Wednesday, April 26, 2017

Immunization on the move: Improving the health and well-being of disadvantaged children in Cambodia

By Meas Bunly


Mothers are encouraged by Village Health Volunteer Sokly Ye (standing)
 to take advantage of free vaccines offered by a mobile outreach team in March 2017; 
©UNICEF Cambodia/2017/Fani Llaurado   

“Bring your child for free vaccines tomorrow!” Sokly Ye, a robust 44-year-old woman, called out to passers-by as she slowly drove her motorbike down a narrow dirt road lined with small, ramshackle homes.


It was 7 in the morning, and Ms. Ye, an experienced village health volunteer, knew this was the best time to catch villagers at home and let them know that outreach health workers from a local health centre would be coming the next day.

From time to time, she parked and went door-to-door, speaking directly with residents about the free life-saving services scheduled.

Ms. Ye has been a village health volunteer for 10 years in Svay Pak, an urban poor settlement nine kilometres north of the Cambodian capital, Phnom Penh. She acts as an important messenger to this vulnerable community, sharing the benefits of practices such as vaccination and appropriate pre- and postnatal health for mothers, while also encouraging regular check-ups at the local health centre for all family members.

Around 5,000 people, or 1,000 families, live here. A third are migrants from rural areas in search of work. They live in informal settlements comprised of small wooden houses with tin roofs squeezed next to one another. Most are packed beyond capacity with inhabitants, including many small children.

Because some of these settlements are typically illegal and unorganized, they cannot get registered with the municipality and therefore receive no public services. Clean water and electricity are supplied by private providers, which are more expensive than public lines. In such communities, there is neither proper drainage nor garbage collection, resulting in a dangerous situation of poor sanitation and hygiene.

Diarrhoea, pneumonia, dengue fever, skin infections and malnutrition are commonplace, particularly among children.

A 2014 UNICEF assessment showed that of Phnom Penh’s population of 1.6 million, a quarter earn less than US$1.60 a day. Many are migrant workers like those in Svay Pak; in 2016, migrants numbered 82,000 across 205 registered poor communities in the city. These disadvantaged communities not only face economic hardships but are also disproportionately affected by disease: according to a national survey, only 6 of 10 children in Cambodia’s poorest households are vaccinated, compared to 9 of 10 in the wealthiest homes.

To address this gap, since 2011 UNICEF has worked with the Municipal Health Department to improve newborn and child health services (including vaccination) from 26 to 183 urban poor communities. This includes training health staff and village health volunteers to conduct face-to-face educational sessions and outreach activities.

Efforts to boost vaccine coverage are complemented by a host of activities to strengthen children’s overall well-being, such as education about proper nutrition and feeding practices to stem malnutrition and behaviour change campaigns that inform caregivers about the dangers of acute respiratory illness (pneumonia).

UNICEF also supports the Ministry of Health to organize outreach sessions in remote or disenfranchised communities at least once every quarter, like the upcoming services in Svay Pak. Mobile outreach plays an important role in promoting and improving maternal, newborn and child health and protecting children from unnecessary vaccine-preventable diseases like tuberculosis, diphtheria, pertussis, tetanus , poliomyelitis, hepatitis B and measles.  

Vaccination day


An outreach worker vaccinates mother Mao Leav against tetanus, 
after her daughter received shots; ©UNICEF Cambodia/2017/Fani Llaurado

Early the next morning, Ms. Ye arrives to the meeting spot in the village where the vaccines will be administered, next to the community’s Kilometre Nine health centre. “I know the mothers will come,” she says with confidence.

She’s right: shortly before 8am, women start arriving with children on their hips. Ms. Ye greets them with a smile and makes small talk until two health workers drive up on a motorbike with a box of medical supplies.  

The session starts immediately and the health team hurries to administer the vaccines; they know villagers are anxious to get started on the duties of the day.

A three-month-old baby receives two drops of polio vaccines, a seven month old cries after getting a shot for measles and a one-year-old boy smiles after having a vitamin A tablet.
Their mothers also receive tetanus shots. Two hours later, more than 20 people have been treated.

Ms. Ye is happy, as are the two health workers. “It was as successful as we hoped!” she exclaims.

