less the same depth, depending on the knowledge and experience of the interviewee. At the same time, the researchers were urged to follow leads that might expose feelings, preferences, attitudes and complaints, which can only be discussed once rapport, or a situation of mutual trust and respect, has been established.

Our researchers presented themselves as members of an independent NGO devoted to research. We made it clear that we were not connected to the government, or to any International or United Nations organization. We assured every informant of anonymity and tape-recorded the interview only with the express consent of the interviewee. We expressed the aims of the research to our informants as an effort to obtain their experiences and views to provide input to the process of improving and extending the health system.

Our researchers worked in two teams. One team was led by a Cambodian physician, Dr Ouk Piseth working with Ms Chan Kanha, B.A., and Ms In Sokritya, B.A. The second team was led by Mrs. Lim Sidedine, M.A., Professor of Biology at the University of Phnom Penh and included Mr. Heng Kim Van, M.A. and Ms Kin Tepmoly, B.A. These team members have extensive experience on projects involving surveys and interviews in Cambodian villages.

The research was conducted in May and June, when farmers were involved in the intensive work of transplanting rice. A large number of the informants we visited in villages at this time were women or old people. The men we encountered were often sick and unable to work in the fields.

The interviews typically began with a conversation about the most obvious and natural subject at the moment, rice cultivation. Our researchers usually tried to elicit the expected rice yield from the household land holdings in order to verify the socio-economic status of the interviewees. An expected and usual surplus of rice indicated the informant was rich. Just enough food for the family for the year indicated a medium family. An expected and usual shortfall in rice supply for the family indicated the family was poor, for the purposes of our research.

The interviewers then attempted to shift the conversation to the subject of any recent serious illness in the family, or pregnancy and delivery. Following the interview guide, the researchers attempted to gain an understanding of what providers of health care services were known to the household and what services were sought, for what reasons and at what cost.

Uppermost in our interviewing strategy was an interest in probing the reasons some providers were chosen over others and in learning what providers were returned to repeatedly, and what providers were avoided. By understanding the customary and usual health seeking behavior of our informants, we aimed to uncover the values and preferences that underlay those choices.

Some informants who initially agreed to participate in the study withdrew once they understood our detailed aims. Apparently they feared that we were actually government agents, despite our assurances to the contrary. Some informants had to cut the interview short because of some interruption in their attention such as a crying child. Accordingly, the resulting sample is composed of people who were in the village during the day when we conducted the research, who were willing and able to talk to our researchers for one to one and half hours, and sometimes even longer, to discuss their experiences with health care.

A very few interviews were conducted with individuals who, as became clear during the interview, were not reliable informants. In a very few cases the respondents volunteered the information that they suffered from mental illness. In these and some other cases the informants gave such contradictory and garbled accounts of their experience with health care providers that we were obliged to exclude these interviews from our consideration as we developed our analysis.

It is important to stress that a qualitative study like this cannot answer some questions like “How prevalent is that practice?” or “What is the distribution of that attitude?” Those are questions that can be answered by a second step of research involving a quantitative methodology. But the construction of a useful quantitative survey questionnaire depends on knowing what practices or attitudes are problematic for the purpose at hand. The qualitative research step identifies the significant categories of cultural attitude, values, preference, customary practice and worldview that are present in the population. A subsequent quantitative step utilizing more rigorous sampling procedures could ascertain with precision the actual prevalence or distribution of the attitudes or values in the population, which appear to be important from the perspective of the purposes of the research.

The value of qualitative findings is that they suggest habits, mores and preferences from which the concepts of “quality” of health care held in the culture can be analyzed. This construction of an understanding of concepts of “quality,” from the consumers’ point of view should, should help service providers fine-tune the delivery of their services to meet customer perceptions and preferences. The recommendations that grow out of this study are intended to inform policy makers as they consider reforms to the health care system in Cambodia to serve the needs of the people, who are largely rural and poor.

