Asian Journal of Psychiatry 13 (2015) 75–80
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Mental health services in Cambodia, challenges and opportunities in a post-conflict setting Bhoomikumar Jegannathan a,*, Gunnar Kullgren b, Parameshvara Deva c a
Center for Child and Adolescent Mental Health, Chey Chumneas Hospital Takhmau, Kandal Province, Cambodia Psychiatry, Department of Clinical Sciences, University of Umea˚, 901 85 Umea˚, Sweden c Faculty of Medicine and Health Sciences, University Tunku Abdul Rahman, Sg. Long, Selangor, Malaysia b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 August 2014 Received in revised form 12 December 2014 Accepted 14 December 2014
Cambodia had suffered enormously due to war and internecine conflict during the latter half of the twentieth century, more so during the Vietnam War. Total collapse of education and health systems during the Pol Pot era continues to be a challenge for developing the necessary infrastructure and human resources to provide basic minimum mental health care which is compounded by the prevailing cultural belief and stigma over mental, neurological and substance abuse disorders (MNSDs). The mental health research and services in Cambodia had been predominantly ‘trauma focused’, a legacy of war, and there is a need to move toward epidemiologically sound public health oriented mental health policy and service development. Integrating mental health program with primary health care services with specifically stated minimum package of activities at primary level and complementary package of activities at secondary level is an opportunity to meet the needs and rights of persons with mental, neurological and substance abuse disorders (PWMNSDs) in Cambodia, provided there is mental health leadership, government commitment and political will. ß 2014 Elsevier B.V. All rights reserved.
Keywords: Mental health Challenges Opportunities Cambodia Post-conflict setting
1. Background The Khmer empire extended as far as Thailand, Malaysia, Vietnam and Laos during the eighth to twelfth centuries, a golden period that is enshrined in the magnificent temples of Angkor, a
Abbreviations: ATS, Amphetamine type of stimulants; CCAMH, Center for Child and Adolescent Mental Health, Cambodia; CMHTP, Cambodian Mental Health Training Program; HICs, High Income Countries; HTPC, Harvard Training Program in Cambodia; IMCI, Integrated Management of Childhood Illnesses; IBSA, India Brazil South Africa Trust Fund; IOM, International Organization for Migration; KRT, Khmer Rouge Tribunal; LMICs, Low and Middle Income Countries; MNSDs, Mental, Neurological and Substance Abuse Disorders; NIMH, National Institute for Mentally Handicapped, Secunderabad; NIMHANS, National Institute of Mental Health and Neurosciences, Bangalore; NORAD, Norwegian Aid; PNES, Psychogenic NonEpileptic Seizures; PWE, People With Epilepsy; RQC, Reporting Questionnaire for Children; TPO, Transcultural Psychosocial Organization; UNCRPD, United Nations Convention of Rights for People with Disability; UNTAC, United Nations Transitional Authority in Cambodia. * Corresponding author at: Center for Child and Adolescent Mental Health (CCAMH), Chey Chumneas Hospital, Takhmau, Kandal Province, Cambodia. Tel.: +855 23 983348; fax: +855 23 216258. E-mail addresses: [email protected] (B. Jegannathan), [email protected] (G. Kullgren), [email protected] (P. Deva). http://dx.doi.org/10.1016/j.ajp.2014.12.006 1876-2018/ß 2014 Elsevier B.V. All rights reserved.
world heritage monument in Cambodia. Cambodia has been a land of perennial conflict since Angkorean times. Following the independence from French colonial rule, the country deteriorated to become the poorest in the region, a ‘victim of its geography and political underdevelopment’ (Shawcross, 1994). The spillover of Vietnam War and the social engineering and pogrom of Pol Pot regime in the 1970s resulted in collective trauma of the entire population. A million and a half died due to starvation and sickness, half a million were eliminated in the name of agrarian revolution and about two million people were internally displaced between 1975 and 1978. Studies in the refugee-sites along the Thai border revealed the impact of war and internecine conflict on the mental health of the Cambodian population (Mollica et al., 1997). The end of the Cold War and the Paris Peace Agreement of 1991, followed by UNTAC-intervention (United Nations Transitional Authority in Cambodia) brought an uneasy peace and stability but the country continues to suffer from political instability and the impact of chronic conflict (Deth, 2009). The people of Cambodia are in the process of reconciling with the trauma of war and conflict of the past whereas lack of institutional structures remains to be a challenge for the growth and development of the nation, particularly health services
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(Bockers et al., 2011). Deva et al. (2009) outlined the development of mental health services in Cambodia and the challenges ahead in the backdrop of sparse human resource and meager allocation of national health budget to the mental health program. Research and development of mental health services in post-conflict countries such as Cambodia, had been trauma focused and there is a need to move beyond post-traumatic stress disorder (PTSD)paradigm to address the range of common mental and neurological disorders (de Jong et al., 2003; Murthy and Lakshminarayana, 2006). This article, a follow-up to the update on the mental health situation of Cambodia by Deva et al. (2009), underscores the importance of epidemiologically sound, public health model of mental health service delivery, with an emphasis on integration of mental health services with the primary, secondary and tertiary health care systems in Cambodia.
2. Trauma-led research and mental health care, a legacy of conflict-ridden Cambodia The socioeconomic situation, health and development of the people of Cambodia, particularly the mental health, had been adversely affected, either directly or indirectly due to border disputes which remain a source of conflict between neighboring countries (Sothirak, 2013). There are an estimated 400,000 migrant workers in Thailand and the enormity of their mental health challenges in the background of poverty, migration and lack of access to services is a cause for concern (Meyer et al., 2014; Van de Put and Eisenbruch, 2004). The recent regime change in Thailand led to the influx of more than 200,000 migrant workers back to Cambodia within the brief period of a week, indicating the fragility of the psychosocial situation and the challenge for mental health service providers. The recurring mental health crisis and reliving of trauma by the people of Cambodia was exemplified by the study among the survivors of Pol Pot regime in the backdrop of ongoing Khmer Rouge Tribunal (KRT) (Field and Chhim, 2008). A mental health survey among landmine-victims in Siem Reap province of Cambodia reported high prevalence of mental health problems, 62% anxiety disorders, 74% depressive disorders and 34% PTSD, and recommended ‘mental health services embedded within the primary health care system’ (Lopes Cardozo et al., 2012). The study that looked at lifetime events and PTSD in four conflict settings, viz. Algeria, Cambodia, Ethiopia and Gaza, found 28.4% Cambodian survivors suffering from PTSD, next only to the respondents from Algeria (de Jong et al., 2001). Many epidemiological studies in post-conflict countries such as Libya, and among war-refugees of Rwanda, Somalia and Vietnam highlighted the impact on the mental health of the population well beyond the period of conflict, that is further worsened by poverty, health and human resource constraints (Charlson et al., 2012; Onyut et al., 2009; Steel et al., 2002). The geopolitical situation, the chronic and recurrent upheavals in Cambodia and the international focus on PTSD led to many trauma related studies, and it is time common mental, neurological and substance abuse disorders (MNSDs) were given equal importance if not more (Van de Put and Eisenbruch, 2002). A study by Somasundaram et al. (1999) underscored the need for ‘culturally informed approach in finding solutions to psychosocial problems’ and the importance of establishing community based interventions to meet the huge mental health needs of Cambodia. The World Health Organization emphasizes the importance of evidence based intervention and recommends guidelines for management of MNSDs and neurodevelopmental problems that include epilepsy, and child and adolescent mental health and related conditions to reduce the burden of mental morbidity in low and middle income countries (LMICs) (Dua et al., 2011; Thornicroft, 2012).
