Cambodia at A Glance

POPULATION, GENDER AND REPRODUCTIVE HEALTH
CAMBODIA
AT A GLANCE
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Pictures by: Nhem Sothun, Ly Sensonyla & Mariolein Coren Design by: graphicroots@online.com.kh
ACKNOWLEDGEMENTS
his report is the result of a consultative review process undertaken by UNFPA, United Nations Population Fund, Cambodia in collaboration with the Royal Government of Cambodia. This joint process strengthened existing partnerships, and ensured a wide degree of
consultation and debate. It served as a critical evidence base for development of UNFPA's next Country Programme, and contributed to the joint common country assessment process of the United Nation's Country Team, The World Bank, The Asian Development Bank and The Department for International Development. During this process, key staff from governmental and non-governmental organizations, universities and partners provided critical insight into the achievements and challenges seen during the 2001 to 2005 period. Special thanks go to The Ministry of Planning, The Ministry of Women's Affairs, The Ministry of Health, The Ministry of Education, Youth and Sport, The National Committee for Population and Development, and the Population, Gender and Reproductive Health working groups. This analysis would not have been complete without their valuable inputs.
ACRONYMS
ANC ART ASRH CDHS CIPS CMDG COMMIT CPA CPR CSES CSWG DFID EmOC GDP ICPD IUD KAP MDG MoEYS MoH MPA NGO NPP PMTCT RH RHIYA STI SWAP TBA TFR UNCT UNDAF UNFPA VCCT Antenatal Care Antiretroviral Therapy Adolescent Sexual and Reproductive Health Cambodian Demographic and Health Survey Cambodian Inter-censal Population Survey Cambodia Millennium Development Goals Coordinated Mekong Ministerial Initiative Against Trafficking Complimentary Package of Activities Contraceptive Prevalence Rate Cambodia Socio-economic Survey Contraceptive Security Working Group Department for International Development Emergency Obstetric Care Gross Domestic Product International Conference on Population and Development Intrauterine Device Knowledge, Attitude and Practice Millennium Development Goals Ministry of Education, Youth and Sport Ministry of Health Minimum Package of Activities Non-Governmental Organization National Population Policy Prevention of Mother-to-Child Transmission Reproductive Health Reproductive Health Initiative for Youth in Asia Sexually Transmitted Infection Sector-Wide Approach Traditional Birth Attendant Total Fertility Rate United Nations Country Team United Nations Development Assistance Framework United Nations Population Fund Voluntary Confidential Counselling and Testing
TABLE OF CONTENTS
1. Introduction..........................................................................................................................6 1.1. 1.2. Country Context........................................................................................................................7 UNFPA in Cambodia................................................................................................................7
2.
Population & Development..................................................................................................8 2.1 Informing policy, practice and planning............................................................................10
3.
Gender..................................................................................................................................12 3.1 3.2 Promoting gender equity and women's empowerment................................................13 Addressing gender-based violence ...................................................................................15
4.
Reproductive Health...........................................................................................................18 4.1 4.2 4.3 4.4 Making motherhood safer.....................................................................................................19 Providing choices: birth spacing and family planning.................................................23 Preventing HIV and STIs......................................................................................................25 Supporting adolescents and youth...................................................................................29
5.
Conclusion...........................................................................................................................32
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INTRODUCTION
eproductive rights and gender equality are essential for achieving human rights and human dignity. There is now wide acknowledgement that the full implementation of The International Conference on Population and Development's (ICPD) Programme of Action is a critical pre-requisite for achieving of the Millennium Development Goals (MDG). Gender equality and sexual reproductive health must be recognized as rights in themselves, and there is strong evidence to support investment in these areas. When women and men are relatively equal, economies grow faster, the poor move more quickly out of poverty, and the well-being of men, women and children is enhanced. Good reproductive health enables couples and individuals to lead healthier, more productive lives, and in turn to make greater contributions to their household incomes and to national savings. Having access to reliable quantitative and qualitative population based data for monitoring demographic, economic and health trends; and using this information to inform policy, strategy development and planning, is essential to ensure plans and interventions are responsive to the real situation and needs of the people and are cultural sensitive. In 2004, UNFPA, the United Nations Population Fund, Cambodia undertook a Population, Gender and Reproductive Health analysis in collaboration with The Royal Government of Cambodia. This joint analysis was part of UNFPA Cambodia's Country Programme Review, and served as a contribution to the overall United Nations, World Bank, Asian Development Bank and Department for International Development Common Country Assessment. Data and insights from this analysis were used by the United Nations Country Team (UNCT) in the United Nations Development Assistance Framework (UNDAF) development process, and are being used by UNFPA in development of its next programme of assistance 2006 to 2010. The purpose of this document is to capture key findings from the Population, Gender and Reproductive health analysis, and reinforce the importance of understanding population dynamics, and investing in reproductive health and gender equality as key pre-requisites for poverty reduction and achievement of Cambodia's Millennium Development Goals (CMDGs.)
CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH
Introduction
1. . Country Context 1
Peace and stability were progressively re-established throughout Cambodia following the Paris Peace Agreements in October 1991. The country's first national elections were held in 1993, and subsequent elections were held in July 1998, July 2003, and the country's first commune elections were held in February 2002. The formation of a new government in July 2004 represented a step forward in the political development of Cambodia. This was the first time political parties were able to resolve their differences through dialogue and without recourse to violence, as was the case during the earlier elections. With peace and macroeconomic stability more firmly entrenched, Cambodia now has an opportunity to focus on long-term development. The government recently developed the "Rectangular Strategy", a tool to implement its political platform and to meet the Cambodia Millennium Development Goals (CMDGs). The CMDGs and the Rectangular Strategy will be the basis for Cambodia's National Strategic Development Plan. This plan will guide Cambodia's development 20062010, and is scheduled to be completed by the end of 2005. Despite the significant progress since 1991, the country continues to face many challenges. Poverty rates remain very high, and 35 percent of the population subsists below the poverty line and an estimated 15 percent subsist in extreme poverty. Poverty is overwhelmingly rural, and is aggravated by very limited sources of growth, few linkages to the domestic economy, limited access to social services, landlessness, environmental degradation, and a lack of genuine participatory processes. Cambodia's gross domestic product (GDP) grew an average of 6.8% between 1999 and 2002. It peaked at 10.8% in 1999, and is now on a declining trend. GDP 1 growth was estimated at 5.2% in 2003 , and economic growth continues to be narrowly based, and inequality is increasing. At present, GDP is just over US$300 per capita, and levels of official development assistance remain 2 high, at US$39 per capita as of 2002 .
1.2. UNFPA in Cambodia

In 2004, UNFPA celebrated its tenth anniversary of support to Cambodia. Early assistance led to the nationwide introduction of birth spacing services, and the successful completion of the 1998 census - the first census undertaken in 3 decades. A second programme of assistance was developed and implemented during 2001-2005. This programme encompassed a full range of gender, population and reproductive health initiatives in line with the ICPD Programme of Action and the Millennium Declaration. Key achievements of this Country Programme include the development and approval of Cambodia's first National Population Policy (NPP), successful completion of the Cambodian Inter-censal Survey (CIPS) 2004, the expansion of quality reproductive health services, and the introduction of adolescent health and gender mainstreaming initiatives. Within the context of the United Nations Development Assistance Framework 2006-2010, UNFPA Cambodia's Third Country Programme of support 2006-2010, will contribute to achievement of the MDGs through support for interventions in the areas of population and development, gender and reproductive health.
1ADB, World Bank, UNCT and DFID, 2004. 2DFID, 2005.
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POPULATION & DEVELOPMENT

