*Population in 2020、GNI and life expectancy are updated based on UN's 2019 data.
*Medical information is based on WHO's 2017 report Mental Health Atlas-country profile.
The Kingdom of Cambodia, formerly known as Khmer and now commonly known as Cambodia, is located in the Indochina Peninsula in Southeast Asia and Phnom Penh is the capital. It is a member of the United Nations and a member of the Association of Southeast Asian Nations (ASEAN). The population is 16.72 million with a total area of 181,035 square kilometers, and there are about 20 ethnic groups in the country, in which 97.6% of them are Khmer, while more than 95% of the people believe in Buddhism. It shares the border with Thailand and Laos in the north, and Vietnam is at its south. The most famous attraction and an UNESCO heritage site is Angkor Wat, which is also the main pattern of the national flag. Cambodia became a French protectorate in 1863, and was once occupied by the Japanese army during the World War II, and finally to be independent from France on November 9, 1953, after a series of struggles. However, since then, the political turmoils and the influence of successive years of wars have caused the disparity between the rich and the poor in the country. The lack of infrastructure, which has caused serious social problems such as health concerns and the low level of people’s knowledge, it has evolved into a severe ordeal of current economic development. The domestic transportation and related equipment are still inadequate, even there have some gradual improvement after decades of reconstruction, the road construction is so far concentrated in the capital Phnom Penh area.
Cambodia held its first general election in May 1993. In September of the same year, a new constitutional monarchy was promulgated and the country was renamed as "Kingdom of Cambodia" with 24 provinces and 1 municipality (the capital) under the central government. Its GDP reached 26.8 billion U.S. dollars in 2019, an increase of 7.1% than that of 2018. At present, Taiwanese investment in Cambodia is gradually increasing, as of October 2019, the total amount has attained 725 million U.S. dollars. As the economy continues to develop, the government's health care expenditures will gradually be increased and so do the increase of Taiwanese cadres in Cambodia. The demand for local health and medical resources shall also be enhanced, which means that more Taiwanese-funded hospitals in Cambodia will become a strong medical backup for the Taiwanese in there.
The central government for the health authority is the Ministry of Health (hereinafter called MoH) who is responsible for managing all healthcare organizations, including also the non-governmental organizations related to public health and mental health. At the same time, it manages and regulates the activities of the country's medical professionals, hospitals and clinics. There are 24 provincial health departments, and the main office is located in the capital Phnom Penh.
In 1992, the Mental Health Subcommittee under the Cambodian MoH was established to develop mental health services in the country.
II. Mental health policy and system
There is a lack of attention to patients with mental illness, so far, Cambodia still has no mental health laws and judicial psychiatric hospitals.
In 2010, the Cambodian government issued the "Mental Health and Substance Misuse Strategic Plan" for 2011-2015, which established the vision, mission and strategy for the development of mental health services in Cambodia, as well as the key challenges it faces. The vision is "all Cambodians have a high level of mental health and social mental health and contribute to the quality of life", while the mission is to ensure that "all Cambodians have access to the highest quality mental health and the services for substance abuse addicts."
Since 2016, the National Social Security Fund (NSSF) has implemented a Social Health Insurance Scheme to provide workers in formal institutions with contribution-based medical insurance (insurance contributions are deducted from wages). However, workers in informal institutions and the family members of workers in formal institutions are still not covered by this insurance because their income levels are immeasurable and it is difficult to set the best contribution amount for them. In addition, the Cambodian Health Equity Fund (HEF) provides free medical services to approximately 3 million people classified as extremely poor. The government plans to extend the social health insurance program to other populations by 2025. According to statistics, as of December 2017, NSSF or HEF provided health insurance for approximately 31% of Cambodian citizens.
The Cambodian medical care system is divided into three levels: the national/central level, the provincial level, and the local level (such as county/district/township/village). At the local level, it can be subdivided into Referral Hospital and Health Center. Although the government is working hard to develop social medical insurance (including medical vouchers, medical equity funds, community medical insurance, and national social insurance funds, etc.), the coverage is insufficient, and the economic gap also leads to differentiated treatment models with different prices. Take the capital Phnom Penh as an example. The most well-known Royal Phnom Penh Hospital was built according to the standard plan of the Joint Commission International (JCI). Others such as Calmette Hospital, funded by the Cambodian and French governments, and it is a public and tertiary hospital managed by the MoH; Sun International Clinic, a Japanese hospital with many Japanese doctors in service that provides advanced Japanese medical services to Cambodia; Sihanouk Hospital Center of Hope (a NGO hospital managed by the HOPE organization in the United States); Cho Ray Phnom Penh Hospital, which is jointly run by the Cambodian and Vietnamese governments. Generally, it can be seen that most of the well-known hospitals in Phnom Penh are medical facilities invested by foreign capital which are very costly. As a matter of fact, community residents mainly rely on primary health care centers. According to the National Health Coverage Plan, each health care center is responsible for the medical care of 8,000-12,000 people. If people need secondary or tertiary care, they require to be referred by a referral hospital to the national/central or provincial care system. Currently, Cambodia does not have national clinical guidelines for the diagnosis and treatment of mental disorders, nor does it have mental health legislation. However, the "2011-2015 Mental Health and Substance Misuse Strategic Plan" has included the main topics of mental health policy and has begun to pay attention to mental health intervention issues.