3. Prevalence of mental, neurological and substance abuse disorders (MNSDs) in Cambodia Until recently, most of the published studies on mental health situation of the people of Cambodia are from the immigrant population living in high income countries (HICs) (Fazel et al., 2005; Marshall et al., 2005) and there are a few population based prevalence studies on MNSDs in Cambodia. Most of the rural areas were inaccessible due to poor infrastructure in terms of connectivity and landmines, a legacy of war, which may explain the lack of nationwide prevalence study of MNSDs in Cambodia. A study among the clinical population in an out-patient setting revealed the following profile: anxiety 18%, depression 15%, epilepsy 15%, psychosis 15% and schizophrenia 18% (Somasundaram et al., 1999). The authors reiterated the need for community based care and integration of traditional healers in the mental health service delivery in the background of inadequate number of trained mental health personnel and non-availability of essential medicines in Cambodia, a scenario common to most LMICs. A recent survey among 2600 adults aged 21 and above in nine provinces of Cambodia reported high prevalence of suicide attempts, post-traumatic stress disorder (PTSD), and anxiety disorder in the general population (Schunert et al., 2012). According to this survey, there were 42 suicides per 100,000 of the population per year, which is high but comparable to countries in transition such as Belarus, Estonia, Hungary and Kazakhstan (Hoven et al., 2010). The most common reported stressor leading to suicidal thoughts in this study was poverty and indebtedness, similar to the travails of the cotton farmers of India (Grue`re and Sengupta, 2011). This is of serious concern, particularly when 23% of the population in Cambodia is below poverty line (Ministry of Planning, 2013). In the study by Schunert et al. (2012), 27.4 and 16.7% of the respondents reported anxiety and depression, respectively, and 2.7% experienced symptoms of PTSD, which were overall higher than in other post-conflict countries such as Ethiopia and Palestine, with the exception of Algeria (de Jong et al., 2003). Epilepsy adds to the mental health burden, as it is considered a mental illness and it is referred to as ‘‘Chikoot Chiruk’’ in Khmer (Cambodian language), a derogatory expression, which literally means ‘pig madness’. It is important to understand the cultural belief system and stigma around MNSDs in order to improve help seeking behavior, as 70% of the people with epilepsy (PWE) seek help with the traditional healers or monks before reaching a hospital (McLaughlin and Wickeri, 2012; Eisenbruch, 1992). Epilepsy is a global problem affecting 2–3% of the population and 80% of the burden of epilepsy is among LMICs (Barraga´n, 2012). Anxiety, mood disorders, psychosis, attention deficit hyperactivity disorders and autism are most common comorbidities, having ‘bidirectional relationship’ with seizure disorders (Gaitatzis et al., 2004). Therefore, it is important to consider management of epilepsy as part and parcel of mental health treatment package in LMICs, particularly in Cambodia where there are not many trained neurologists. A population based study of epilepsy in Cambodia reported a life-time prevalence of 5.8/1000, slightly lower than that in other countries in the region but the treatment gap was 65.8%. Among those treated, only 30% had access to antiepileptic medication and about 60% were reported to be using herbal products. Furthermore, 54% of the respondents considered epilepsy to be contagious and the prevailing stigma was associated with type of seizure and quality of life (Bhalla et al., 2012). In a door-to-door universal survey in 15 villages among 2564 children (M = 1261, F = 1303) in the age group of 2–16 years using Reporting Questionnaire for Children (RQC), 7.6% of the parents responded ‘yes’ to the question, ‘Did the child ever have fit or fall to the ground for no reason’ (Ahmad et al., 2007; Center for Child and Adolescent
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Mental Health, 1999). This figure is high, as the respondents might have included febrile seizures and secondary seizures due to brain infections, as observed by other researchers in Asia (Gourie-Devi et al., 2004). Epidemiological studies reveal high prevalence of psychiatric morbidities among PWE when compared with general population and in young people epilepsy is more often associated with developmental disorders (Davies et al., 2003; Devisnky, 2003). At the out-patient department (OPD) of the Center for Child and Adolescent Mental Health, 29% of the clients are children with epilepsy, often associated with comorbidities such as hemiplegia, developmental disability and psychogenic non-epileptic seizures (PNES), leading to stigmatization, over protective parenting and school drop-out (Center for Child and Adolescent Mental Health, 2013). In the study by Bhalla et al. (2012), 65.66% of the people with epilepsy (PWE) were children and adolescents, which highlights the enormity of the challenge in terms of unmet needs and the disease burden in Cambodia, particularly when 32% of the population is below 15 years of age (National Institute of Statistics, 2011). Bhalla et al. (2013) observed good remission with minimal dosage of conventional monotherapy and reported high acceptability for antiepileptic medication among PWE in Cambodia, which underscores the possibility for scaling-up. World Health Organization has prescribed epilepsy care guidelines for LMICs as a part of ‘mhGAP Action plan’ (Katchanov and Birbeck, 2012), which when adapted to Cambodian health service setting, the therapeutic needs of majority of PWE can be met at the primary health care level. Prevalence of substance abuse, other than alcohol and tobacco in Asia and the Pacific, was estimated to range from 0.01 to 4.6% in the population and was reported to be higher than 2% in Cambodia, Hong Kong, the Philippines and Thailand. Amphetamine type of stimulants (ATS), cannabis, heroin and opium were the most commonly used drugs in Cambodia, whereas use of injectable drugs was lower, similar to the situation in Laos and the Philippines (Devaney et al., 2007). The United Nations Office on Drugs and Crime (2004) predicted a change in the mode of intake of drugs in the context of growing influx of newer varieties of ATS, leading to increase of HIV/AIDS in Cambodia. Substance abuse was high among street children as 52% were drug dependent, and among them 49% reported using Yama (amphetamine), 31% glue and 7% heroin. Among girls living in rehabilitation units run by non-governmental agencies, 14% met the criteria for drug dependence and 14% of them had used Yama and 5% heroin (Barett, 2006). Community-based drug treatment was recommended as a sustainable alternative to compulsory treatment centers that were introduced by the government, as the former were voluntary, cost-effective and offered ‘rights-based deaddiction program and care within the reach of the communities’ (United Nations Office on Drugs and Crime, 2013). In the above report 62% of the drug users were reported to be below the age of 20. Increasing recreational use of drugs by young people is worrisome and prevention of high risk behavior among young people and promotion of child and adolescent mental health in Cambodia is crucial to the health and development of the future generation. 4. Child and adolescent mental health and related conditions in Cambodia Globally, neuropsychiatric disorders among children and young people account for 15–30% of the disability adjusted life-years (DALYs) lost. World’s 80% of the children and young people live in LMICs and therefore the magnitude of the service need and the mhGAP is enormous. A systematic survey of 16 studies in LMICs show10–20% prevalence of mental health problem among children and young people, similar to studies from high income countries
