Situational review of Cambodian systems and progress related to building a SLP profession in Cambodia
Written by Ruth Bryce and Debbie Bong, November 2020, OIC Cambodia
Understanding the Landscape: Cambodian systems and context
The World Health Organisation predicts Cambodia will soon be viewed as a lower-middle-income country (Cambodia WHO Country cooperation strategy 2016-2020). Although Cambodia is no longer a country emerging from conflict, ongoing challenges of inequality, inconsistent service quality and poor regulation within the health and education sectors remain.1
The emerging profession of speech therapy falls under the juristriction of three seperate givernment ministries: The Ministry of Health (MOH), the Ministry of Education, Youth and Sport (NOEYS) and Ministry of Social, Vetran Rehbilitation and Youth Affairs (MOSVY). Understandig the context of each of these service and workforce systems is important for the future intergrtion of a wholistic and comprehensive Cambodian speech therapy profession.
The Cambodian Health system and services
Cambodia has a mixed private and public health system.12 Data from the 2015 Kingdom of Cambodia health system review details varied funding sources for health care including government (~20%), foreign donor sources (~20%) and the majority of the costs contributed by the individual seeking treatment (~60%). These “user pays” services are provided by government services, private business and non-government organisations.2
Government health services provide nationwide coverage through systems of health centres, referral hospitals, national, provincial and district level hospitals, centres and posts, however, both specialist services and intensive care unit access is still limited .3
Patient satisfaction data suggest that the increase in coverage has not been matched by improved service delivery. Challenges for the Cambodian health system, listed by both patients and providers, included
1World Health Organization. (2015). The Kingdom of Cambodia health system review.
212 13Department of Planning and Health Information. (2016) Health Strategic Plan 2016-2020 “Quality, Effective and Equitable Health Services” 3
4
“low-quality health services and persistent inequalities” of access. Private service providers supply a significant percentage of the health and education services used by Cambodians. Private health services account for the majority of services with two-thirds of public health staff providing additional private services. Service delivery in the private sector is understandably varied, described as “insufficiently regulated and monitored”.5
Training for health professionals in Cambodia
The high visibility of physical disabilities in Cambodia has influenced NGOs to invest in some health professions more than others (Bryce, Possnet & Yit 2017). Cambodia’s Prosthetics and Orthotics (P&O) profession is well established with a designated school offering a 12-month technician qualification and a 2-year internationally recognized diploma course. Physiotherapy has developed over the last 20 years, with training developing from certificate to the current Bachelor degree. Government universities offer Bachelor and Master degrees in Social work, Psychology and Linguistics. Audiology has a 2-year “Ear health specialist” 6
training program run by a non-government organization . At present, there are no Cambodian university programs in the allied health fields of Speech therapy, Occupational therapy, Podiatry, or Audiology.
The training, employment and regulation of health professionals is managed by a number of different government ministries. Training of most medical and allied health professionals comes under the joint responsibility of the Ministry of Health (MoH) and the Ministry of Education Youth and Sport (MoEYS). However, training and employment of P&O professionals come under the Ministry of Social Affairs, Veteran and Youth Rehabilitation (MoSVY). Physiotherapy training is under the Ministry of Health (MoH) and employment under both MoH and MoSVY. The Cambodian Physiotherapy Association (CPTA) was established in 1994 and is increasingly involved in regulation and advocacy of Physiotherapy in the country.
In the public sector, the University of Health Science (UHS) is a significant provider of the healthcare workforce including undergraduate degree courses for the training of medical doctors, pharmacists and dentists and associate degrees in nursing, midwifery, laboratory technology, physiotherapy and medical imaging. In 2017, UHS launched a Physiotherapy bridging program to upgrade the previous associate degree qualification to a Bachelor Degree. There are now a growing number of private institutions providing health-related education. Australia’s Department Foreign Aid and Trade 2010 data showed that the number of private education providers in Cambodia exceeded the number of public providers by approximately 2:1 with an overall growth in the number of health training institutions.