Study Findings

Introduction

The basic distinction that medical anthropologists often make is between traditional and modern approaches to healing. This distinction can serve as a model that we can adapt to organize the presentation of our findings. The modern, or what I call the “global” approach, depends on the use of international standards of manufactured pharmaceuticals and technical skills of trained medical specialists. The traditional, or what I prefer to call the “indigenous” system, depends on herbal remedies and a mixture of natural and supernatural interventions, and is rooted in Cambodian traditional culture.

The practitioners of modern medicine in Cambodia are called peyt. International Organizations such as the World Health Organization are actively helping the modern or “global" sector of Cambodian health providers through the Ministry of Health. In Cambodia, prime examples of the traditional or indigenous healers are the kru khmer, herbalists and spiritual healers, and the yiey mop, midwives.

The interview material we collected suggests that the Cambodian case reflects many of the features medical anthropologists have described in other cultures in regard to the traditional/modern distinction. The global paradigm is defined by an assumption that a systematic, impersonal, naturalistic approach to illness based in the biological sciences should supplant the traditional conflation of physical, mental and supernatural factors in understanding illness and providing treatment. In Cambodia, as elsewhere, the indigenous paradigm is characterized by a holistic view that sees socio-psychological, emotional, spiritual and physical factors of illness and healing as inseparable or intertwined.

The global paradigm depends on medicines and technology produced by global specialists who are involved in a very costly process of research and development, marketing and distribution of their products. The indigenous paradigm depends largely on locally available herbs and other remedies, which are part of local knowledge built up by trial and error over generations. These products of traditional wisdom are available at minimal cost to the patient or to society.

The costliness of modern medicines and the concomitant cost of the training of medical personnel and the construction and maintenance of specialized treatment facilities raise the question how a sound and appropriate health care system can be designed for Cambodia, which enables the poor to obtain essential health services.

These troublesome issues are at the heart of concerns expressed by WHO and the Cambodian Ministry of Health in the terms of reference for this study.

The distinction of indigenous and global paradigms serves our analytical purposes to highlight patterns in health seeking behavior. Understanding these patterns will enable us to grasp the concepts of “quality” of health care that emerge from the material. The concept of “quality” is a factor in decision making and customer preferences that we infer from a mass of interview data. It is our interpretation of the sentiments, beliefs and practices expressed by our informants that they are participating in what we call the indigenous or global paradigm of health care. This tidy distinction is useful for our presentation, but may not occur to a seeker of health care services and providers in Kampong Chhnang. The respondents in our study in Kampong Chhnang are likely to combine any and all remedies available for a treatment. It is we, the outside observers, trying to make sense of the patterns we see in the choices of our respondents, who invoke the contrast between traditional and modern healing, or as I have phrased it, between the indigenous and the global paradigms.

Our view will become more nuanced as we discern the contours of “customer preference” in the statements, practices and themes voiced by our informants. We will analyze the concepts of quality implicit in the choices made among providers and in the tendency of customers to return to providers repeatedly and in the statements of satisfaction and complaint voiced by our informants about health care service received.

One narrative strategy would have been to move from village herbalist to provincial hospital physician along a spectrum of increasingly specialized and expensive health care provider roles, which are recognized and named by Cambodians. In this way the derivation of the customers’ concept of “quality” would follow from an analysis of socio-cultural dimensions of health seeking behavior within the indigenous paradigm. From the perspective of the Cambodian concept of “quality” care, we would then be able to discuss the complaints voiced about the public sector health services in the global paradigm. These complaints would be intelligible by understanding the point of view of the consumers who use the indigenous paradigm for health care as their frame of reference.

However, since the clients for this report are health program managers in the Ministry of Health, it is probably more reasonable to begin our presentation with the providers in the global paradigm and include an identification of the areas that need to be strengthened. Then we can indicate the virtues and advantages presented by the providers in the indigenous paradigm and conclude with stress on the quality of caring practices that might be transferred to the institutional setting in order to improve trust and confidence in obtaining essential priority health services, which would achieve pubic health goals.

As a guide and summary of the detailed material that follows, we can chart the important differences between the global and indigenous paradigms as follows.