This study aims to analyse and address the question of how policy is made for children and HIV in Cambodia.
First however, we look at the background of Cambodia, its HIV epidemic and vulnerable children. We then explain our methodology in the study, summarise findings on three areas of policy for children relating to HIV and conclude with some lessons.
Almost half of the Cambodian – predominantly Buddhist and rural – population (13.8 million people) are aged 18 years and under. Since the peace treaty was brokered in the early 1990s, the country has enjoyed increased economic growth (8.4 per cent per annum from 1994 to 2006) and relative stability, despite bouts of targeted political violence. Poverty persists, with 36 per cent of people living on less than US$0.63 a day (NIPH and NIS 2006), while there are growing inequalities in wealth, with increased urbanisation, mobility and people marginalised in the process, many turning to informal peri-urban livelihoods strategies (World Bank 2007a). Involvement in economic activity starts early and rises sharply with age, contributing to delayed school entry and early school dropout. A recent study found that an estimated 52 per cent of 7–14-year-olds and 16 per cent of children aged six were economically active (World Bank 2006).
Cambodia has had one of the highest HIV prevalence rates in Asia, but prevention efforts have been relatively successful and there has been a steady decrease in HIV prevalence from an estimated 2 per cent in 1998 to the current level of 0.9 per cent among people 15–49 years, as described in Figure 1. Prevention efforts are targeting female sex workers, their clients and other sexual partners, men who have sex with men (MSM) and the small but growing numbers of injecting drug users (IDU), as well as broader groups (NAA 2007). The epidemic is primarily driven by heterosexual transmission and many men who have sex with men are married to – and also have sex (and children) with – women. Approximately one-third of all new infections are among children (with considerable numbers through sexual transmission) and half are among females(NCHADS 2007a).
An estimated 8.8 per cent of Cambodians aged 0–17 years are orphans3 and a further 6.1 per cent have a chronically ill parent (op cit.). These two groups (ca. 15 per cent of children) make up the predominant proportion of the category referred to as ‘orphans and vulnerable children’ (OVC), which (being an orphan or ill) is not necessarily related to HIV per se. To differentiate and describe the more HIV-relayed category of children infected or otherwise directly affected by HIV and AIDS, we use the concept of children affected by HIV or AIDS (CAA). However, we have no reliable estimates of the number of CAA, though we can be fairly certain that they represent a minority of all OVC. The number of children aged 0–14 years living with HIV/AIDS in Cambodia and the number of new HIV infections occurring each year among children in this age group were projected to be 2,790 children in 2007 (NCHADS 2007a). By September 2007, there were 22 sites providing care and treatment to 2,960 children including 1,739 receiving antiretroviral treatment (ART) (NCHADS 2007b).
National expenditure on health and education has increased, but the government is constrained by relatively low levels of capacity and resources (CDRI 2007), while the country continues to receive substantial international aid. Expenditure of national resources on HIV, education or support to OVC is limited, but includes support for basic wages for staff, infrastructure, school buildings and at least one orphanage in each of the 24 provinces (World Bank 2007b).
The National AIDS Programme of the Ministry of Health was reorganised in the late 1990s into the National Centre for HIV/AIDS, Dermatology and STIs (NCHADS), now the focal point of the health sector response to the epidemic. This was followed in 1999 by the establishment of the National AIDS Authority (NAA), with a mandate to ensure a multi-sectoral response. The Royal Government of Cambodia (RGC) ratified the United Nations Convention on the Rights of the Child in 1992 without reservations and children’s rights were incorporated into the Constitution of Cambodia in 1993. In 2007, the government made a commitment to universal access to HIV prevention, treatment and impact mitigation by 2010 and the response to HIV/AIDS is outlined in the recently revised National Strategic Plan for a Comprehensive and Multi-sectoral Response to HIV/AIDS 2006–2010, known as NSP II (NAA 2007).
This study attempts to describe and assess the process, developments and effects of three sets of policies, as well as to speculate on the major drivers of change in each case in order to compare and to draw out key lessons, namely:
- The Policy for Alternative Care for Children
- The Impact Mitigation chapter of the second National AIDS Strategy (NSP II), which had led to a draft National Plan of Action for OVC at the time of the fieldwork
- The policies under the Continuum of Care, related to paediatric ART.
This article comes from the IDS Bulletin 39.5 (2008) Policy Process for Children and AIDS in Cambodia: Drivers and Obstacles