Allied health training programs appear to differ widely in their combination of practical and theoretical content. Increasingly academic programs and ongoing professional development in Cambodia are seeking to increase their teaching quality and methodology. A health work force educator explained, “we use student-centred methods of teaching and competency-based assessments which are preparing our graduates well for practice” .7
Recognition of the need to deepen the depth and breadth of Cambodia’s health workforce comes from both inside and outside Cambodia. The World Health Organisation (WHO) lists “transforming the health workforce, and ensuring decent employment [as] key to transforming Cambodia’s health system to meet 8
population health needs and for advancing universal health coverage” . The Government’s 2016 Health
4 15World Health Organization. (2015). The Kingdom of Cambodia health system review.
5
6 All Ears Cambodia. (2020) Personal communication, Glyn Vaughan April 2020.
7Joint WHO and International Labour Organization (ILO) week-long mission in September 2019
https://www.who.int/cambodia/news/feature-stories/detail/investing-in-the-health-workforce-for-the-future
8 https://www.who.int/cambodia/news/feature-stories/detail/investing-in-the-health-workforce-for-the-future accessed 2nd September 2020.
Strategic plan, notes that currently both the competencies and the skill-mix of Cambodia’s health workforce is limited (Dept. Planning and Health). Whilst neither of these documents identifies speech therapy specifically, there appears opportunity to use this momentum for future development of speech therapy workforce within both private and public systems.
Speech Therapy and Health
Early speech therapy input in Cambodia began in the specialized area of services for individuals with cleft palates, with the arrival of international speech therapists who were part of the visiting treatment teams. Cleft palate services developed at both the Cambodian National Surgical Centre (part of the National Rehabilitation Centre in Phnom Penh) and the National Pediatric hospital, with a foreign speech therapist training staff in aspects of post-surgery habilitation. These Cambodian practitioners subsequently participated in a 3-month intensive training in post-cleft surgery speech therapy in Taiwan in 2015.
Three national-level hospitals based in the capital, Phnom Penh, have had ongoing speech therapy support from Speech and Swallowing Therapy Cambodia (SSTC). Since 2013, SSTC has been working in Cambodia providing competency-based workplace training of nurses, physiotherapy and medical staff in the area of dysphagia. This training includes core theory required to assess and treat adult dysphagia in the acute setting, with supervision and support. Trainees receive 25 hours of teaching and undergo written and practical assessments that they are required to pass in order to work as recognized “dysphagia clinicians” with SSTC support and supervision. Dysphagia clinicians have skills to screen a patient’s swallowing, administer a bedside swallowing assessment and provide rehabilitation strategies. In 2019 SSTC had seven active dysphagia clinicians and three dysphagia clinicians with additional experience who supervise and support others. All dysphagia clinicians work closely with a university-qualified speech therapist.9
From 2018 until early 2019, the National Pediatric Hospital (NPH) provided speech therapy services within their multidisciplinary rehabilitation unit. These limited services ceased when NPH’s partnership with international NGO (HCVI) ended in early 2019. Since May 2020, OIC Cambodia has been conducting a speech therapy pilot project within the outpatient rehabilitation department. This pilot involves 1) capacity building of the multidisciplinary team to provide basic information and strategies for NPH patients with communication and swallowing difficulties, 2) direct speech therapy services and 3) research into speech therapy needs within the hospital system. In September 2020 this project was modified to include competency based speech therapy coaching and training of NPH staff to become speech therapy assistants under the supervision of OIC speech therapist and NPH rehabilitation team.