ambodia's total population is currently estimated at 13.1 million, and approximately 80% live in rural areas3. The country's national population growth rate decreased from 2.4% in 1998 to 1.8% in 2004, and there was a corresponding and rapid decline in total fertility from 4.0 to 3.34 during the same period. This decline is in line with Cambodia's MDG targets, and exceeds Cambodia's CMDG Total Fertility Rate (TFR) target of 3.4 by 2010. Life expectancy is increasing, and is now 63.4 years for women, and 57.1 years for men. The age dependency ratio decreased during the 1998 to 2004 period, and is currently 74.0. Of particular note is the changing population structure, with increasing youth and elderly cohorts. As of 2004, 60% of the population is below 25 years of age, 36.5% is between 10 and 24 years of age, and 12% is above the age of 50 (see Figure 1 below).
Population and Development
While Cambodia has experienced a rapid decline in fertility, maternal and child mortality rates remain high and are currently estimated at 437 per 100,000 live births and 124 per 100,000 live births, respectively. At 5.1, the average size of households has marginally decreased during 1998-2004, both in urban and rural areas. A high proportion of households are headed by women (29%), and this represents a slight increase over the 1998 figure. While households headed by women are not significantly poorer than others, they are often more vulnerable, have less land and thus are more reliant on risky coping strategies, such as selling assets, or taking children out of school and sending them to work. The economically active population increased from 55.5% in 1998 to 65.5% in 2004, and the participation rate of males, 66.4%, is slightly higher than that for females, 64.6%. The labour force is growing at 3.3% per year, but growth of employment opportunities is slower. Correspondingly, the percentage of unemployed amongst the economically active group increased from 5.3% in 1998, to 7.1% in 2004.
There is an overall improvement in literacy levels in Cambodia. In 1998, nearly two thirds of the population could read and write with understanding, and this proportion has increased to nearly three quarters in 2004. Adult literacy rates also increased, from 67% in 1998 to 74% in 2004, although the adult literacy rate for males (85%) is considerably higher than that for females (64%). Considerable improvement was also seen in the overall school enrolment of both boys and girls, although current male enrolment (63%) is still higher than female enrolment (55%). Nevertheless, general educational levels remain low; the 2004 CIPS 2004 reveals that 82% of the literate population aged 25+ have not gone beyond primary level of education, and 54% have not even completed primary level. Levels of migration have exhibited a slight increase from 31% in 1998 to 35% in 2004, with no male-female differentials either in size or pattern of migration. Rural-to-rural migration constitutes the largest percentage of migrants within Cambodia (69%), followed by rural-to-urban migration (14%). Migrants from outside Cambodia constitute only about 4% in 2004, as against 6% in 1998.
Population Trends
Decreasing total fertility rate, but overall population size continues to increase Infant, child and maternal mortality rates remain high Changing population structure, with increasing youth and elderly cohorts More than one third of the population lives below the poverty line High, and increasing proportion of female headed households Improvements in school enrollment and literacy levels, but general education levels remain low Significant gender differentials in education levels, literacy levels, post-primary enrollment levels and dropout rates Slight increase in overall level of migration; most migration rural to rural
3All population data in this section is taken from the 1998 census or the 2004 Cambodian Intercensal Population survey unless otherwise noted.
All mortality data is taken from the Cambodian Demographic and Health Survey 2000.
4CIPS : Demographic Estimates and Revised Population Projections, 2005.
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2. Informing policy, practice 1 and planning

In recent years, Cambodia made significant strides in monitoring, analyzing and prioritizing population issues. In 2004, The National Institute of Statistics successfully completed its first Inter-censal Population Survey (ICPS), and the country launched its first National Population Policy (NPP). During the same year, Cambodia also launched CamInfo, the country's national system for monitoring progress toward the CMDGs. These are significant achievements, and function as key building blocks for development of Cambodia's upcoming National Strategic Development Plan 2006-2010. However, much remains to be done to ensure practical population issues, such as increasing youth and elderly populations, increasing unemployment and high levels of migration, are understood and able to be addressed at local levels. At present, there is limited capacity and resources to undertake research on emerging population issues, and provincial, district and commune planners often don't have access to current population data. The capacity of local level planners to analyze and use this data as part of a participatory planning and budgeting process is also quite limited.
Current Situation
Limited capacity and resources for research, data collection and analysis of population issues Limited availability of data on emerging issues such as increasing elderly and youth cohorts, increasing unemployment and migration Limited availability of disaggregated population data at local levels Population issues not yet adequately addressed in development plans
Achievements
In the last five years, significant achievements were made in the area of Population and Development. National capacity to collect and analyze population based data was strengthened, and increasingly data was used to inform policy development and planning. Several significant surveys were undertaken in this period, including Cambodia's Demographic and Health Survey 2000 (CDHS), and Cambodia's Inter-censal Population Survey 2004 (CIPS). CamInfo was also introduced and launched as a national data monitoring tool. During the same period, Cambodia developed and launched its first National Population Policy (NPP). Implementation of the NPP is a core priority in the new government's Rectangular Strategy, and this is seen as critical for ensuring effective mainstreaming of population concerns into sectoral and decentralized planning and policy making. UNFPA was a key supporter of statistical capacity development, national survey implementation, and policy formation and monitoring. During this period, UNFPA provided significant support for development of the NPP and for implementation of the CDHS and the CIPS. This builds on UNFPA's earlier support for the 1998 census, which was Cambodia's first census since 1962.
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Achievements
National Population Policy launched by Prime Minister in February 2004 Implementation of national population policy incorporated as priority in government's Rectangular Strategy Demographic and Health Survey undertaken in 2000 and Intercensal Population Survey undertaken in 2004 Administration & health facilities mapping undertaken in 2004 Urban reclassification undertaken in 2004 CAMInfo introduced as national data monitoring tool
Next Steps
Key next steps include strengthening evidence based planning and monitoring at the national and local levels, including development and monitoring of the National Strategic Development Plan 2006-2010. Capacity for collection, analysis and interpretation of population and poverty data will also be strengthened, and further in-depth analysis of recent surveys, including the CIPS and the Cambodia Socio-economic Survey, will be undertaken to provide more detailed information on emerging population issues. Likewise, implementation and analysis of the 2005 CDHS and the 2008 Census, will ensure adequate data is available for on-going evidence based planning, monitoring and policy making. In line with Cambodia's overall commitments toward harmonization and alignment, donors have committed to increased coordination of inputs in support of national planning and poverty monitoring. UNFPA will support increased coordination efforts, and will provide specific support for improved research, statistical capacity development and use of data for decision making. UNFPA will also support sensitization work at the national and decentralized levels to ensure practical population issues are understood and able to be addressed at all levels.
Next Steps
Pursue sector-wide approach for national planning, statistics and poverty monitoring Undertake further in-depth studies on key population issues such as increasing youth and elderly cohorts, increasing unemployment and migration Undertake 2005 Demographic and Health Survey and 2008 Census Strengthen evidence based planning and monitoring, including development and monitoring of the National Strategic Development Plan Sensitize national and decentralized decision makers on key population issues and their practical impact
3
GENDER
he Cambodian Constitution (1993) and The Marriage and Family Law (1989) enshrine equality between men and women, and Cambodia is a signatory to International Human, Women's and Children's Rights Conventions that regard men and women as equal partners. These conventions and laws combat discrimination against women, and promote equal opportunities for women, girls, men and boys. Gender equality and the necessity of gender mainstreaming are prioritized by the Royal Government of Cambodia, and are integrated into all major policies, including the 2002 National Poverty Reduction Strategy, the 2003 Cambodian Millennium Development Goals, the 2003 National Population Policy, and the 2004 Rectangular Strategy. The Rectangular Strategy recognizes that "women are the backbone of our economy and society," and calls for "ensuring the rights of women to actively and equally participate in nation building."5 The National Strategic Development Plan clearly defines gender mainstreaming and a human rights approach as strategic to all sectors. The adoption of draft laws on domestic violence and trafficking were included as 2005 targets in Cambodia's Millennium Development Goals Document. This is particularly noteworthy as Cambodia was the first country in the world to do so. The Cambodia Gender Assessment - A Fair Share for Women, 2004, provides a detailed overview of the gender 'terrain' in Cambodia. It highlights that gender inequalities in Cambodia remain high, and social attitudes and tradition deem women to be of lower status than men. The consequences are manifested in significant gender inequities in access to education, representation in decision-making processes, and access to paid and skilled employment opportunities. The gender disparities in Cambodia are particularly severe for women in rural and remote areas. Gender roles in Cambodia are undergoing rapid change, especially in the urban areas and among the younger population, and these changes will potentially have major social and developmental impact.
5Rectangular Strategy, 2004.
Gender
13
Current Situation
Gender equality guaranteed by the Cambodian Constitution and the Marriage and Family Law Gender mainstreaming acknowledged as a pre-requisite for human, social and economic development, and integrated in national development policies and plans Significant gender inequities persist and society regards women of lesser status than men Changing gender roles, especially amongst urban youth
3. Promoting gender equity 1 and women's empowerment