III. Human Resources
When the Cambodian medical system became independent from France in 1953, many French medical practitioners left the country, which lead to encounter a manpower crisis at that time. Therefore, the government established the Cambodian Royal School of Medicine for the requirement. It was a national university and merged into the University of Health Science in 1997 with schools of medicine, dentistry, and pharmacy together, while the nursing staff, midwives, functional therapists, medical radiologists, and examiners were affiliated to the Medical Care Technology Institute. There are also 2 private institutions with affiliated medical schools. There are many new medical practitioners who have been actively trained by the government in recent years, especially the cultivation and development of nursing staff. However, there is still a lack of institutional standards for medical curriculum planning for physicians, and a complete training system for residents in the hospital has not been established after their graduation from the medical schools.
It takes six years to complete medical school in Cambodia which includes one year of medical basic education and five years of medical specialty. To become a general practitioner, it requires an additional two years of internship. The four best medical schools in Cambodia are located in Phnom Penh, which cover:
(1). The University of Health Sciences. Since 2005, it had taken over a three-year psychiatric residency training program.
(2). International University (IU). IU School of Medicine and Children's Science is considered to be one of the best medical schools in Cambodia, mainly because it receives the International Medical Education Directory (IMED), the Foundation for Advancement of International Medical Education and Research (FAIMER) and the Educational Commission for Foreign Medical Graduates' (ECFMG) international certification so that the medicine schools' graduates are qualified with three steps for the United States Medical Licensing Examination (USMLE).
(3). Norton University Faculty of Health Sciences is the first private university in Cambodia which offers a doctor of medicine degree, and has become the first choice for students to study medicine, nursing, pharmacy and dentistry.
(4). University of Puthisastra provides eight years' curricula of medical doctorate, including 6 years of general courses and 2 years of internship.
The Mental Health Status of ASEAN Countries published in 2016 pointed out that mental health personnel in Cambodia are very less, only 57 psychiatrists and 45 psychiatric nurses work full-time in the hospitals. The number of psychiatrists, nurses and other mental health workers per 100,000 people is 0.39, 0.3 and 4.0, respectively. The data of psychologists, social workers and occupational therapists are lacking. According to the Mental Health Manpower Statistics of the World Health Organization (hereinafter called WHO) in 2011, if the estimate of prevalence and facilities are concerned, the country's demand for psychiatrists and nurses should be 1.46 and 14.85 per 100,000 people, respectively. Cambodia’s mental health manpower status is obviously insufficient compared to other countries. Since 1994, there had been about 600 primary care physicians and nurses who received the aforementioned basic training and worked in referral hospitals and health care centers, however, only 20% of the said medical staff continue to serve. Currently, there are about 70 psychiatrists in Cambodia, and only 3-4 psychiatrists practice in the private clinics as for the primary medical services. There are still no psychiatric hospitals nationwide, and the authorities (MoH) have no plans to establish one.
Regarding the education and training of medical manpower, the psychiatric residents still have no standardized training courses anyhow. Possibly because it needs a three-year post-graduate training courses of psychiatry in the regional area, while the training of psychiatric nurses is about 18-month related training courses; on the contrary, the training of internal medicine physicians requires only a 4-week basic training in mental health.
IV. Mental health system and promotion
Cambodia has eight national hospitals, 80 referral hospitals and 1,000 health centers, but no psychiatric hospitals (see table below, Department of Mental Health and Substance Abuse Report 2013) so far. Most mental health services are in the public health sector; and general medical institutions, such as referral hospitals and health centers, provide some mental health services anyway.
In 2012, Cambodia had 11 to 14 drug treatment and social affairs centers. These centers are mainly addressing substance dependence problems and providing social rehabilitation services. Since then, a community-centered approach has been proposed to deal with the high incidence of drug abuse in Cambodia.