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(HICs) (Kieling et al., 2011). To our knowledge there are no nationwide population based epidemiological studies published on neuropsychiatric problems among all age groups of children in Cambodia. A door-to-door universal survey was conducted in 15 villages of Kandal province among 1741 school-going children (M = 871, F = 870) using Strength and Difficulties Questionnaire (SDQ), as a part of community and school based mental health project-planning (Vostanis, 2006). The respondents, mainly the primary caregivers, reported 13% of their children having problem (SDQ-parent version), while the SDQ-teacher version revealed 20% prevalence (Center for Child and Adolescent Mental Health, 1999), which is consistent with other studies in Asia (Mullick and Goodman, 2005; Srinath et al., 2010). Cambodian school students in the age group of 15–20, responding to a self-reporting questionnaire (YSR), reported higher mean scores on most of the YSR syndromes than that of referred children in the USA, a pointer to the magnitude of mental morbidity among young people in Cambodia (Jegannathan and Kullgren, 2011). Almost all the YSRsyndrome scores with the exception of rule-breaking behavior in both genders, and withdrawn depressed and externalizing syndrome among boys in Cambodia were significantly higher than that of their Nicaraguan counterparts (Obando Medina et al., 2012), indicative of the need for adolescent mental health services in Cambodia. Last year, the mental health team at Chey Chumneas Referral Hospital, Takhmau, offered 5227 consultations of which neuropsychiatric problems (mainly epilepsy) constituted 29%, mental health problems (mainly psychosis) 11% and developmental disorders including autism 60% (Center for Child and Adolescent Mental Health, 2013) which authenticates the view of incorporating services for children with neurodevelopmental problems with the child and adolescent mental health services in low-income countries (Patel et al., 2008). Studies across the world estimated the prevalence developmental disabilities to be 1–3% (Harris, 2006). A systematic review from India reported wide variation in prevalence, 1/1000 to 32/1000, which was explained by the differing age-criteria, diverse instruments used in the studies and the context, whether rural or urban, in which the study was carried out (Girimaji and Srinath, 2010). In Cambodia, the prevalence might be higher in the background of prevailing risk factors such as iodine deficiency disorder (IDD), iron deficiency anemia (IDA) and severe malnutrition during pregnancy, birth asphyxia, consanguinity, older mothers and brain infections during perinatal and early childhood, a scenario akin to many low income countries (Ali, 2013; Durkin, 2002). There are no nationwide published prevalence studies on developmental disabilities in Cambodia. In a door-to-door universal survey using RQC in rural Cambodia in 15 villages, 21.8% of the parents reported that their children ‘appear backward or slow to learn as compared with other children of the same age’ (Center for Child and Adolescent Mental Health, 1999), an overinclusive response that might have included slow learners, children with attention deficit disorder and specific learning disability (dyslexia), as reported elsewhere (Jeevanandam, 2009; Vanleit et al., 2007). Poverty, developmental disability and mental disorders are a vicious cycle and an impediment for the development of children and young people in LMICs (Lund et al., 2011; Simkiss et al., 2011). To break this vicious cycle, the Ministry of Health, Royal Government of Cambodia and Caritas Cambodia had jointly established a comprehensive, ‘one-stopservice’ for children with developmental disabilities, with an emphasis on parent training and human resource development at the CCAMH, Chey Chumneas Referral Hospital, Takhmau. This was made possible through the support of India Brazil South Africa (IBSA) Trust Fund, an outcome of trilateral support and South-South collaboration, a maiden effort in Indochina region (Wilm, 2013).
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5. Bilateral and multilateral agencies support for mental health service development Cambodia has been fortunate to have received continued assistance through bilateral and multilateral collaboration and funding support for the past two decades to develop human resource and services for people with MNSDs. The Marcel Charles Roy Foundation for the Children of Cambodia from Canada founded the child and adolescent mental health unit (CCAMH) at Chey Chumneas Hospital, a referral hospital in Kandal Province in the year 1991 in collaboration with the Ministry of Health, Royal Government of Cambodia and Caritas Cambodia, an international non-governmental organization. A building was renovated (1991– 1993), and the first ever mental health training in post-war Cambodia was held in this premise (1993–1995) for 25 primary mental health care providers, comprising general physicians and nurses with a UN Volunteer from Tanzania as a resource person. This unit, located at former mental asylum of Cambodia at Takmau, was formally inaugurated by late Father His Majesty Preah Bat Norodom Sihanouk in January, 1995. What was started as a center based unit to provide clinical service for children and adolescents with neuropsychiatric and developmental problems has expanded to offer community and school based mental health program with the support of international agencies through Caritas Cambodia, a model espoused by researchers and policy makers (Cohen et al., 2011). Over the years the team at CCAMH, Cambodia has developed an enduring partnership with the National Institute for Mentally Handicapped (NIMH-Secunderabad) and National Institute of Mental Health and Neurosciences (NIMHANSBangalore) in India for placement and training opportunities for Cambodian mental health professionals and has made linkages with University of Bergen, University London and University of Umea, a global partnership, to sustain the quality of services through in-service training (Tareen et al., 2009). The Transcultural Psychosocial Organization (TPO), based in Amsterdam engaged in promotion of mental health in war and conflict zones worldwide, started a community based mental health program in Cambodia with the ‘aim of identification, prevention and management of psychosocial problems’ in the year 1995 (de Jong, 1997). Since then TPO-Cambodia has played a key role in research and documentation of mental health problems in Cambodia with trauma, mental health and human rights perspective, particularly about the impact of Khmer Rouge Tribunal (KRT) on the victims of Pol Pot era (Chhim, 2013; Field and Chhim, 2008). In the year 1996, the Harvard Training Program in Cambodia (HTPC) started an outpatient department (OPD) for the mentally ill at the referral hospital, Siem Riep Province and trained 48 general physicians and medical assistants in trauma-counseling and primary mental health care. Henderson et al. (2005) report the successful outcome of this project in terms of enhanced confidence, attitude change and improved mental health skills among the primary care practitioners at the end of this part-time training. The same year Norwegian Council for Mental Health commenced a formal academic program, the Cambodian Mental Health Training Program (CMHTP), to train psychiatrists and psychiatric nurses in collaboration with the International Organization for Migration (IOM) and with the help of Norwegian Aid (NORAD) (Somasundaram et al., 1999). Under this program, 26 psychiatrists and 25 psychiatric nurses were trained. Subsequently, equal numbers of psychiatrists have been trained by the first generation of Cambodian mental health professionals who graduated from the CMHTP, a laudable achievement in a post-conflict setting. Incorporating mental health modules into the curriculum for medical students and training of mental health professionals continue to be a challenge due to shortages of qualified trainers and lack of on the job coaching and mentoring. Though there has