Cambodia's Gender Empowerment Measure is among the lowest in Asia, reflecting low female representation in parliament, and at all levels of government6. At present, only 8% of the commune councillors, 16% of National Assembly members and 18% of Senate members are women. Despite achievements in ensuring gender sensitive policy development and planning at the national level, gender specific issues are not well integrated into sectoral and local development plans. There is a weak understanding of key issues, and commitment and budgets for implementation are often limited. A lack of opportunities is also a concern, particularly for poor girls and women in rural and remote areas. While almost equal numbers of boys and girls are enrolled in primary school, dropout rates for girls are higher, particularly at secondary and higher levels. Female enrolment in primary school is 90%. However, by lower secondary this has fallen to 21% and to 8% by upper secondary7. Women, especially those between the ages of 10 and 49, have increased health risks. Access to essential health services is limited, and this places women at a particular disadvantage. Cambodian women face significant reproductive health concerns, including limited access to birth spacing and safe delivery services, and high levels of malnutrition. (See also chapter 4 on reproductive health.) High-risk sexual behaviour of men, gender dynamics that limit women's ability to negotiate sex and condom use, and sexual violence, make women especially vulnerable to unwanted pregnancies, sexual transmitted infections (STIs) and HIV/AIDS. Traditional attitudes towards education of girls, and "appropriate" occupations for women and men continue to perpetrate gender inequalities in Cambodia's labour markets. However, 80% of women of working age are economically active, and this is the highest female participation rate in the region8. Despite their level of economic involvement, women have limited landownership, limited access to credit, and few women benefit from agricultural extension services. This is despite the fact that women comprise the majority of farmers. Women are the major producers of vegetables and fruit, and make significant contributions to both rice and fish production.
6Neary Rattanak II, 2004
- 7MoEYS, 2004 - 8A Fair Share, 2004.
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Gender
Current Situation
Participation of women in decision making at all levels limited Gender inequities in literacy and education Increased health risks Gender inequalities in labour market, and limited access to credit and rural resources Limited understanding and support for gender mainstreaming, particularly at decentralized levels Women and girls increasingly at risk of contracting HIV/AIDS
Achievements
Over the past several years, considerable progress was made in establishing and strengthening national institutions and structures, and in gender mainstreaming national policies and plans. The Cambodian National Council for Women was established in 2001, and was tasked with advocacy, and monitoring and evaluating government laws and policies from a gender perspective. In 2004, The Ministry of Women's Affairs developed its next Strategic Plan, Neary Rattanak II 2005-2009, and restructured to better address future challenges. Gender focal points and gender mainstreaming action groups were established in a number of line ministries, and some progress was made in undertaking sector specific gender analysis work, and in developing gender specific action plans. There were also gains in terms of increased female literacy and improved access to basic education. Between 1998 and 2004, the overall literacy rate amongst females increased from 55.4%9 to 67.4%10, with the largest increases seen amongst the youngest age groups. Between 1998 and 2002, there was a 3% increase in girls attending primary school, and primary enrolment for girls in the poorest income quintile increased 26% in 2001/2002. During the same time period, lower secondary enrolment for girls from the poorest quintile increased by 50%. UNFPA provided critical support to strengthen capacity of The Ministry of Women's Affairs, Non-governmental organisations (NGOs) and parliamentarians to undertake gender advocacy and mainstreaming initiatives. Support was provided for development of a media network, and for development of sector specific gender mainstreaming initiatives, including training and establishment of gender mainstreaming action groups in priority line ministries. UNFPA supported youth initiatives also promote gender awareness and gender responsive approaches.
Achievements
Gender issues integrated into national policies and plans Increases in female literacy and school enrollment for girls Creation of Cambodian National Council for Women (2001) Strategic Plan for Ministry of Women's Affair agreed for 2005-2009 Gender focal points and gender mainstreaming action groups established in selected sectors
Census, 1998 -
10
CIPS, 2004.
Gender
15
Next steps
Continued action is required to strengthen institutional mechanisms, and to foster socio-cultural practices that promote and protect the rights of women and girls. Gender mainstreaming action groups in line ministries need to be strengthened to ensure the integration of gender concerns within national and decentralized plans and budgets. Advocacy initiatives will also be required to bring about positive attitude changes towards gender equality. UNFPA will support gender mainstreaming and empowerment initiatives at both the national and decentralized levels. Key activities will include gender mainstreaming at national and local levels, strengthening women's and children's focal points in selected commune councils, and supporting community awareness initiatives to advance gender equity and women's rights.
Next Steps
Strengthen capacity to undertake gender responsive planning and budgeting Improve enrollment and retention rates for girls, especially in secondary education Establish and support gender mainstreaming action groups in priority ministries Strengthen women and children focal points in commune councils Support awareness campaigns to promote gender equity and empower women and girls
3.2 Addressing gender based violence