Within the Cambodia’s medical sectors, there appears to be rapid growth in specialist services. Two areas of significant growth in the health sector, which intersect with speech therapy, are Autism-related services and Cochlear Implant services- these initiatives are often supported by services or companies from neighboring
countries in the region. For example government hospital Preah Anduong Hospital Eye and Ear and the National Pediatric Hospital are working with international cochlear implant specialists and have expressed desire to have speech therapy support for those involved .10
The Cambodian Rehabilitation and Disability system and services
The Cambodian government expresses its intention to develop health and education services to serve all Cambodians. Evidence of this includes ratification of global and regional treaties including the Convention on the Rights of Persons with Disabilities (CRPD), the Convention on the Elimination of All Forms of
9 Personal communication. Annie Johnson Speech and Swallowing Therapy Cambodia, 4th May 2019
10 Personal communication Dr Keo Vanna, Department of Ear Nose and Throat, National Pediatric hospital, 2nd October 2020
Discrimination Against Women; the International Covenant on Economic, Social and Cultural Rights; and the Anti-Personnel Mine Ban Convention and the Incheon Strategy. At a national level, key policies and strategic plans include the Law on the Protection and Promotion on the Rights of Persons with Disabilities (under review in 2020) and the National Disability Strategic Plan 2019-2023, which was launched in 2019.
The promotion and enforcement of the rights of people with disabilities in Cambodia involves a range of actors including government ministries and agencies, DPOs, international development partners and NGOs.
Main actors relevant to the disability sector
Ministry of Social Affairs, Veterans, Youth and Rehabilitation (MoSVY) is the lead ministry on disability with the overall responsibility of ensuring the welfare and well being of adults and children with disabilities and other vulnerable groups. Disability Action Council (DAC) is an inter-Ministerial, multi-stakeholder coordination and advisory body, which was established in 1997. It is the key mechanism for coordination, technical advisory services and implementation of disability rights at national and sub-national levels. The Department of Welfare for Persons with Disabilities (DWPD) was established by MoSVY to lead and manage disability-related work. Its responsibilities include the promotion, monitoring, inspection and enforcement of policies and legislation on disability. Cambodian Disabled People’s Organisation (CDPO) is an umbrella organisation of persons with disabilities, which represents the voices and promotes the rights of persons with disabilities. Its membership includes approximately 60 DPOs at sub-national level.
Disability services
The Persons With Disabilities Foundation (PWDF) is a government institution linked to MoSVY, which was established by sub-decree in 2010. PWDF oversees the management of rehabilitation services including Physical Rehabilitation Centres (PRC) within the country. These PRC’s are located in larger provincial towns and are linked with local health centres for referral and service coordination. They support both children and adults with disabilities within the geographical area. Although initially established by international NGOs, most PRCs are now managed by PWDF, with some ongoing technical and financial support from International Red Cross (ICRC) and other NGOs. Physiotherapy, and Prosthetics and Orthotics services are the key services available at all PRC sites. Some services such as social work and inclusive sporting programs are available at a limited number of PRCs. At the time of the writing this report, the Children’s surgical centre, located next to the National Rehabilitation Centre in Phnom Penh provides a specific aspect of speech therapy support (cleft palate, post-surgery support). The remaining centres throughout the country have no speech therapy support.
Relevant government policies relating to speech therapy and disability
Unlike physical disability, communication or swallowing difficulties are rarely highlighted in government documents or policies. This is likely due to the hidden nature of communication or swallowing difficulties and the historic lack of focus on these specific areas by disability advocates. The 2009 Law on the Protection and Promotion of the Rights of Persons with Disabilities, provides no specific mention of communication or swallowing difficulties, however, by definition they are included within this laws coverage. The National Community Based Rehabilitation Guidelines developed by MOSVY include examples of aids needed for people with communication disabilities however there is no systematic plan for incorporation of speech 11
therapy as a profession. The Law on the Protection and Promotion of the Rights of Disabled Persons, 2009, 11 Yeoh, W. (2013) Speech Therapy Situational Analysis Cambodia.
with the addition of Article 27 and 28, promotes inclusive education and specialized spaces for students with disabilities.
Speech Therapy in Disability and Rehabilitation
NGO’s have provided the bulk of speech therapy interventions for people with disabilities. CCAMH is a lead provider of community based therapy support for families with children with communication delays, Autism and other disabilities. Safe Haven , Grace House and CABDICO 12 are organisations known to have had foreign speech therapy volunteers upskill their Cambodian staff providing direct support to Cambodians with disabilities.