been considerable improvement in the number of trained mental health professionals due to continued engagement of international agencies, there is more scope for improving the quality of mental health training and scaling-up services, as currently most of mental health professionals and, therefore, the services are concentrated in and around Phnom Penh city, the capital, a feature not uncommon to most of the LMICs (Lancet Global Mental Health Group; Chisholm et al., 2007). A sincere attempt was made by the planners of the CMHTP postgraduate training program to scale up the mental health service to several provinces, other than the capital city, but the program could no more be sustained when the NORAD funding support came to an end. It is of paramount importance that there is government commitment to develop epidemiologically sound mental health policy and evidence based practice to address the needs of people with MNSDs throughout Cambodia, particularly the rural majority who constitute 80% of the population (Eaton et al., 2011; Stockwell et al., 2005; Thornicroft, 2012). 6. Evidence based collaborative care model, an opportunity to bridge mhGAP in Cambodia McLaughlin and Wickeri (2012) looked at the plight of people with MNSDs with a human rights perspective and underscored the role of Royal Government of Cambodia (RGC) in fund allocation, policy development and enhanced commitment in meeting the mental health needs in Cambodia, while acknowledging the role of international organizations. This is an important observation in the context of impending donor-fatigue, as increasingly the resources of international organizations are more thinly spread across conflict-prone zones elsewhere in Africa, Asia and the Middle East. The authors recommended education campaigns for destigmatization, establishment of community based mental health program that is integrated with the rest of services cross-cutting across other government sectors, and ratification and implementation of international of conventions to meet the legal obligations for people with MNSDs. The RGC had ratified the UN Convention of Rights for People with Disability (UNCRPD) and came out with the National Disability Strategic Plan (NDSP) for the period 2014–2018 which was formally launched by Samdech Techo Hun Sen, the prime minister of Cambodia, recently (Disability Action Council, 2014). The evidence for efficacy of mental health programs that are integrated at primary health care setting in LMICs is reassuring (Hanlon et al., 2014), and this may be a golden opportunity to strengthen the mental health services at primary care level in Cambodia as the NDSP is inclusive of the rights and needs of people with MNSDs. The Second Health Sector Strategic Plan (HSP2) 2008–2015 of the ministry of health (MoH), Royal Government of Cambodia, a document that laid out clear strategies to reduce morbidity and mortality due to HIV/AIDS, malaria, tuberculosis and other communicable diseases also mentions about reducing the burden of non-communicable diseases and other health problems. The health sector plan lists minimum package and complementary package of activities at the primary and secondary levels of health care, respectively, to tackle infectious diseases (Collins et al., 2009; Ministry of Health, 2008). The needs of people with MNSDs can be adequately met when the package of activities related to mental health program are clearly stated and incorporated at respective levels of care (Patel and Thornicroft, 2009). Maternal depression has public health implications, as it is associated with mortality and morbidity among women and has long-term repercussion on child and adolescent mental health. Studies have shown that this problem can be effectively dealt with at primary health care level when the team implementing maternal and child care programs receive adequate and appropriate training (Patel et al., 2009).
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Health care seeking practice in Cambodia is the lowest in the Asia Pacific region, and the RGC considers implementation of community based IMCI (integrated management of childhood illnesses) as a high priority to improve child survival (World Health Organization-Western Pacific Region, 2007). Primary and secondary prevention activities geared to prevent child and adolescent mental health problems can be easily integrated into community based IMCI and vulnerable children can be reached by building cross-system referrals to provide collaborative care (Carter, 2009; Pollard et al., 2014). Two-thirds of the adult mental illnesses have their origin during childhood and adolescence and early identification and intervention may mitigate some of these problems. This is possible only when there is concerted effort on the part of the mental health professionals to build the capacity of health care providers at both the primary and secondary levels in Cambodia, enabling them to transform the landscape of mental health service provision (Hanlon et al., 2014; Kakuma et al., 2011; Sapag et al., 2013). Innovative models such as ‘Theory of Change (ToC)’ claim enablement of stakeholder-participation at different levels of health care system leading to better integration of mental health services with the existing health care system (Breuer et al., 2014; Hernandez and Hodges, 2006) and is worth giving a try in lowincome post-conflict countries such as Cambodia.
7. Challenges, opportunities and the future The Second Health Sector Strategic Plan (HSP2) 2008–2015 (Ministry of Health, 2008) gives due importance to public–private partnership in developing human resource and service delivery. Couple of private institutions engaged in graduate and postgraduate level medical education may reduce the gap in trained health professionals in Cambodia while giving an opportunity to introduce modules related to MNSDs early on in the medical curriculum. The HSP2-2008–2015 document acknowledges that non-communicable diseases will increase due to life style changes and therefore will ‘rapidly claim increased involvement from the health system as a whole’ but mentions a ‘number of mental health cases reported in public sector’ as the only ‘core indicator’ for measurement of progress of mental health services. This needs further elaboration in the next planning phase in order to give due importance to mental health services in public sector. Establishing four regional training centers for human resource development in mental health spread over the country was planned which when materializes may bring about equitable access to mental health services both to rural and urban areas. Recent establishment of the Department of Mental Health and Substance Abuse by the Ministry of Health, Royal Government of Cambodia, gives tremendous scope and opportunity to bring about the necessary and long pending systemic changes in the primary and secondary health care levels to incorporate mental health component, provided there is consensual leadership from within the mental health professional community, sustained commitment on the part of the government and political will.
Conflict of Interest None for all the authors.
Author information BJ wrote the first draft of the article GK gave feedback and suggestions to improve the successive drafts and help to finalize it PD gave feedback and suggestions to improve the successive drafts and help to finalize it.
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Acknowledgements We acknowledge the role of international and national agencies who contributed generously for initiating mental health training and services in Cambodia and the sincere efforts of national and international mental health experts, professionals and volunteers who braved the dire living conditions in the immediate aftermath of war to kick-start the mental health program in Cambodia.