Gender-based violence, including domestic violence, sexual abuse and trafficking is widespread in Cambodia. Genderbased violence is associated with inequitable power relations between men and women, and takes place in an environment of weak legal mechanisms and a culture of impunity and acceptance. Trafficking in women and children, both internal and cross border, is widespread, and is primarily for the purpose of commercial and sexual exploitation. It is estimated that at any given time 100.000 people are being trafficked in Cambodia11. According to the 2000 Cambodian Demographic Health Survey, 23% of women have experienced physical violence since age 15, and 25% of ever-married women have suffered emotional, physical and sexual violence12. The concept of male responsibility in addressing gender equity and reducing gender-based violence is poorly understood or accepted. Rape and indecent assault disproportionately affects young women and girls. Out of all rape cases investigated in 2002-2003, 38.3% were girls aged 11-15, and this age group accounted for the highest proportion of all victims. In 2002, the average age of reported victims was 13. In 2003, 78% of the victims were less than 18 years old, 41% of them were 12 years old or younger, and 9% were below the age of six13. In a recent national survey of youth behaviour, 7.5% of sexually active male youths reported forcing someone to have sex14. There is also emerging evidence of gang rape, perpetrated by young men and adolescent males. Gang rape of sex workers is also practised and not widely condemned. Data on gender-based violence is fragmented and incomplete, and it is suspected that reported cases represent only a fraction of actual incidents. There are a number of factors that discourage survivors from reporting violence. Women
11
A Fair Share, 2004
12
CDHS, 2000 -
13
LICADHO, 2004 -
14
MoEYS 2004.
16
Gender
often feel a sense of shame, and bear a misplaced burden of blame for the assault, especially when it involves violence within the household, or sexual abuse. Survivors of violence are often regarded as having provoked the incident themselves, and in the absence of protective mechanisms, survivors who report incidents are at risk of intimidation and further abuse by their attacker(s). In addition, women are often discouraged from reporting by family and community members. Women are expected to be submissive to men, and family members and local authorities often mediate and "solve" cases of violence through financial payments, a written contract between survivor and perpetrator, or by arranging marriages in order to "save the face" of the
families involved. Officials, especially within the legal system, are pre-dominantly male, and this hinders female accessibility to the legal system, as do high legal costs, especially for the poor. Health professionals, like most Cambodians, are often unaware of the causes of gender-based violence, and are unable to recognise the physical and mental signs of abuse. They are often afraid to discuss abuse openly, and may believe that survivors of violence brought abuse upon themselves. There is limited availability of services for survivors. Policies and strategies for addressing perpetrators of violence are virtually non-existent.
Current Situation
Gender-based violence, including domestic violence, sexual abuse and trafficking is widespread Rape and indecent assault disproportionately affect young women and girls Emerging evidence of gang-rape Data on gender-based violence is fragmented and incomplete Gender-based violence takes place in an environment of weak legal mechanisms, impunity and acceptance Limited services for survivors, and limited strategies for addressing perpetuators of genderbased violence
Achievements
The legal framework to protect Cambodians against genderbased violence is improving. Rape, physical violence, abuse and torture are defined as criminal acts, and several laws to combat gender-based violence are currently under development. In 2004, The Ministry of Women's Affairs drafted a Domestic Violence Law to "Protect Victims of Domestic Violence and Prevent Domestic Violence", and this draft law will be presented to the National Assembly for ratification in 2005. This law will enable local authorities to intervene at household level, allow the justice system to issue protection orders, and will lead the way for a National Action Plan for Prevention of Domestic Violence. At present, The Ministry of Justice in cooperation with the Ministry of Women's Affairs and other ministries, are drafting an Anti-Human Trafficking Law, as well as a National Action Plan to combat all forms of human trafficking. This is in response to Cambodia's recent regional commitments to combat human trafficking, such as The 2004 Coordinated Mekong Ministerial Initiative Against Trafficking (COMMIT)15, and a memorandum of understanding with Thailand. UNFPA supported improved advocacy and awareness of gender-based violence issues as part of its larger work on gender equality and gender mainstreaming. UNFPA also undertakes joint advocacy and monitoring as part of the UN-Donor coordination group on Human Trafficking in Cambodia.
15
COMMIT, 2004.
Gender
17
Achievements
Legal framework improving, and laws to combat gender based violence under development Government signed regional COMMIT treaty and Action Plan to combat human trafficking Memorandum of Understanding signed between Cambodia and Thailand to combat human trafficking
Next steps
In order to strengthen implementation, there is an urgent need for ratification and enforcement of laws to combat gender-based violence. There is also a need to improve awareness and understanding of all forms of gender based violence, and to ensure that national actions plans and strategies are developed and implemented at all levels. Services for survivors and strategies for addressing perpetuators of violence need to be developed, and identification, counselling and referral for survivors of gender-based violence integrated into the basic health service packages. To enable a more systemized approach to combat domestic violence and provide tools for monitoring trends, there is an urgent need to develop a system for the collection of comprehensive and reliable data on the incidence of genderbased violence. UNFPA will continue to advocate against gender-based violence, and support implementation of policies, laws and action plans to combat gender-based violence at decentralized levels. UNFPA will support community focused campaigns to raise awareness and address gender-based violence, and further strengthen integration of gender-based violence concerns into peer education and life skills programmes in the formal and non-formal education systems. As part of its support to the National Reproductive Health Programme, UNFPA will also support integration of gender-based violence identification, counselling and referral services into the basic health service packages.
Next Steps
Adopt and implement national policies, laws and action plans to combat gender-based violence at all levels Establish system for routine collection and monitoring of gender-based violence data Raise community awareness of gender-based violence Integrate identification, counseling and referral for survivors of gender based violence into basic health service packages and training curricula
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REPRODUCTIVE H E A LT H
ambodia has made remarkable progress over the last decade, but the health sector still faces persistent challenges. These include a high maternal mortality rate, high infant, child and neonatal mortality rates, a low level of deliveries assisted by trained health providers, a large unmet need for family planning, high levels of anaemia, and high levels of sexual transmitted infection (STI) and HIV transmission. The public health system faces severe constraints in its ability to respond to these challenges. Public health staff are often inadequately skilled, suffer from poor access to resources and supplies, and salaries are so low as to create little or no incentive to work. The Cambodian Government is working to address these issues through the Public Administrative Reform Programme and The Public Financial Management Programmes. However, progress is slow and aggravated by limited public resource allocations to the sector. At present, the national budget allocation to the Ministry of Health (MoH) represents only 7.6 % of the national budget, and 1.26% of GDP. Public health expenditure per capita is also strikingly low at only USD 2.96/capita16. The situation gets worse at the sub-sectoral level, where allocations for reproductive health (RH) are minimal, and donor support relatively limited. As a consequence, access to quality health services is limited, especially for the poor, and people often try to self-medicate before seeking care from a trained provider. People seek treatment and medication from outlets such as pharmacies, drug sellers and traditional healers, many of whom are unfamiliar with reproductive health problems, correct drug usage and correct clinical protocols. Health-seeking behaviour is often inappropriate, and consumers over-rely on self-prescribed medications and intravenous infusions, and self-refer late to tertiary facilities. These practices result in high out of pocket health expenditures, continuing ill health, debt and increased poverty. A key element in the MoH's response to these issues has been the launch of the Health Sector Strategic Plan, 2003-2007, which includes the provision of a Minimum Package of Activities (MPA) at health centres,
16
JAPR, 2005.
Reproductive Health
19
and a Complementary Package of Activities (CPA) at referral hospitals. The MPA provides a basic package of preventive and curative services at the primary care level, and the CPA provides a complementary package of services for in-patient and out-patient care at the hospital level. Basic reproductive health services, such as deliveries, antenatal care (ANC), birth spacing, STI treatment, and basic reproductive health commodities, have all been integrated into the MPA and CPA packages. Increasing quality, accessibility and utilization of the basic service packages is a key priority and challenge for the government and its development partners. A national coverage plan was developed in 1995, and intensive efforts have been made to develop and upgrade both infrastructure and staff capacity in the last ten years. Innovative approaches
to improve district performance, and to improve access for the poor, such as contracting of health services and equity funds, have shown promising results, and there are several on-going public private partnership initiatives. While Cambodia has a number of policies and strategies related to reproductive health (e.g. safe motherhood policy and action plan, birth spacing policy, abortion law, etc.), these remain fragmented, and there is an identified need for an overall reproductive health strategy that brings cohesion to this critical sub-sector. Reproductive health, HIV and child health services are still delivered through vertical programmes, and services to address the sexual and reproductive health needs of young people, and for survivors of gender-based violence, are not yet part of the basic service packages.
Current Situation
Limited access to comprehensive reproductive health services, particularly for young people and the poor Limited public resources for health and reproductive health services Poorly skilled and inadequately motivated public health staff Poor health practices and health-seeking behaviour resulting in high health care expenditure, continuing ill health, debt and increased poverty Reproductive health integrated into health sector strategy and basic service packages, but no overall reproductive health strategy
4. Making motherhood safer 1

