August 7, 2022

Revamping how Cambodia tackles malnutrition


• Cambodia has made great economic progress but undernutrition remains a major impediment to its human capital development.

• A multisectoral approach from all stakeholders is needed to address child and maternal undernutrition.

• Providing high quality nutrition services, through a mixture of facility- and community-based approaches, needs to be a top priority.

Did you know that prior to the COVID-19 pandemic Cambodia became one of the world’s leaders in economic growth, poverty reduction and shared prosperity? Cambodia achieved lower-middle income country status in 2015. Poverty incidence relative to the national poverty line fell from 47.8% in 2007 to an impressive 17.8% in 2019. Through strong political commitment and willingness to innovate, the Cambodian government has set a strong example in changing the paradigm in financing and provision of health care services to accelerate progress on health outcomes. Life expectancy increased almost twofold, mortality rates were halved, and the under-five mortality rate saw a huge drop from 106.3 deaths per 1,000 live births to only 26.6 deaths between 2000 and 2019.

But despite progress on so many fronts, child and maternal undernutrition remain intractable challenges. According to the World Health Organization thresholds, the child stunting and wasting levels are still considered high. Almost one-third (32%) of Cambodian children under 5 are stunted (low height for age) and over 10% of children suffer from wasting (low weight for height). Gender factors also figure prominently. Maternal undernutrition is common—14% of women of reproductive age are underweight and as much as 45% suffer from anemia. Poor maternal health and nutrition during pregnancy contribute to a high prevalence of low birth weight (11%), predisposition to stunting and elevated maternal and neonatal mortality. Furthermore, Cambodia’s rural, indigenous, and socioeconomically challenged women and children are disproportionately affected by poor health and low nutritional status. As a result, undernutrition remains a major impediment to strengthening Cambodia’s human capital formation. It is a major contributor to mortality, and decreased health and productivity. So what needs to change moving forward?

Policymakers should shift focus to the in-utero origins of growth faltering and its underlying drivers — food insecurity, poor care for women and children, low access to health services...

Multisectoral approach from all stakeholders

With undernutrition having multiple, interacting and multisectoral determinants and drivers, it is all hands-on deck to reduce the burden of child stunting and wasting. Beyond the immediate drivers of undernutrition (nutrient intake and disease), focus of policymakers should shift to the in-utero origins of growth faltering and its underlying drivers. The latter includes food insecurity, poor care for women and children, low access to health services, poor availability and quality of counseling for infant and young child feeding. Poor access to water, sanitation, and hygiene are also important factors. Stronger cross-sectoral collaboration and coordination at both national and subnational levels are thus critical for progress on nutrition outcomes.

The good news is that Cambodia has already adopted a multisectoral approach. The World Bank and its funding partners—the Australian Department of Foreign Affairs and Trade (DFAT) through the Advance Universal Health Coverage Multi-Donor Trust Fund, the *KfW *Development Bank of Germany (KfW), and the Global Financing Facility (GFF)—are supporting the government of Cambodia in rolling out the Cambodia Nutrition Project. This project supports a subset of priority maternal and child health and nutrition services identified by the Ministry of Health and the National Committee for Sub-national Democratic Development of the Ministry of Interior. It involves the scaling-up of coordinated actions and mechanisms for interventions across ministries and at subnational levels (i.e. provincial health departments). Aimed at improving maternal and child nutrition outcomes and human capital formation in the early years, nutrition governance with all involved stakeholders (e.g. UN agencies, civil society) is also a critical component for this project. Existing foundations will be leveraged: a national strategy, a cross-sectoral coordinating agency, a high level of awareness across key stakeholders, and even a multisectoral National Strategy for Food Security and Nutrition.

Addressing key bottlenecks of nutrition services

Significant bottlenecks in the healthcare system limit coverage and impact of priority nutrition services. Recent findings from a Health Financing System Assessment yielded valuable information on key gaps and opportunities in health care delivery and financing arrangements at national and sub-national levels in Cambodia. These include weak accessibility and quality of nutrition services; fragmented and vertical financing and service delivery for priority programs; lack of training and capacity of providers; and low community awareness and demand for preventive, promotive, and curative health services. No administrative data are collected on child growth, coupled with only ad hoc supervision of nutrition interventions.

Providing high quality nutrition services needs to be a top priority of the Cambodian government. The ongoing nutrition project supported by the World Bank, DFAT, KfW, and GFF aims to do just that. It aligns closely with the strategic goal of the Ministry of Health and leverages the recently launched decentralization and deconcentration reform to improve reproductive health and reduce maternal, newborn and child mortality, as well as undernutrition. A mixture of facility- and community-based approaches can improve the coverage and quality of priority nutrition service provision. On one hand, the facility-based approach delivered through health centers strengthens the delivery of priority health and nutrition services. This includes the performance-based service delivery grants to improve the availability and quality of priority services, and health equity funds to ensure equitable utilization of service by the poor. On the other hand, the community-based approach stimulates demand, increases utilization of facility-based priority services, and encourages the adoption of improved nutrition behaviors. In particular, the latter targets pregnant and lactating women, young children, and vulnerable population groups in rural and urban poor communities. To start with, seven target provinces were chosen for the Cambodia Nutrition Project given their seriously lagging health outcomes, their high level of deprivation revealed by multidimensional poverty indicators, and their service readiness gaps.

Slow but steady progress amidst COVID-19 impacts

Progress in the implementation and launch of interventions in the seven target provinces has been slower than anticipated, primarily due to community transmission of COVID-19 and the resulting containment measures. To date, 98 out of 303 health centers have rolled out supply side interventions and 73 out of 416 communes have rolled out demand-side interventions. These interventions include but are not limited to: the screening, management and treatment of severe acute malnutrition nationwide; the availability of maternal, infant and young child feeding promotion (including exclusive breastfeeding and complementary feeding) in health facilities and communities; and the availability and accessibility of ante- and post-natal care which includes maternal nutrition. Nevertheless, adaptations of planned activities, such as trainings, assessments, and supportive supervisions, are currently being undertaken amidst COVID-19 related challenges. This revamped nutrition project has the potential to comprehensively address Cambodia’s persistent undernutrition levels and have long lasting impacts on the burden of childhood stunting by reducing neonatal mortality, improving maternal and child nutrition, and improving routine immunization coverage.

Source: World Bank