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Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Mental health services in Cambodia, challenges and opportunities in a post-conflict setting Bhoomikumar Jegannathan a,*, Gunnar Kullgren b, Parameshvara Deva c a
Center for Child and Adolescent Mental Health, Chey Chumneas Hospital Takhmau, Kandal Province, Cambodia Psychiatry, Department of Clinical Sciences, University of Umea˚, 901 85 Umea˚, Sweden c Faculty of Medicine and Health Sciences, University Tunku Abdul Rahman, Sg. Long, Selangor, Malaysia b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 August 2014 Received in revised form 12 December 2014 Accepted 14 December 2014
Cambodia had suffered enormously due to war and internecine conflict during the latter half of the twentieth century, more so during the Vietnam War. Total collapse of education and health systems during the Pol Pot era continues to be a challenge for developing the necessary infrastructure and human resources to provide basic minimum mental health care which is compounded by the prevailing cultural belief and stigma over mental, neurological and substance abuse disorders (MNSDs). The mental health research and services in Cambodia had been predominantly ‘trauma focused’, a legacy of war, and there is a need to move toward epidemiologically sound public health oriented mental health policy and service development. Integrating mental health program with primary health care services with specifically stated minimum package of activities at primary level and complementary package of activities at secondary level is an opportunity to meet the needs and rights of persons with mental, neurological and substance abuse disorders (PWMNSDs) in Cambodia, provided there is mental health leadership, government commitment and political will. ß 2014 Elsevier B.V. All rights reserved.
Keywords: Mental health Challenges Opportunities Cambodia Post-conflict setting
1. Background The Khmer empire extended as far as Thailand, Malaysia, Vietnam and Laos during the eighth to twelfth centuries, a golden period that is enshrined in the magnificent temples of Angkor, a
Abbreviations: ATS, Amphetamine type of stimulants; CCAMH, Center for Child and Adolescent Mental Health, Cambodia; CMHTP, Cambodian Mental Health Training Program; HICs, High Income Countries; HTPC, Harvard Training Program in Cambodia; IMCI, Integrated Management of Childhood Illnesses; IBSA, India Brazil South Africa Trust Fund; IOM, International Organization for Migration; KRT, Khmer Rouge Tribunal; LMICs, Low and Middle Income Countries; MNSDs, Mental, Neurological and Substance Abuse Disorders; NIMH, National Institute for Mentally Handicapped, Secunderabad; NIMHANS, National Institute of Mental Health and Neurosciences, Bangalore; NORAD, Norwegian Aid; PNES, Psychogenic NonEpileptic Seizures; PWE, People With Epilepsy; RQC, Reporting Questionnaire for Children; TPO, Transcultural Psychosocial Organization; UNCRPD, United Nations Convention of Rights for People with Disability; UNTAC, United Nations Transitional Authority in Cambodia. * Corresponding author at: Center for Child and Adolescent Mental Health (CCAMH), Chey Chumneas Hospital, Takhmau, Kandal Province, Cambodia. Tel.: +855 23 983348; fax: +855 23 216258. E-mail addresses: [email protected] (B. Jegannathan), [email protected] (G. Kullgren), [email protected] (P. Deva). http://dx.doi.org/10.1016/j.ajp.2014.12.006 1876-2018/ß 2014 Elsevier B.V. All rights reserved.
world heritage monument in Cambodia. Cambodia has been a land of perennial conflict since Angkorean times. Following the independence from French colonial rule, the country deteriorated to become the poorest in the region, a ‘victim of its geography and political underdevelopment’ (Shawcross, 1994). The spillover of Vietnam War and the social engineering and pogrom of Pol Pot regime in the 1970s resulted in collective trauma of the entire population. A million and a half died due to starvation and sickness, half a million were eliminated in the name of agrarian revolution and about two million people were internally displaced between 1975 and 1978. Studies in the refugee-sites along the Thai border revealed the impact of war and internecine conflict on the mental health of the Cambodian population (Mollica et al., 1997). The end of the Cold War and the Paris Peace Agreement of 1991, followed by UNTAC-intervention (United Nations Transitional Authority in Cambodia) brought an uneasy peace and stability but the country continues to suffer from political instability and the impact of chronic conflict (Deth, 2009). The people of Cambodia are in the process of reconciling with the trauma of war and conflict of the past whereas lack of institutional structures remains to be a challenge for the growth and development of the nation, particularly health services
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(Bockers et al., 2011). Deva et al. (2009) outlined the development of mental health services in Cambodia and the challenges ahead in the backdrop of sparse human resource and meager allocation of national health budget to the mental health program. Research and development of mental health services in post-conflict countries such as Cambodia, had been trauma focused and there is a need to move beyond post-traumatic stress disorder (PTSD)paradigm to address the range of common mental and neurological disorders (de Jong et al., 2003; Murthy and Lakshminarayana, 2006). This article, a follow-up to the update on the mental health situation of Cambodia by Deva et al. (2009), underscores the importance of epidemiologically sound, public health model of mental health service delivery, with an emphasis on integration of mental health services with the primary, secondary and tertiary health care systems in Cambodia.
2. Trauma-led research and mental health care, a legacy of conflict-ridden Cambodia The socioeconomic situation, health and development of the people of Cambodia, particularly the mental health, had been adversely affected, either directly or indirectly due to border disputes which remain a source of conflict between neighboring countries (Sothirak, 2013). There are an estimated 400,000 migrant workers in Thailand and the enormity of their mental health challenges in the background of poverty, migration and lack of access to services is a cause for concern (Meyer et al., 2014; Van de Put and Eisenbruch, 2004). The recent regime change in Thailand led to the influx of more than 200,000 migrant workers back to Cambodia within the brief period of a week, indicating the fragility of the psychosocial situation and the challenge for mental health service providers. The recurring mental health crisis and reliving of trauma by the people of Cambodia was exemplified by the study among the survivors of Pol Pot regime in the backdrop of ongoing Khmer Rouge Tribunal (KRT) (Field and Chhim, 2008). A mental health survey among landmine-victims in Siem Reap province of Cambodia reported high prevalence of mental health problems, 62% anxiety disorders, 74% depressive disorders and 34% PTSD, and recommended ‘mental health services embedded within the primary health care system’ (Lopes Cardozo et al., 2012). The study that looked at lifetime events and PTSD in four conflict settings, viz. Algeria, Cambodia, Ethiopia and Gaza, found 28.4% Cambodian survivors suffering from PTSD, next only to the respondents from Algeria (de Jong et al., 2001). Many epidemiological studies in post-conflict countries such as Libya, and among war-refugees of Rwanda, Somalia and Vietnam highlighted the impact on the mental health of the population well beyond the period of conflict, that is further worsened by poverty, health and human resource constraints (Charlson et al., 2012; Onyut et al., 2009; Steel et al., 2002). The geopolitical situation, the chronic and recurrent upheavals in Cambodia and the international focus on PTSD led to many trauma related studies, and it is time common mental, neurological and substance abuse disorders (MNSDs) were given equal importance if not more (Van de Put and Eisenbruch, 2002). A study by Somasundaram et al. (1999) underscored the need for ‘culturally informed approach in finding solutions to psychosocial problems’ and the importance of establishing community based interventions to meet the huge mental health needs of Cambodia. The World Health Organization emphasizes the importance of evidence based intervention and recommends guidelines for management of MNSDs and neurodevelopmental problems that include epilepsy, and child and adolescent mental health and related conditions to reduce the burden of mental morbidity in low and middle income countries (LMICs) (Dua et al., 2011; Thornicroft, 2012).