Maternal and child health indicators continue to be among the worst in the region. The maternal mortality rate averages 437 deaths per 100,000 live births. Child mortality is estimated to be 124 per 1,000 live births, and one in every eight children born in the country dies before his or her fifth birthday. As of 2000, 57.8% of women were anaemic17, and as of 2004, less than half of all pregnant women received 2 or more antenatal care visits, and only a half received adequate tetanus toxoid injections18. Approximately 89 percent of babies are still delivered at home, and skilled personnel attend less than one third of all births. Traditional beliefs that negatively influence delivery practices, health seeking behaviour and child feeding practices remain prevalent. There are significant variations in utilization of preventive health services, depending on socio-economic status. The national health survey of 1998 revealed that affluent women are three times more likely to have received tetanus
17
CDHS, 2000
18
JAPR, 2005.
20
Reproductive Health
toxoid injections than poor women, two and a half times more likely to have received ANC, and five times more likely to have had trained medical assistance at delivery. Children of affluent parents are three times more likely to be fully immunized by age one, than children of poor parents. Evidence from a recent UNFPA funded study19 suggests that demand for and utilization of trained providers at the time of delivery are increasing. The study shows that most rural and remote women would prefer to deliver with a trained provider in a health facility, and that there is a strong correlation between receiving ANC and using a trained provider for delivery assistance. The study notes that trained providers are significantly more expensive than Traditional Birth Attendants (TBAs), and shows that the main barriers to use of ANC and trained providers are distance and cost. It reveals that TBAs are less knowledgeable in terms of danger signs and overconfident in dealing with problems. Those who delivered with a TBA were also much less likely to seek help when problems arose. The study notes that the main reasons for preferring trained providers are that they are experienced and skilled, can help women access emergency
care, and because they can provide some traditional practices such as "hot injections". There is almost universal utilization of such traditional postpartum practices. Although some breastfeeding of every child is nearly universal in Cambodia, mothers traditionally do not breastfeed immediately following delivery, and exclusive breastfeeding is rare. Access to emergency obstetric care (EmOC) is improving, but remains limited, and access for poor patients is a critical area of concern. While an increasing number of hospitals have ambulances and communication equipment, referral systems remain weak, equity funds are limited, and poor, remote families often face significant obstacles in accessing EmOC. An overall shortage and mal-distribution of midwives exacerbates this problem, and there is an identified need to review midwifery training, recruitment and deployment plans. Abortion has been legal in Cambodia since 1997. While there are indications that unsafe abortion contributes to Cambodia's high maternal mortality rate, there is very little data on the number of abortions and abortion-related morbidity and mortality.
Current Situation
High child and maternal mortality rates Shortage, and mal-distribution of midwives High demand for deliveries by trained health staff but access and utilization limited by cost and distance Limited access to referral systems and equity funds Limited access, utilization and quality of antenatal care and emergency obstetric care, particularly for poor rural/remote women Potentially harmful traditional practices associated with childbirth and feeding Traditional birth attendants less knowledgeable about danger signs than trained providers, and overconfident in dealing with problems High levels of unsafe abortion
19
Obstacles to deliveries by trained health providers, 2005.
Reproductive Health
21
Achievements
There has been a steady increase in the number of referral hospitals with the physical infrastructure to provide EmOC, and this number is expected to increase with on-going supply of standard equipment and training of key staff. Although the country continues to suffer from an acute shortage of midwives, the MoH has prioritized midwifery recruitment and training. In 2004, an additional 100 health centres had staff with updated midwifery skills20, and the MoH recently committed itself to ensuring that an additional 100 remote health centres will have a midwife by the end of 2005. The number of midwives, especially in the north-east region, increased steadily over the last three years. In 2002, 361 health centres had staff with updated midwifery skills, and this number increased to 434 in 200321. In 2004, the percentage of pregnant women who received at least 2 ANC consultations increased to 47%, up from 33% in 2003, and 7 percentage points above the 2004 target22. Thirty three percent of deliveries were attended by trained health professionals23, and this also represents a significant increase over the 2003 figure of 22%. At the policy level, the MoH has developed a National Policy on the Prevention of Mother-to-Child Transmission of HIV, and Maternal and Child Health was included in both the Socio-economic Development Plan (2001-2005) and in the National Poverty Reduction Strategy (2003-2005). Through its support to training and district level initiatives, UNFPA contributed to increasing the availability of midwives, and increasing the access and utilization of ANC and delivery services by trained providers, especially in remote areas. UNFPA also supported training to increase the number of health staff able to deal with obstetric emergencies and manage the complications of unsafe abortion.
Achievements
Increase in referral hospitals able to manage obstetric emergencies Recruitment and training of midwives prioritized by Ministry of Health Increased availability of midwives, especially in the North East region Increase in women receiving 2 or more antenatal checks during pregnancy to 47% Increase in deliveries by trained attendants to 33% Safe Motherhood Policy and Action Plan 2001-2005 National Policy on prevention of maternal to child transmission
Next Steps
The MoH and its health sector partners are seeking to improve access to quality RH services, especially for the poor and for women living in remote areas. Strategies include increasing the number of facilities with capacity to deliver quality EmOC, improving financial access for
20 21 22 23
the poor, developing performance-based health systems, and developing and implementing effective referral systems between communities, health centres and referral hospitals providing EmOC.
JAPR, 2005
JAHSR, 2004 -
JAPR, 2005 -
JAPR, 2005.
22
Reproductive Health
Work will also be done to strengthen the policy and strategy context, and the MoH has committed to developing a national reproductive health strategy for the period 20062010. UNFPA will support the MoH in this effort, and support implementation of the strategy. UNFPA will also support initiatives to address the shortage and mal-distribution of midwives, including the review and revision of plans for midwifery recruitment, training and
allocation. In addition, UNFPA will support initiatives at both the national and decentralized levels to increase access and utilization of ANC and delivery services by trained providers. This will include support for equity funds, outreach services, referral systems, provision of EmOC, training of providers, and demand side initiatives aimed at raising awareness and increasing empowerment and participation of the community.
Next Steps
Develop and implement a national reproductive health strategy Develop performance-based health systems Increase number of facilities delivering full service packages Increase number of Referral Hospitals with capacity to deliver quality emergency obstetric care Update midwifery training, recruitment, and allocation plans Improve training and deployment of midwives in remote areas Develop and implement effective referral systems Improve financial access to safe delivery services for the poor Demand side initiatives
24
Data in this section is from the CDHS 2000 unless otherwise noted.
Reproductive Health
23
4.2 Providing choices: birth spacing and family planning