Cambodia provides mental illness and substance abuse treatment in referral hospitals, including consultation, health education, outpatient, hospitalization and day care services, etc. The goal is to provide complete and comprehensive services for such patients, to play a supporting role in the medication behavior of patients and their families, and to encourage them to take the medicine regularly. Community mental health emphasizes the health promotion and prevention.
The mental health services provided by the health center are mainly handled by professionally trained physicians or nurses, which include:
(1). Basic care for common mental illnesses (including substance abuse diseases);
(2). Tracking the treatment of patients referred by referral hospitals;
(3). Medication and consultation;
(4). Cooperate with regional non-profit organizations and other organizations to screen cases and give them the referrals when necessary;
(5). Community health education and home visits;
(6). Follow-up the cases for the interruption of treatment.
In Cambodia, the stigma of mental illness is extremely high, and mental patients are often turned away by relatives and friends. Therefore, there are currently some organizations and personnel in Cambodia who are committed to good mental health services and reduce the stigma surrounding mental health. The following is a brief description of organizations which is aimed at promoting mental health awareness in Cambodia:
CAMBODIA–WHO Country Cooperation Strategy 2016–2020. It is mainly to improve the coverage of national health, to assist Cambodia in the development of community-based rehabilitation、treatment and counseling services, and to expand medical resources for mental health and physical disabilities. It is expected to gain the achievement of the United Nations' Sustainable Development Goals by 2030, and has attained some progress up to now. For example, in 2014, the establishment of the "Department of Mental
Health and Substance Abuse" which was under the MoH, and it provided many mental health services and legalized the importance of mental health in life.
Cambodia has four organizations that improve the mental health in the country:
(1). Transcultural Psychosocial Organization Cambodia (TPO) is a non-profit organization, it is mainly to build and raise the awareness and to provide the psychotherapy services in the community. Through the cultural background, TPO is developing culturally the treatment options for Cambodian patients.
(2). The Center for Child and Adolescent Mental Health (CCAMH) is a joint project of the MoH and Caritas Cambodia in Phnom Penh. Its center is located in Kandal Province. It is protecting the growth of the younger generation in Cambodia by focusing on the neglected mental health symptoms of children, the organization is promoting the overall mental health awareness in Cambodia. CCAMH establishes support groups between parents, conducts mental health research surveys, sets up counseling services in local schools, and promotes beneficial facilities such as libraries and playgrounds that promote campus health.
(3). The Social Services of Cambodia SSC, whose main task is to eliminate negative stigma related to Cambodian mental health professionals by communicating to schools, government officials and the public, thereby changing negative public opinion. In addition, SSC encourages future college students to participate in social work and recognizes the value of social work professionals.
(4). The Cambodian National Program for Mental Health (CNPMH). The main goal of the program is to support the MoH of Cambodia and help increase the number of appropriately trained mental health professionals in Cambodia. In addition to the training, it also provided the services to 23 of Cambodia's 24 provinces, introduced electronic data and supported the primary mental clinics in Phnom Penh and the development of psychosocial rehabilitation centers.
V. Major issues, challenge, and opportunities
Cambodia lacks mental medical manpower and attention to mental disease. Therefore, the government strives to promote the public to understand common mental illnesses, diagnosis, treatment and rehabilitation, and to strengthen the connection between different organizations and institutions, and it is hoped that patients can get good support and care in the community network of general medical and health promotion. However, to achieve such a vision will inevitably increase the burden on individuals, institutions and the country. Therefore, long-term and complete planning is urgently needed. Destigmatization of mental illness and further training of primary care manpower will increase the quality of services anyway. The coverage rate of mental health services is still far below the national "health coverage plan", and the main reason is the government’s limited budget. The shortage of resources hinder the capacity of mental health services, but it also highlights the rapid growth of the country’s mental health needs. The referral hospitals in Cambodia are responsible for psychiatric care、treatment and drug dependent patients, and to provide mental health and drug treatment services anyhow.
In addition, Cambodia’s historical trauma has caused a huge mental health burden on society, and has led to the prevalence of domestic violence and drug abuse. The government authorities are actively introducing resources and are gradually improving.
VI. Potential exchange issues
The crisis creates a turning point, and the government has established the "Department of Mental Health and Substance Abuse" in 2014 to respond to the people's needs. It strongly supports and allocates budget for continuous primary mental health care services and training, and looks forward to strengthening its quality and quantity of the mental health system through such changes, and improving the services of primary medical units. Future exchanges on the issue of drug abuse and addiction and the training of psychiatric medical personnel are expected.