The Cambodian Education sector and services
For many Cambodian children living with disabilities, there has been little opportunity to access formal education. Whilst Cambodian and international NGO’s have been promoting inclusion of people with disabilities, the limited capacity and resources of the general education system, especially in rural areas, has resulted in most learners with disabilities being entirely excluded from educational opportunities, (The National Education For All 2015 review report, 2014, RCG).
Cambodia has a small number of specialist school settings providing education support for children with disabilities set up over the last 30 years. Some of these are for specific disabilities such as Krousar Thmey: children with vision or hearing impairments and Hands of Hope Cambodia: Children with Autism or intellectual disabilities whilst others like Rabbit School and Pour un Sourire D’Enfant have broader criteria. Many of these services have specialised schools as well as program activities supporting the inclusion of children within mainstream schools. These services have been a powerful lobby voice in the special education sector and have played an important role in shaping government policy and practice. Many of these specialised services are in the process of transitioning to management by the government.
Training for Special Education professionals in Cambodia
In 2018, the government established the National Institute of Special Education to provide specialised education to experienced teachers as part of the localisation of Krousar Thmey schools to government management. Early initiatives in 2019 and 2020 have focused on training government teachers in specific support of children with vision and hearing disabilities. Planned initiatives in the coming future include training to focus on intellectual disabilities.
Specific departments within MoEYS identified as relevant for speech therapy are:
● The Special Education Department: promotes inclusion amongst government preschool, primary and secondary schools including in-service training
● The Early Childhood Department: manages community preschools and other early childhood initiatives
● The Teacher Training Department: designs and implements pre-service and in-service training ● The Education Research Council: policy development and research priorities in education
Speech Therapy in Education
12 Personal communication Jess Whitely, Director of Safe Haven, July 2019.
● Speech therapy was piloted within the mainstream government education system in 2018, as part of OIC Cambodia’s “speech therapy coaching project for teachers” in Kandal province. In 2019, OIC Cambodia provided a 6-day training on Childhood Development of Communication and Language” to the MoEYS’s Special Education Department (SED) and key provincial preschool teacher trainers.
● National Institute of Special Education delivered two 10-month courses in 2019 to equip government teachers to support children with hearing impairment and vision impairment. ● An increasing number of private schools in Phnom Penh are contracting the services of private clinics to seek ST services for individual students or training and support for their teaching staff.
Documented speech therapy initiatives in Cambodia:
Documented communication and swallowing needs: Cambodian prevalence data
The accurate collection of data on communication and swallowing impairments remains challenging in Cambodia. This is compounded by limited identification of communication and swallowing impairment (including self-identification) and a lack of tools to collect contextually relevant data. Previous estimates using hearing impairment and intellectual disability data from the 2009 National Disability Survey suggested a conservative figure of 600,000 people needing communication and swallowing services in Cambodia .13
Documented review and analysis of speech therapy in Cambodia
Published literature and research documentation on speech therapy-related initiatives in Cambodia remain limited. A 2017 Evaluation report summarized, “Input from foreign Speech Therapists has largely focused on acute medically related needs within the hospital setting; training existing medical practitioners in assessment and intervention techniques for people with swallowing difficulties or cleft palate recovery…. mainly through consultancy or training for specific organisations” .14
OIC Cambodia’s 2013 Speech Therapy Situational Analysis showed a variety of NGO disability services developed to meet the needs of specific populations. This report found 12 organisations who self-identified as providing elements of speech therapy. Specific client populations and services included educational facilities for children with physical or hearing difficulties, hospital-based support for cleft palate repair, as well as special school settings supporting children with intellectual, physical or sensory difficulties.15
Key non-government organisations in speech therapy:
Organisations based in Cambodia:
There are many NGOs working to provide health, community and education services within Cambodia. There is also an active disability sector involving local NGO’s and INGO’s and self-advocacy groups with people with disabilities and their families. Four local organisations have invested significantly in establishing speech therapy services within their sphere of influence, these include:
● Center for Child Adolescent Mental health (CCAMH)
● Krousar Thmey (KT)
13 Yeoh, W. (2013) Speech Therapy Situational Analysis Cambodia, OIC Cambodia Project
14 Bryce,R. Possnett, M and Yit, V (2017) “An independent evaluation: Inclusive Education for Students with Communication Disabilities: 2016 Teacher Training Project” OIC Cambodia