The contraceptive prevalence rate (CPR), while still low, exhibited a steady increase from 7% in 1995 to 18.5% in 200024. However, both the TFR and CPR vary significantly with geographical location, education level and income. CPR for the wealthiest quintile is approximately twice that of the poorest, the highest provincial coverage rate is about three times that of the lowest, and the CPR of women with the highest education level is almost twice that of women with no education. A range of birth spacing methods are available in the MPA and CPA packages, and short-term methods are also available through the social marketing programme. At present, the method mix at the health centre level includes condoms, daily pills, injectables and Intrauterine Devices (IUD), and the method mix at the hospital level includes the above options plus surgical methods. Emergency contraception and female condoms are not yet widely available, although female condoms were piloted with sex workers. Knowledge of contraceptive methods is high, with 92% of all women aged 15-49 knowing at least one method of family planning. The daily pill and the injectable are the most widely known modern methods (90%), followed by the IUD (83%) and the male condom (79%). Twenty three percent of all women and 37% of married women age 15-49 report using a contraceptive method at some time. Among currently married women, the most commonly used modern method was injectables (15%) followed by the daily pill (11%). There is a marked discrepancy between ever use and current use of family planning. Whereas 37% of married women have used a method of family planning at some time, only 24% are currently using a method. The difference between ever use and current use is highest for injectables and the daily pill, implying high discontinuation among the users of these methods. The main reported reasons for non-use and drop-out are side effects and health concerns. Only around 1% of women currently use condoms as a method of family planning, and use in long-term relationships is minimal. This highlights a critical need to promote condoms as dual protection (e.g. protection from unwanted pregnancy and protection against STI and HIV transmission). The unmet need for family planning remains high at 32.6%, and is significantly affected by wealth status. Women in the poorest quintile demonstrate an unmet need for both spacing and limiting approximately twice that of women in the wealthiest quintile. In response to the rapid expansion of RH services in Cambodia, the MoH set up the Contraceptive Security Working Group, whose main task is to monitor contraceptive distribution to ensure continuity of supplies. However, the MoH's forecasting capacity is limited, and there is an identified need for improving comprehensive RH commodity forecasting, both for public sector and social marketed products. While in general, the supply of RH commodities is good, financial constraints and delays in procurement have resulted in some unexpected shortfalls and requests for emergency procurement. As government and donor resources for commodities are limited, long-term commodity security remains a challenge. Although reproductive health commodities are part of the MPA/CPA packages, the government only funds the supply of male condoms to the public sector. The socially marketed Number One condom is the most widely used and available condom in Cambodia, with sales estimated at 20 million units in 2003, which accounts for approximately 80% of the country's condom use25. While supply systems are expanding through the public and private sectors, and through social marketing and community based distribution programmes, simply improving access and availability of contraception fails to recognize several key issues. Male responsibility and female empowerment in family planning must be addressed, as well as the fear and misconceptions of possible side effects. As noted earlier, the 2000 CDHS revealed that health concerns and side effects were the most frequently cited reasons (32%) for non-use of contraception. Younger women, below the age of 30, were more likely to cite side
24
Data in this section is from the CDHS 2000 unless otherwise noted
25
PSI, 2003.
24
Reproductive Health
effects and health concerns than older women, age 30-49 (40% versus 30%). These findings indicate a need to focus on appropriate counselling and follow-up to correct
misinformation, and to provide knowledge in a clear, easily understandable way to ensure confidence in the effectiveness and safety of modern methods.
Current Situation
High levels of knowledge and approval of family planning Low, but increasing contraceptive prevalence rate High unmet need for family planning Limited availability of long-term methods High discontinuation rates for family planning methods Main reasons for non-use and discontinuation of methods are health concerns and fear of side effects Use of condoms by married couples and within long-term relationships minimal Limited capacity for long-term commodity forecasting Female condoms and emergency contraception not widely available
Achievements
Knowledge and access to birth spacing or family planning services expanded dramatically in recent years and this contributed to the dramatic decrease in the annual growth rates and total fertility rate. During this time, there was increased availability of both short and long-term methods, and expansion of community-based distribution programmes, and social marketing. UNFPA provided critical support for expanding availability of birth spacing services through both the public sector, and through the socially marketed programmes. UNFPA supported the introduction of new contraceptive methods, enhanced provider counselling and communication skills, and supported the development and dissemination of the Behaviour Change Communication Policy approved in 2004.
Achievements
Rapid expansion in knowledge and access to birth spacing services Increased availability of both short and long term methods Expansion of social marketing and community based distribution programmes
Reproductive Health
25
Next Steps
Key next steps include expanding availability of birth spacing methods, including long-term and permanent methods, in rural and remote areas. Improved counselling and follow-up of drop-outs is essential to reduce the high level of unmet need, as is further expansion of the community based distribution and social marketing programmes. Further work will also be done to strengthen RH commodity forecasting and coordination of inputs. Promoting responsible male involvement in reproductive health will also help to provide support for women who want to use modern birth spacing/family planning methods, and will help to foster safer sexual behaviour. Closely linked with this is the need to promote condoms for dual protection. Introducing and promoting the female condom within the general population will expand options and choice. The female condom, in particular, will also help empower women to protect themselves against STIs/HIV and unwanted pregnancy. UNFPA will continue to support increased availability of birth spacing services, and will support introduction of the female condom within the general population, and promotion of condoms as dual protection. Behaviour change initiatives and demand side issues will be supported through training health providers in communication and counselling skills, strengthening RH-related behaviour change communication initiatives including male involvement, and supporting community empowerment and involvement in health centre management committees. Work to strengthen RH commodity security will also be supported.
Next Steps
Expand availability of family planning methods, including long-term and permanent methods Address health concerns and side effects as reasons for non-use of birth spacing Strengthen behaviour change initiatives and improve provider communication and counseling skills Promote condoms for dual protection Introduce and promote female condom Develop long-term commodity security plan Promote responsible male involvement in reproductive health
4.3 Preventing HIV and STIs