3. Prevalence of mental, neurological and substance abuse disorders (MNSDs) in Cambodia Until recently, most of the published studies on mental health situation of the people of Cambodia are from the immigrant population living in high income countries (HICs) (Fazel et al., 2005; Marshall et al., 2005) and there are a few population based prevalence studies on MNSDs in Cambodia. Most of the rural areas were inaccessible due to poor infrastructure in terms of connectivity and landmines, a legacy of war, which may explain the lack of nationwide prevalence study of MNSDs in Cambodia. A study among the clinical population in an out-patient setting revealed the following profile: anxiety 18%, depression 15%, epilepsy 15%, psychosis 15% and schizophrenia 18% (Somasundaram et al., 1999). The authors reiterated the need for community based care and integration of traditional healers in the mental health service delivery in the background of inadequate number of trained mental health personnel and non-availability of essential medicines in Cambodia, a scenario common to most LMICs. A recent survey among 2600 adults aged 21 and above in nine provinces of Cambodia reported high prevalence of suicide attempts, post-traumatic stress disorder (PTSD), and anxiety disorder in the general population (Schunert et al., 2012). According to this survey, there were 42 suicides per 100,000 of the population per year, which is high but comparable to countries in transition such as Belarus, Estonia, Hungary and Kazakhstan (Hoven et al., 2010). The most common reported stressor leading to suicidal thoughts in this study was poverty and indebtedness, similar to the travails of the cotton farmers of India (Grue`re and Sengupta, 2011). This is of serious concern, particularly when 23% of the population in Cambodia is below poverty line (Ministry of Planning, 2013). In the study by Schunert et al. (2012), 27.4 and 16.7% of the respondents reported anxiety and depression, respectively, and 2.7% experienced symptoms of PTSD, which were overall higher than in other post-conflict countries such as Ethiopia and Palestine, with the exception of Algeria (de Jong et al., 2003). Epilepsy adds to the mental health burden, as it is considered a mental illness and it is referred to as ‘‘Chikoot Chiruk’’ in Khmer (Cambodian language), a derogatory expression, which literally means ‘pig madness’. It is important to understand the cultural belief system and stigma around MNSDs in order to improve help seeking behavior, as 70% of the people with epilepsy (PWE) seek help with the traditional healers or monks before reaching a hospital (McLaughlin and Wickeri, 2012; Eisenbruch, 1992). Epilepsy is a global problem affecting 2–3% of the population and 80% of the burden of epilepsy is among LMICs (Barraga´n, 2012). Anxiety, mood disorders, psychosis, attention deficit hyperactivity disorders and autism are most common comorbidities, having ‘bidirectional relationship’ with seizure disorders (Gaitatzis et al., 2004). Therefore, it is important to consider management of epilepsy as part and parcel of mental health treatment package in LMICs, particularly in Cambodia where there are not many trained neurologists. A population based study of epilepsy in Cambodia reported a life-time prevalence of 5.8/1000, slightly lower than that in other countries in the region but the treatment gap was 65.8%. Among those treated, only 30% had access to antiepileptic medication and about 60% were reported to be using herbal products. Furthermore, 54% of the respondents considered epilepsy to be contagious and the prevailing stigma was associated with type of seizure and quality of life (Bhalla et al., 2012). In a door-to-door universal survey in 15 villages among 2564 children (M = 1261, F = 1303) in the age group of 2–16 years using Reporting Questionnaire for Children (RQC), 7.6% of the parents responded ‘yes’ to the question, ‘Did the child ever have fit or fall to the ground for no reason’ (Ahmad et al., 2007; Center for Child and Adolescent
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Mental Health, 1999). This figure is high, as the respondents might have included febrile seizures and secondary seizures due to brain infections, as observed by other researchers in Asia (Gourie-Devi et al., 2004). Epidemiological studies reveal high prevalence of psychiatric morbidities among PWE when compared with general population and in young people epilepsy is more often associated with developmental disorders (Davies et al., 2003; Devisnky, 2003). At the out-patient department (OPD) of the Center for Child and Adolescent Mental Health, 29% of the clients are children with epilepsy, often associated with comorbidities such as hemiplegia, developmental disability and psychogenic non-epileptic seizures (PNES), leading to stigmatization, over protective parenting and school drop-out (Center for Child and Adolescent Mental Health, 2013). In the study by Bhalla et al. (2012), 65.66% of the people with epilepsy (PWE) were children and adolescents, which highlights the enormity of the challenge in terms of unmet needs and the disease burden in Cambodia, particularly when 32% of the population is below 15 years of age (National Institute of Statistics, 2011). Bhalla et al. (2013) observed good remission with minimal dosage of conventional monotherapy and reported high acceptability for antiepileptic medication among PWE in Cambodia, which underscores the possibility for scaling-up. World Health Organization has prescribed epilepsy care guidelines for LMICs as a part of ‘mhGAP Action plan’ (Katchanov and Birbeck, 2012), which when adapted to Cambodian health service setting, the therapeutic needs of majority of PWE can be met at the primary health care level. Prevalence of substance abuse, other than alcohol and tobacco in Asia and the Pacific, was estimated to range from 0.01 to 4.6% in the population and was reported to be higher than 2% in Cambodia, Hong Kong, the Philippines and Thailand. Amphetamine type of stimulants (ATS), cannabis, heroin and opium were the most commonly used drugs in Cambodia, whereas use of injectable drugs was lower, similar to the situation in Laos and the Philippines (Devaney et al., 2007). The United Nations Office on Drugs and Crime (2004) predicted a change in the mode of intake of drugs in the context of growing influx of newer varieties of ATS, leading to increase of HIV/AIDS in Cambodia. Substance abuse was high among street children as 52% were drug dependent, and among them 49% reported using Yama (amphetamine), 31% glue and 7% heroin. Among girls living in rehabilitation units run by non-governmental agencies, 14% met the criteria for drug dependence and 14% of them had used Yama and 5% heroin (Barett, 2006). Community-based drug treatment was recommended as a sustainable alternative to compulsory treatment centers that were introduced by the government, as the former were voluntary, cost-effective and offered ‘rights-based deaddiction program and care within the reach of the communities’ (United Nations Office on Drugs and Crime, 2013). In the above report 62% of the drug users were reported to be below the age of 20. Increasing recreational use of drugs by young people is worrisome and prevention of high risk behavior among young people and promotion of child and adolescent mental health in Cambodia is crucial to the health and development of the future generation. 4. Child and adolescent mental health and related conditions in Cambodia Globally, neuropsychiatric disorders among children and young people account for 15–30% of the disability adjusted life-years (DALYs) lost. World’s 80% of the children and young people live in LMICs and therefore the magnitude of the service need and the mhGAP is enormous. A systematic survey of 16 studies in LMICs show10–20% prevalence of mental health problem among children and young people, similar to studies from high income countries