15 Yeoh, W. Speech Therapy Situational Analysis Cambodia 2013.
● Organisation for Improving Communication and swallowing therapy services in Cambodia (OIC Cambodia (OIC Cambodia)
● Speech and Swallowing Therapy Cambodia (SSTC)
Each of these organisations has sought sector-wide influence in the formation of sector services and partnership with government to inform policy in the areas of therapy provision .16
Organisations based outside of Cambodia
The majority of foreign speech therapy input has come from individual speech therapists; however, some initiatives have involved speech therapists coming to Cambodia within a group. Generally, support has been provided to specific organizations or service locations. Several universities have run multi-year programs, providing a Cambodian-based learning opportunity for their students or graduates. Over the last decade, United Kingdom-based, City London University has sent graduate speech therapists to Cambodia for three-month placements upon the completion of their degree. This program independently connects with many education and health providers within Cambodia’s public and private sectors, offering direct speech therapy and training to Cambodians in a wide variety of speech therapy topics on an annual basis. In 2019, the City London team of 8 new graduates connected with at least 18 different organisations during their 3-month visit to Cambodia. In recent years, Australian based Latrobe University has also independently brought student teams for two weeks to provide clinical speech therapy and audiology intervention and assessment.
In 2013, 48 Cambodians graduated from a certificate course for disability, health and early childhood development, with a focus on pediatric speech therapy. This course was designed and taught by Singapore 17
International Foundation in partnership with Cambodian Centre Adolescent Mental Health (CCAMH). The authors of this paper are not aware of subsequent skills assessment, systematic follow up of the participants or broader evaluation of this training course.
In 2017, City London University, SSTC and Teachers in Cambodia partnered with private education entity Pannasastra University, to conduct a short course (approximately 120 hours) on the “introduction to speech therapy”. This part-time course contained modules on general speech therapy topics such as swallowing difficulties and language development. Participants came from a variety of education and disability organisations. Lecturers included foreign therapists and new graduates from the City London program. Participant feedback revealed a reported an increase in of understanding of speech therapy and motivation to learn more. There is no publically available evaluation of this course.
Private speech therapy services in Cambodia
Private speech therapy services have existed in Cambodia’s capital city for approximately 10 years. Initial services existed within a multidisciplinary counselling service, Indigo Cambodia, which ceased its services in 2017. Current Phnom Penh-based private speech therapy services include Happy Kids Clinic, Bright Minds and Mobile Education Testing Unit (METU), which all have a pediatric focus- these clinics are staffed by foreign, university-qualified speech therapists and Khmer speech therapy practitioners. Advertised prices for these clinics include initial consultations around $80 and most have a waiting list due to high client demand. Over the last eight years, a number of private freelance Cambodian practitioner clinics have opened which provide services at a fraction of the cost of the foreign-staffed clinics. ST services, including presently available private services, are not regulated.
16 These organisations participated in this research, so their 2018-2019 services are included in the mapping results.17 https://www.phnompenhpost.com/national/speech-therapists-help-fill-void
Mechanisms for co-operation within speech therapy in Cambodia
In addition to the collaboration between organisations detailed so far, in 2017, OIC Cambodia and SSTC, jointly founded the Cambodian Speech therapy network (CSTN), an open network of university-qualified speech therapists to share resources, experience, cultural and contextual knowledge with an aim to influence the development of broader speech therapy in Cambodia. This volunteer network continues to meet 4-5 times a year in Phnom Penh.
In January 2020, OIC Cambodia, SSTC and Singapore International Foundation ran a multiday workshop for practitioners in the health and rehabilitation sectors aimed at increasing awareness of speech therapy and multi-disciplinary practice. In June 2020, OIC Cambodia and SSTC facilitated workshops on “Ethics in speech therapy” attended by nine speech therapy practitioners from seven different workplaces. The Cambodian workshop resulted in the formation of a special interest group amongst these Cambodian speech therapy practitioners, currently facilitated by OIC Cambodia.
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