Although Cambodia still has the highest level of HIV/AIDS prevalence in Asia, impressive progress has been made and Cambodia is likely to achieve its MDG targets for 2015. Between 1997 and 2003, the estimated adult prevalence rate declined from 3.0 to 1.9, and Cambodia is one of the few countries in the world to achieve such a significant and rapid decline in HIV prevalence. High levels of commitment from government, civil society and partners have enabled Cambodia to achieve this success, and Cambodia has been able to attract significant resources to address this issue, including multiple rounds of support from the Global Fund for AIDS, Tuberculosis and Malaria.
26
Reproductive Health
The reduction in HIV prevalence amongst direct sex workers, from 42.6% in 1998 to 20.8% in 200326, has been attributed to Cambodia's effective 100% condom use programme. This programme resulted in a rapid increase in consistent condom use with sex workers from 43% in 1997, to 87% in 2003. However, condom use in marital relationships and longer-term relationships remains low, in part because of the association of condoms with illicit sex and HIV-prevention. While the overall decrease in prevalence rates is impressive, there is concern that the epidemic is shifting, and the prevalence rate in the general female population and among pregnant women has decreased only slightly27, and infection from husband-to-wife is now the major mode of transmission. Furthermore, increasing high-risk sexual behaviour among young people and increasing illicit drug use could act as new potential drivers of HIV transmission in the country. -Married-women, children, youth, drug users, garment factory workers, migrants, and men who have sex with men are all potential high risk groups. Prevention activities addressing the causes of risky behaviour are presently limited, and there are few programmes specifically targeting married women, or addressing condom use for people in long-term relationships. There is little integration between HIV/AIDS and RH services, and gender responsiveness is limited. At present, one third of all new HIV infections are from mother to child. While the availability of services to prevent maternal to child transmission (PMTCT) have increased, the proportion of identified HIV- infected mothers, and HIV-exposed infants, receiving antiretroviral therapy (ART) remain low. At the end of 2004, there were 13 PMTCT pilot projects located in 11 operational districts 28. The MoH plans to scale-up PMTCT services by establishing programmes where voluntary confidential counselling and testing (VCCT) and ANC services exist. However, there are still significant challenges to scaling up PMTCT. Only half of all pregnant women attend ANC, and the proportion who agrees to be tested for HIV is low.
During recent years, there was also a rapid expansion of VCCT services. The first VCCT centre was opened in 1995, and by the end of 2004 there were 86 VCCT centres throughout Cambodia, administering over 82,000 HIV tests. Continued expansion of VCCT sites is planned, with 122 public sector VCCT centres expected by the end of 200729. While the number of sites providing PMTCT and VCCT services is increasing, the quality of counselling remains variable, due to the shortage of trained counsellors. While there is high knowledge across all populations of HIV transmission, there is limited awareness of other STIs. A national Knowledge, Attitude and Practice (KAP) survey conducted in 2004 revealed that less than two thirds of men and women interviewed knew that condoms were also effective in the prevention of STIs30 . Provision of ART began in 2001 through NGOs working in collaboration with the Ministry of Health. In 2004, it was estimated that 26% of AIDS cases eligible for ART were receiving treatment. The Ministry of Health has begun an aggressive expansion of ART services, with plans to provide ART to a minimum of two-thirds of those ART-eligible by 200731. While great strides were made in scaling up ART treatment, a number of challenges remain. The limited amounts of drugs, coupled with the small pool of trained clinicians and the limited capacity of health facilities, mean that not all who are ART-eligible will receive treatment for some time to come. The Cambodian Government has recently passed a law on the prevention and control of HIV/AIDS which has been recognized as good practice. Distribution and understanding of the law are still limited, and guidelines for implementation are under development. In 2001, the National Strategic Plan for Comprehensive and Multi-sectoral response to HIV/AIDS: 2001-2005 was launched. An updated National Strategic Plan 20062010 is currently under development.
26
HSS, 2003 -
27
HSS, 2003 -
28
NAA, 2005 -
29
NCHADS, 2004 -
30
PSI, 2004; -
31
NAA, 2005.
Reproductive Health
27
Current Situation
High levels of commitment and resources Overall HIV prevalence rate decreasing dramatically; prevalence rate amongst pregnant women decreasing only slightly Continued high risk behavior of men and youth High level of transmission from husband to wife New high risk groups: -married-women, children, youths, men who have sex with men, drug users, garment factory workers and migrants High knowledge of HIV transmission, but limited awareness of STIs Use of condoms for STI prevention and birth spacing poorly understood or accepted Limited distribution and implementation of HIV/AIDS policies and guidelines HIV/AIDS interventions not well integrated with reproductive health services Shortage of trained counsellors for voluntary and confidential counselling and testing and prevention of maternal to child transmission services Expansion of antiretroviral therapy services, but limited availability of drugs and capacity for antiretroviral therapy management
28
Reproductive Health
Achievements
Largely due to the concerted efforts of the Royal Government of Cambodia and its development partners, Cambodia has experienced a steady decrease in the HIV-prevalence rate among all the sentinel groups over the past 8 years. Knowledge of HIV/AIDS is now high, especially among young people, and consistent condom use with sex workers is in line with CMDGs. The Royal Government of Cambodia has provided a supportive policy environment to help address the HIV/AIDS epidemic. HIV/AIDS prevention was integrated into Cambodia's second Socio-Economic Development Plan, The National Poverty Reduction Strategy 2003-2005, and the National Population Policy. HIV/AIDS also features prominently in the Government's recently launched Rectangular Strategy, highlighting its importance within the context of Cambodia's development agenda.
Achievements
Decreasing HIV prevalence among all sentinel groups High knowledge of HIV/AIDS within general population High level of condom use with sex workers National HIV/AIDS Strategic Plan 2001-2005 HIV/AIDS integrated into Socio-Economic Development Plan and National Poverty Reduction Strategy Rectangular Strategy acknowledges importance of HIV/AIDS as a key development issue HIV/AIDS Law regarded as best practice Services to provide antiretroviral therapy initiated and expanding Increased access to voluntary and confidential counseling and testing and services for prevention of maternal to child transmission
In July 2002 the Law on the Prevention and Control of HIV/AIDS was passed by the National Assembly. This law is regarded as best practice in Asia, particularly in relation to anti-discrimination, privacy and confidentiality, and protection offered to people attending for voluntary counselling and testing. In 2002, the Royal Government of Cambodia passed the Policy on Religious Response to the HIV/AIDS Epidemic in Cambodia, while 2003 saw the launch of the Policy on Women, the Girl Child and STI/ HIV/AIDS, and the Code of Practices Regarding HIV/AIDS in the Workplaces.
In 2003, the MoH launched the Continuum of Care Operational Framework, which includes a model of providing comprehensive care services to people living with HIV/AIDS through partnerships between public and private medical services, people living with HIV/AIDS groups, and NGOs at operational district level. In the last 5 years there was also marked expansion of VCCT and PMTCT services, and the MoH, in collaboration with NGOs, has initiated and expanded ART services. In 2002, the PMTCT Working Group formulated a National Policy on the Prevention of Mother-to-Child Transmission of HIV.
Reproductive Health
29
UNFPA's Country Programme supports HIV prevention as an integral component of RH, ASRH and advocacy initiatives. A particular focus was support for HIV prevention activities amongst youth and adolescents. Through its core resources and regional resources from the European Union, UNFPA improved the sexual and reproductive health status of young people at risk through targeted interventions to vulnerable sub-groups, and by increasing access to youthfriendly clinical services.
of school youth, expansion of VCCT, PMTCT and ART services, integration of RH and HIV initiatives, promotion of condoms as dual protection and introduction of the female condom. Continued efforts must also be made to ensure proper monitoring of the epidemic, to ensure strategy and plans are up-to-date, and to ensure interventions are achieving results. The Government is currently developing a new National Strategic Plan for HIV/AIDS for 2006-2010, and this will be a key tool for prioritizing initiatives, coordinating efforts, and monitoring and evaluating effectiveness of the national response. In line with these evolving strategies, UNFPA will support prevention strategies addressing individuals in long-term relationships and amongst young people. Initiatives will include the integration of RH and HIV initiatives, promoting the use of condoms for dual protection, introducing and promoting the female condom amongst the general population, expanding youth initiatives, and developing enabling environments and gender responsive interventions.
Next Steps
In order to consolidate the decrease in prevalence rates, changes in behaviour must be sustained, and prevention efforts designed to address sexuality and the contexts of risky behaviour. Prevention efforts must be expanded to address the groups at highest risk, including women, mobile populations, young people, men who have sex with men, and injecting drug users. Although work has started, much more needs to be done. This includes expansion of educational and life skills programmes for both in and out
Next Steps
Adopt and disseminate National Strategic Plan for HIV-AIDS 2006-2010 Expand prevention efforts for women, couples, youth, orphans and vulnerable children, mobile populations, men who have sex with men, and drug users Integrate HIV/AIDS and reproductive health services Promote condoms for dual protection Introduce and promote the female condom Continued expansion of services for prevention of maternal to child transmission, voluntary and confidential counseling and testing and antiretroviral therapy
4.4 Supporting adolescents and youth