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(HICs) (Kieling et al., 2011). To our knowledge there are no nationwide population based epidemiological studies published on neuropsychiatric problems among all age groups of children in Cambodia. A door-to-door universal survey was conducted in 15 villages of Kandal province among 1741 school-going children (M = 871, F = 870) using Strength and Difficulties Questionnaire (SDQ), as a part of community and school based mental health project-planning (Vostanis, 2006). The respondents, mainly the primary caregivers, reported 13% of their children having problem (SDQ-parent version), while the SDQ-teacher version revealed 20% prevalence (Center for Child and Adolescent Mental Health, 1999), which is consistent with other studies in Asia (Mullick and Goodman, 2005; Srinath et al., 2010). Cambodian school students in the age group of 15–20, responding to a self-reporting questionnaire (YSR), reported higher mean scores on most of the YSR syndromes than that of referred children in the USA, a pointer to the magnitude of mental morbidity among young people in Cambodia (Jegannathan and Kullgren, 2011). Almost all the YSRsyndrome scores with the exception of rule-breaking behavior in both genders, and withdrawn depressed and externalizing syndrome among boys in Cambodia were significantly higher than that of their Nicaraguan counterparts (Obando Medina et al., 2012), indicative of the need for adolescent mental health services in Cambodia. Last year, the mental health team at Chey Chumneas Referral Hospital, Takhmau, offered 5227 consultations of which neuropsychiatric problems (mainly epilepsy) constituted 29%, mental health problems (mainly psychosis) 11% and developmental disorders including autism 60% (Center for Child and Adolescent Mental Health, 2013) which authenticates the view of incorporating services for children with neurodevelopmental problems with the child and adolescent mental health services in low-income countries (Patel et al., 2008). Studies across the world estimated the prevalence developmental disabilities to be 1–3% (Harris, 2006). A systematic review from India reported wide variation in prevalence, 1/1000 to 32/1000, which was explained by the differing age-criteria, diverse instruments used in the studies and the context, whether rural or urban, in which the study was carried out (Girimaji and Srinath, 2010). In Cambodia, the prevalence might be higher in the background of prevailing risk factors such as iodine deficiency disorder (IDD), iron deficiency anemia (IDA) and severe malnutrition during pregnancy, birth asphyxia, consanguinity, older mothers and brain infections during perinatal and early childhood, a scenario akin to many low income countries (Ali, 2013; Durkin, 2002). There are no nationwide published prevalence studies on developmental disabilities in Cambodia. In a door-to-door universal survey using RQC in rural Cambodia in 15 villages, 21.8% of the parents reported that their children ‘appear backward or slow to learn as compared with other children of the same age’ (Center for Child and Adolescent Mental Health, 1999), an overinclusive response that might have included slow learners, children with attention deficit disorder and specific learning disability (dyslexia), as reported elsewhere (Jeevanandam, 2009; Vanleit et al., 2007). Poverty, developmental disability and mental disorders are a vicious cycle and an impediment for the development of children and young people in LMICs (Lund et al., 2011; Simkiss et al., 2011). To break this vicious cycle, the Ministry of Health, Royal Government of Cambodia and Caritas Cambodia had jointly established a comprehensive, ‘one-stopservice’ for children with developmental disabilities, with an emphasis on parent training and human resource development at the CCAMH, Chey Chumneas Referral Hospital, Takhmau. This was made possible through the support of India Brazil South Africa (IBSA) Trust Fund, an outcome of trilateral support and South-South collaboration, a maiden effort in Indochina region (Wilm, 2013).
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5. Bilateral and multilateral agencies support for mental health service development Cambodia has been fortunate to have received continued assistance through bilateral and multilateral collaboration and funding support for the past two decades to develop human resource and services for people with MNSDs. The Marcel Charles Roy Foundation for the Children of Cambodia from Canada founded the child and adolescent mental health unit (CCAMH) at Chey Chumneas Hospital, a referral hospital in Kandal Province in the year 1991 in collaboration with the Ministry of Health, Royal Government of Cambodia and Caritas Cambodia, an international non-governmental organization. A building was renovated (1991– 1993), and the first ever mental health training in post-war Cambodia was held in this premise (1993–1995) for 25 primary mental health care providers, comprising general physicians and nurses with a UN Volunteer from Tanzania as a resource person. This unit, located at former mental asylum of Cambodia at Takmau, was formally inaugurated by late Father His Majesty Preah Bat Norodom Sihanouk in January, 1995. What was started as a center based unit to provide clinical service for children and adolescents with neuropsychiatric and developmental problems has expanded to offer community and school based mental health program with the support of international agencies through Caritas Cambodia, a model espoused by researchers and policy makers (Cohen et al., 2011). Over the years the team at CCAMH, Cambodia has developed an enduring partnership with the National Institute for Mentally Handicapped (NIMH-Secunderabad) and National Institute of Mental Health and Neurosciences (NIMHANSBangalore) in India for placement and training opportunities for Cambodian mental health professionals and has made linkages with University of Bergen, University London and University of Umea, a global partnership, to sustain the quality of services through in-service training (Tareen et al., 2009). The Transcultural Psychosocial Organization (TPO), based in Amsterdam engaged in promotion of mental health in war and conflict zones worldwide, started a community based mental health program in Cambodia with the ‘aim of identification, prevention and management of psychosocial problems’ in the year 1995 (de Jong, 1997). Since then TPO-Cambodia has played a key role in research and documentation of mental health problems in Cambodia with trauma, mental health and human rights perspective, particularly about the impact of Khmer Rouge Tribunal (KRT) on the victims of Pol Pot era (Chhim, 2013; Field and Chhim, 2008). In the year 1996, the Harvard Training Program in Cambodia (HTPC) started an outpatient department (OPD) for the mentally ill at the referral hospital, Siem Riep Province and trained 48 general physicians and medical assistants in trauma-counseling and primary mental health care. Henderson et al. (2005) report the successful outcome of this project in terms of enhanced confidence, attitude change and improved mental health skills among the primary care practitioners at the end of this part-time training. The same year Norwegian Council for Mental Health commenced a formal academic program, the Cambodian Mental Health Training Program (CMHTP), to train psychiatrists and psychiatric nurses in collaboration with the International Organization for Migration (IOM) and with the help of Norwegian Aid (NORAD) (Somasundaram et al., 1999). Under this program, 26 psychiatrists and 25 psychiatric nurses were trained. Subsequently, equal numbers of psychiatrists have been trained by the first generation of Cambodian mental health professionals who graduated from the CMHTP, a laudable achievement in a post-conflict setting. Incorporating mental health modules into the curriculum for medical students and training of mental health professionals continue to be a challenge due to shortages of qualified trainers and lack of on the job coaching and mentoring. Though there has