As encouraging as today’s turnout was, there is still great concern over the villagers’ reluctance to use the health centre on a regular basis. Statistics show that many urban dwellers rely on private pharmacies for health care, visiting them for treatment in 40 per cent of cases, rather than seeking proper medical care. The reasons are both economic and social.

Barriers to care

Mao Leav is a 32-year-old mother of two girls who moved to Svay Pak three years ago. She sits with a group of women on the side of the road near the health centre. Her youngest daughter was vaccinated seven months ago, when she was born at the health centre. Ms. Leav did not return for follow-up vaccines but took advantage of the roadside services today.

“I do not know the process of getting vaccines at the health centre, so I am afraid of making mistakes and that the health officers would not be nice to me,” she explains. “And I am sure I need to pay there.”

Her experience with the health outreach team was largely positive: “They were friendly and provided services for free,” she says.

At the health centre, villagers need to pay around 2,000 riels or 0.5 dollars for administrative services (the vaccines themselves are free). Those classified as ‘very poor’ by local authorities are entitled to free health care. But without legal documentation of residency, migrants cannot claim this benefit.

Chanreourn Meas’s two-year-old daughter sits on her lap while she shares her experience. She and her husband migrated from the eastern province of Prey Veng four months ago. They live with siblings and work as garbage collectors. The 27-year-old mother says her family simply can’t afford to wait at the health centre.

Health worker Sokhun Prak has worked in the area for 22 years and 
is a trusted source of advice to the community; ©UNICEF Cambodia/2017/Fani Llaurado

“Every day we earn between 10,000 and 20,000 riels (US$2.5 to US$5) and can only cover the cost of our food; we cannot spend time at the health centre as we must go out and work,” she says.

Sokhun Prak, one of the outreach health workers, says this is common. During a quick break from the vaccine sessions, he describes how most people in the community earn just enough to survive. “Their immediate need is food and work; vaccinations for their children is not a priority,” he says.

Limited knowledge of available public health services makes many unaware of what is available—and affordable—to them. For example, it is common that parents do not know the vaccines their children need and when to get them.

Cambodia’s national immunization programme covers 11 diseases, including tuberculosis, hepatitis B, polio, measles, and tetanus. Children are scheduled to get them six times within the first two years of life to be fully immunized.

A so-called ‘yellow card’ is used to record progress and given to parents at a child’s birth.
“Some parents do not know how to read the yellow cards; we come here and tell them, so they don’t miss the next vaccine,” Mr. Prak explains.

After each session, health staff update families’ yellow cards and separately develop a list with number/names of children vaccinated and need for subsequent treatments. A day or two before the next session, village health volunteers follow up with families due for another shot.

Services on the water


Health volunteer Khamvan Hem greets families in Lou village and checks 
that all children are vaccinated; ©UNICEF Cambodia/2017/Fani Llaurado

While Ms. Ye and Mr. Prak finish their session in Svay Pak, another team is busy in a village three kilometres away.

Lou is an urban poor community along the Tonle Sap river. Here the residents number more than 6,000, mostly migrants from Vietnam.

They live on the riverbank and on boats, working as fishermen, factory workers, garbage collectors and market venders. Conditions and health risks parallel those of Svay Pak: diarrhoea, coughing, dengue fever, skin infections and malnutrition.

Health volunteer Khamvan Hem, 61, walks from boat to boat—sometimes balancing on precariously narrow beams--to talk to families and ensure as many children as possible are taking advantage of the free vaccination services today.

“It is a bit difficult moving from one house to another, but people never object to their children getting vaccinated,” she says. “That makes me happy.”

Ms. Hem was assisting Chantha Yong, one of two health workers from the Kilometre 9 health centre. He has been doing outreach activities since 1995.

By 10:30am, his team has vaccinated about 30 children and mothers.

“We set up our meeting spot two hours ago and people came to us for services,” reports the 50-year-old nurse.

This is not the case during the rainy season however, when water floods the village. People live on their boats and must travel to earn an income. Health workers then must go to them.
“We can’t make a meeting point, and we operate from a boat to reach them,” Mr. Yong says. “Some children miss their schedules as we simply cannot find them.”

By noon, health volunteers and workers in both villages have finished their day. Their invaluable work has helped the women and children of this vulnerable group of migrant workers avert one less unnecessary risk in their challenging lives.

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