Cambodia has an increasingly youthful population. With 60% of the population below 25 years of age, and 36.5% between 10 and 24 years of age32, recognizing the sexual
32
and reproductive health needs and rights of youth, and involving them in policy dialogue and implementation is critical for improving Cambodia's development potential.
CIPS, 2004.
30
Reproductive Health
Cambodia is currently undergoing rapid social and economic change. Greater access to local and international media and a rise in disposable income have helped to fuel an emerging youth culture. There are indications that young Cambodians (especially in urban areas) have different expectations than their parents regarding recreational activities and social bonding. Young Cambodians have different notions of individuality, and are experiencing a greater level of urban wealth and sexual freedom. Gender roles are changing, particularly in urban areas, and these changes will potentially have major social impact. A recent national survey of youth risk behaviour indicated high levels of knowledge about HIV/AIDS, but also revealed that more than 50% of young people are not aware of symptoms of STIs, and that 21% didn't know how to prevent STIs. Although less than 2% admitted being sexually active, of these, 40% reporting engaging in sexual activity after drinking alcohol, and one out of five had either become pregnant or made their partner pregnant33. The 2000 CDHS identified a high unmet contraceptive need (37%) for young women aged between 15-19 years. 34% of urban women and 39% of rural women had their first birth when 19 years or below, and less than 1% of women 19 years or below are using a modern contraceptive method34.
There is clearly a high-unmet need for sexual and reproductive health information and services for adolescents and young people. However, there are significant social and cultural barriers to involving young people in discussions on sexual and reproductive health, and a lack of sensitization on these issues among key gatekeepers, including parents, teachers and decision-makers. Furthermore, as reproductive health interventions in Cambodia are primarily seen as maternal health interventions, the majority of clients in the public health system are married women. This leaves the wider population of potentially sexually active young people largely unreached, except for limited NGO supported services and interventions. Even when young people do access services, responsiveness is limited. Adolescent sexual and reproductive health (ASRH) issues have not yet been incorporated into the basic service delivery packages, and there is limited capacity amongst providers, particularly public providers, to provide quality youth-friendly services and counselling.
Current Situation
Large and increasing youth population Emerging youth culture and exposure to greater sexual freedom Unmet need for information on sexual reproductive health among young people Limited youth-friendly clinical and counseling services Adolescent sexual and reproductive health not yet incorporated into basic service packages Social and cultural barriers to discussion of sexual and reproductive health Lack of sensitization of sexual and reproductive health issues among gatekeepers
33
MoEYS, 2004 -
34
CDHS, 2000.
Reproductive Health
31
Achievements
Local and international NGOs in Cambodia have developed a range of adolescent reproductive health initiatives. Many of these initiatives target hard-to-reach populations, such as street children and out-of-school youth, and address sensitive and emerging issues such as substance and alcohol abuse, family reintegration, sexual health education, and gang rape. Key ASRH issues and practical lessons learned from these initiatives have been used to inform government policy and strategy dialogue, and youth have been increasingly engaged in this process. As a result, The MoH prioritized inclusion of adolescent reproductive health issues in its forthcoming National Reproductive Health Strategy, and the Ministry of Education, Youth and Sport (MoEYS) has committed to nationwide life skills and RH/HIV education programmes. UNFPA is the lead supporter of ASRH initiatives. UNFPA highlighted key ASRH issues in national forums, and will support incorporation of ASRH needs and rights into upcoming policy, strategy and curriculum development. UNFPA provides on-going support for the establishment of youth-friendly clinical services in both the public and NGO sectors, and with regional European Commission funding supports nationwide ASRH initiatives. These include in and out of school peer education activities; work with vulnerable groups, and initiatives involving community leaders, monks and teachers.
Achievements
Sexual and reproductive needs and rights of youth increasingly recognized and prioritized Ministry of Health commits to including adolescent sexual and reproductive health in National Reproductive Health Strategy Ministry of Education, Youth and Sport commits to nationwide youth life skills and reproductive health / HIV education programmes Introduction of adolescent sexual and reproductive health initiatives addressing sensitive and emerging issues and targeting vulnerable populations Introduction of youth friendly clinical services
Next Steps
In moving forward, there is a clear need to address the causes and consequences of youth risk behaviour, and to expand existing training, peer education, sensitization and youth friendly service delivery initiatives. Within these initiatives, it is critical that the sexual and RH needs of an evolving and rapidly changing youth culture are addressed, as well as the cultural sensitivities and barriers to talking about these issues. Both the MoEYS and the MoH have already committed to a range of initiatives. As noted earlier, the MoH will develop youth friendly service delivery guidelines, and plans to incorporate ASRH into its next National Reproductive Health Strategy 2006-2010. The MoEYS has committed to a nationwide Programme of Life Skills and RH/HIV/AIDS education for both primary and secondary school students and out-of-school youth. UNFPA will continue to improve community and young people's awareness of sexual and reproductive health issues, and support involvement of youth in policy dialogue and implementation. UNFPA will support inclusion of ASRH within both the Nationall Reproductive Health Strategy and health service packages, and continue to support youth friendly service delivery, and in and out of school and community based RH/HIV initiatives.
5
CONCLUSION
ambodia is in a stage of rapid change, demographically, economically and socially. Ten years since the International Conference for Population and Development and five years since the Millennium Summit, population, gender equality and reproductive health are increasingly recognized as crucial pre-requisites for rights based development, and poverty reduction in Cambodia. Marked progress has been made in increasing economic growth and literacy, in improving access to and utilization of reproductive health services, and in decreasing total fertility and HIV prevalence rates. However, critical challenges remain for real and sustained reductions in maternal and child mortality, youth risk behaviour, and in gender based violence are to be achieved. Gender equality and universal access to reproductive health and rights will be decisive to overcome these challenges. Increasingly, there is a need to move beyond "easy wins" and to focus on developing long-term capacity and sustainable systems. This is not easy, especially in a context of weak governance, and decreased levels of economic growth. The government of Cambodia has clearly prioritized health, education, population and gender equity in its new Rectangular Strategy, however, coordinated and sustained efforts will be required from all corners, government, private sector, non-governmental organizations, universities, partners and communities, if real change and improvements are to be realized. Government, donor partners and non-governmental organizations have identified increased coordination and harmonization as fundamental stepping stones for improving the effectiveness of development assistance. Partners increasingly subscribe to sector wide approaches in health, education and planning, and are fostering improved mechanisms for joint support to gender mainstreaming. Moreover, partners have recognized the need for common data collection and monitoring systems to ensure priority setting, budgeting and accountability are all geared towards the Cambodian Millennium Development Goals. UNFPA is committed to supporting Cambodia to address these challenges, and to reach the broader set of goals and targets outlined in Cambodia's Millennium Development goals. UNFPA is the first United Nations partner to join the Health Sector sector wide approach, and is seen as a lead partner in the areas of reproductive health, adolescent sexual and reproductive health, population, statistical capacity building
Conclusion
33
and poverty monitoring, and gender. UNFPA intends to maintain a significant presence in each of these areas. However, there is a clear need for increased resources targeting reproductive, sexual health and gender equality if Cambodia is to achieve its Millennium Development Goals by 2015. It is hoped that the data and analysis found in this paper will be used to inform the ongoing development process,
and to stimulate increased dialogue and investments in the areas of reproductive health, population and gender. It is expected that UNFPA's next programme of support 2006-2010, will result in a better understanding of critical population, gender issues and reproductive health, and will contribute toward improving gender equity and the reproductive health status of all Cambodians.
34
List of References
List of References
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National Institute of Statistics, Cambodia Inter-Censal Population Survey 2004: Demographic Estimates and Revised Population Projections, 2005. PSI, Annual Report, 2003. PSI, Love, sex and condoms in the time of HIV. December 2002, PSI, Targeting HIV/AIDS Risk Behaviour; results from a National KAP Survey, 2004. Royal Government of Cambodia, Action Plan for Harmonization and Alignment: 2004-2008, 2004. Royal Government of Cambodia, Implementing the Rectangular Strategy and Development Assistance Needs, 2004. Tarr, Chou Meng and Aggleton, Young People and HIV in Cambodia - Meanings, Contexts and Sexual Cultures. AIDS Care 11(3): 375-384, 1999.
United Nations, United Nations Development Assistance Framework 2006-2010, Draft 2004. UNAIDS, Country Profile: An Overview of the HIV/AIDS/STI Situation & the National Response in Cambodia, 2004 United Nations Development Programme, The Macroeconomics of Poverty Reduction in Cambodia, 2004. UNFPA, KAP Survey on Reproductive Health Among Vulnerable Youth, 1999. UNFPA, Cambodia Country Office Annual Report, 2004. UNFPA, Cambodia Country Programme Document, 2005. Wilkinson, David & G Fletcher, Love, Sex and Condoms: Sweetheart Relationships in Phnom Penh. Report prepared for PSI, Cambodia, 2002. Wilkinson, David, A Model for Adolescent-friendly Sexual and Reproductive Health Services in Cambodia, WHO, 2003.
UNFPA, the United Nations Population Fund, is an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal oppurtunity. UNFPA supports countries in using population data for policies and programmes to reduce poverty and to ensure that every pregnancy is wanted, every birth is safe, every young person is free of HIV/AIDS, and every girl and woman is t r e a t e d w i t h d i g n i t y a n d r e s p e c t .
UNFPA - because everyone counts
No. 225, Pasteur St. (51) Boeng Keng Kang 1, Chamkar Mon PO Box 877, Phnom Penh, Cambodia Tel : (855 23) 215 519 & 216 295 / Fax : (855 23) 211 339 E-mail: unfpa.cmb@unfpa.org / www.unfpa.org m

Cambodia at A Glance

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POPULATION, GENDER AND REPRODUCTIVE HEALTH

Population & Development..................................................................................................8 2.1 Informing policy, practice and planning............................................................................10

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

1.2. UNFPA in Cambodia

1ADB, World Bank, UNCT and DFID, 2004. 2DFID, 2005.

POPULATION & DEVELOPMENT

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

Population and Development

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

Population and Development

2. Informing policy, practice 1 and planning

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

Population and Development

5Rectangular Strategy, 2004.

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

3. Promoting gender equity 1 and women's empowerment

6Neary Rattanak II, 2004

- 7MoEYS, 2004 - 8A Fair Share, 2004.

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

3.2 Addressing gender based violence

A Fair Share, 2004

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

4. Making motherhood safer 1

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

Obstacles to deliveries by trained health providers, 2005.

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

4.2 Providing choices: birth spacing and family planning

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

4.3 Preventing HIV and STIs

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

4.4 Supporting adolescents and youth

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

CAMBODIA AT A GLANCE | POPULATION, GENDER AND REPRODUCTIVE HEALTH

UNFPA - because everyone counts

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