been considerable improvement in the number of trained mental health professionals due to continued engagement of international agencies, there is more scope for improving the quality of mental health training and scaling-up services, as currently most of mental health professionals and, therefore, the services are concentrated in and around Phnom Penh city, the capital, a feature not uncommon to most of the LMICs (Lancet Global Mental Health Group; Chisholm et al., 2007). A sincere attempt was made by the planners of the CMHTP postgraduate training program to scale up the mental health service to several provinces, other than the capital city, but the program could no more be sustained when the NORAD funding support came to an end. It is of paramount importance that there is government commitment to develop epidemiologically sound mental health policy and evidence based practice to address the needs of people with MNSDs throughout Cambodia, particularly the rural majority who constitute 80% of the population (Eaton et al., 2011; Stockwell et al., 2005; Thornicroft, 2012). 6. Evidence based collaborative care model, an opportunity to bridge mhGAP in Cambodia McLaughlin and Wickeri (2012) looked at the plight of people with MNSDs with a human rights perspective and underscored the role of Royal Government of Cambodia (RGC) in fund allocation, policy development and enhanced commitment in meeting the mental health needs in Cambodia, while acknowledging the role of international organizations. This is an important observation in the context of impending donor-fatigue, as increasingly the resources of international organizations are more thinly spread across conflict-prone zones elsewhere in Africa, Asia and the Middle East. The authors recommended education campaigns for destigmatization, establishment of community based mental health program that is integrated with the rest of services cross-cutting across other government sectors, and ratification and implementation of international of conventions to meet the legal obligations for people with MNSDs. The RGC had ratified the UN Convention of Rights for People with Disability (UNCRPD) and came out with the National Disability Strategic Plan (NDSP) for the period 2014–2018 which was formally launched by Samdech Techo Hun Sen, the prime minister of Cambodia, recently (Disability Action Council, 2014). The evidence for efficacy of mental health programs that are integrated at primary health care setting in LMICs is reassuring (Hanlon et al., 2014), and this may be a golden opportunity to strengthen the mental health services at primary care level in Cambodia as the NDSP is inclusive of the rights and needs of people with MNSDs. The Second Health Sector Strategic Plan (HSP2) 2008–2015 of the ministry of health (MoH), Royal Government of Cambodia, a document that laid out clear strategies to reduce morbidity and mortality due to HIV/AIDS, malaria, tuberculosis and other communicable diseases also mentions about reducing the burden of non-communicable diseases and other health problems. The health sector plan lists minimum package and complementary package of activities at the primary and secondary levels of health care, respectively, to tackle infectious diseases (Collins et al., 2009; Ministry of Health, 2008). The needs of people with MNSDs can be adequately met when the package of activities related to mental health program are clearly stated and incorporated at respective levels of care (Patel and Thornicroft, 2009). Maternal depression has public health implications, as it is associated with mortality and morbidity among women and has long-term repercussion on child and adolescent mental health. Studies have shown that this problem can be effectively dealt with at primary health care level when the team implementing maternal and child care programs receive adequate and appropriate training (Patel et al., 2009).
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Health care seeking practice in Cambodia is the lowest in the Asia Pacific region, and the RGC considers implementation of community based IMCI (integrated management of childhood illnesses) as a high priority to improve child survival (World Health Organization-Western Pacific Region, 2007). Primary and secondary prevention activities geared to prevent child and adolescent mental health problems can be easily integrated into community based IMCI and vulnerable children can be reached by building cross-system referrals to provide collaborative care (Carter, 2009; Pollard et al., 2014). Two-thirds of the adult mental illnesses have their origin during childhood and adolescence and early identification and intervention may mitigate some of these problems. This is possible only when there is concerted effort on the part of the mental health professionals to build the capacity of health care providers at both the primary and secondary levels in Cambodia, enabling them to transform the landscape of mental health service provision (Hanlon et al., 2014; Kakuma et al., 2011; Sapag et al., 2013). Innovative models such as ‘Theory of Change (ToC)’ claim enablement of stakeholder-participation at different levels of health care system leading to better integration of mental health services with the existing health care system (Breuer et al., 2014; Hernandez and Hodges, 2006) and is worth giving a try in lowincome post-conflict countries such as Cambodia.
7. Challenges, opportunities and the future The Second Health Sector Strategic Plan (HSP2) 2008–2015 (Ministry of Health, 2008) gives due importance to public–private partnership in developing human resource and service delivery. Couple of private institutions engaged in graduate and postgraduate level medical education may reduce the gap in trained health professionals in Cambodia while giving an opportunity to introduce modules related to MNSDs early on in the medical curriculum. The HSP2-2008–2015 document acknowledges that non-communicable diseases will increase due to life style changes and therefore will ‘rapidly claim increased involvement from the health system as a whole’ but mentions a ‘number of mental health cases reported in public sector’ as the only ‘core indicator’ for measurement of progress of mental health services. This needs further elaboration in the next planning phase in order to give due importance to mental health services in public sector. Establishing four regional training centers for human resource development in mental health spread over the country was planned which when materializes may bring about equitable access to mental health services both to rural and urban areas. Recent establishment of the Department of Mental Health and Substance Abuse by the Ministry of Health, Royal Government of Cambodia, gives tremendous scope and opportunity to bring about the necessary and long pending systemic changes in the primary and secondary health care levels to incorporate mental health component, provided there is consensual leadership from within the mental health professional community, sustained commitment on the part of the government and political will.
Conflict of Interest None for all the authors.
Author information BJ wrote the first draft of the article GK gave feedback and suggestions to improve the successive drafts and help to finalize it PD gave feedback and suggestions to improve the successive drafts and help to finalize it.
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Acknowledgements We acknowledge the role of international and national agencies who contributed generously for initiating mental health training and services in Cambodia and the sincere efforts of national and international mental health experts, professionals and volunteers who braved the dire living conditions in the immediate aftermath of war to kick-start the mental health program in Cambodia.
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