In Cambodia, doctors, nurses, pharmacists, drug dispensers, potion-makers, and folk-medicine practitioners are all referred to as “pheet.” Although the local language has gender-specific names for these occupations, those terms are seldom used colloquially.
This choice of word is indicative of the local people’s perceptions about health care. When someone gets sick, instead of seeing a doctor, he may visit the pharmacist. He would ask for a quick diagnosis and purchase the medicine without questions. No taking the temperature. No inquiry into medical history. No doctor’s prescription. Hence, walking along the streets of Phnom Penh, you can see pharmacy after pharmacy because they are more “popular” than “clinics” and “hospitals.”
These local perceptions represent the demand-side constraints for improving health and nutrition, especially among poor people with little education. In terms of social development, these demand-side constraints are best exemplified by low utilization rates of public services. Pregnant women, for example, may not bother to attend pre-natal check-ups or to have a facility-based delivery. Mothers also do not vaccinate or breastfeed their newborns. They are not motivated to comply with health and nutrition advice. In their minds, these services are simply “not important.”
On the other hand, the lack of health care specialists and facilities may represent supply-side constraints (which is itself a complicated topic and not to be addressed here).
To incentivize utilization of medical facilities and adherence to high-quality diets, some countries have introduced “conditional cash transfers” (CCTs) schemes. As the term implies, these schemes are social assistance programmes which deliver cash to poor households on a regular basis on condition that they fulfil certain obligations. In the context of health, these conditions may be mandatory pre-natal and post-natal visits, delivery process handled by qualified medical doctors or midwives, completion of vaccination protocols, and regular growth monitoring of young infants. Households consisting of pregnant women or babies may then receive some cash benefits through regular compliance to the checklist.
In some Latin American countries, CCTs have shown a good track record of boosting hospital and clinic utilization and reducing malnutrition rates. These successes suggest potential benefits for replicating such programme designs in Asian countries, such as Cambodia.
Nonetheless, the health and nutritional benefits of CCTs are not automatic. A thorough understanding of demand-side constraints in the local context is necessary. Perceptions and cultural norms may influence compliance to conditionality as well as usage of the cash benefits.
Take the example of feeding practices. Also assume that mothers obtain a $10 incentive for bringing their babies to health centres for growth monitoring and vaccination. With higher purchasing power, the family can spend more on food. However, instead of getting a higher quality diet, the family may switch to more preferred food items, such as white bread and milled rice, which do not add any nutritional value.
In Cambodia, malnutrition among the poor and the non-poor affirms that increased income is not always correlated with better health. In the rural areas, in particular, 8.9% of children from non-poor households suffer from malnutrition (technical term: “wasting”), similar to the 9.8% among poor households. These statistics suggest that more education on nutrition and dietary choices, in the form of cooking classes, focus groups, health care advice, etc., should be delivered in line with cash incentives.
Improper parenting practices, also evident in the Cambodian context, may also hamper nutrition and health. Statistics show the percentage of infants receiving complementary feeding decreases significantly from the 12-to-17-month-old group to the 18-to-23-month-old group. In effect, among two-year-olds, there is a greater prevalence of anaemia (lack of iron), vitamins and other minerals. This decline, as some experts suggest, was driven by cultural perceptions that two-year-olds are “old enough” to feed themselves. These perceptions, surely, must be changed through education as well.
In a country which had experienced much trauma and poverty, the problem of “cultural poverty” is also serious. This term refers to households which have adopted a fatalistic attitude about their livelihoods and are unable to take advantage of opportunities to improve their livelihoods. The lack of information about their rights and the lack of means to exercise these rights are also factors sustaining chronic poverty. In turn, once the households receive the money, they take little care to spend wisely. They may buy more wine, cigarettes, and furniture, etc.; but not food. And they may spend all the money in one go. In face of these attitudes, some practitioners have suggested delivering cash directly to women (not the head of the household), who are more likely to make appropriate spending decisions, and disseminating positive messages to children and youth.
On the surface, the reluctance to attend medical check-ups, to purchase nutritious food, and to spend money wisely may look like “carelessness,” “thoughtlessness,” stubbornness”… But at the core of these decisions is ignorance. (It is also a matter of habit. Imagine yourself growing up in the U.S. eating with fork and knife. Then imagine flying into India or China. Instantly you have to eat with your hands or with chopsticks. Note your uneasiness.) In the end, these attitudes have to change so that more people from developing countries would demand health care services. But these changes rely not only on monetary incentives but also widespread and persistent public education.
***
The above analysis includes personal reflections from the author and information synthesized from the Technical Consultation on Safety Nets and Human Capital: The Role of Cash Transfers in Supporting the Poor While Addressing Maternal and Child Malnutrition (Raffles Hotel, Phnom Penh, 19 October 2009). This one-day meeting is a second of a series of consultations working towards a national social safety nets strategy in Cambodia. This article utilized presentations by H.E. Dr. Prak Sophonneary (Deputy Director of the National Maternal and Child Health Centre, Ministry of Health), Dr. Makmur Sunusi (Deputy Minister, Ministry of Social Affairs, Republic of Indonesia), and Mr. Harold Alderman (World Bank Social Protection Advisor, Africa Region).
Wednesday, 21 October 2009
Friday, 16 October 2009
You Get What You've Paid For
Speaking of pro-poor services, free access to education, free meals at school, free health care, free food rations and other social benefits often come to mind. Indeed, it sounds logical that poor people, already made disadvantaged by their financial constrains and social status, should be entitled to some “safety nets” which they can fall back to when they cannot feed themselves or maintain decent standards of living.
But from the point of view of practitioners, pro-poor programmes should not always deliver “free lunches.”
I know a few people in Phnom Penh operating dormitories (cum student centres) for young students from the provinces. More than roofed shelters, these dormitories offer a peer support network for the students. In the morning, they eat breakfast together. In the afternoon, they go to school together. In the evening, they chat with each other. In the night, they study together. Before they sleep, they say goodnight to each other. For many young Cambodians who travelled alone to the city for their education, the dormitories are where they find their first friends.
Students also have to pay a fee – the rent (most probably inclusive of an “activity fee”) – and to support their own daily expenditures on food, electricity, water and transportation. These sums may become a financial burden for those from poor rural villages.
Practitioners say, nonetheless, that there is greater utility, for both the facility and the students, when the centre charges rent and requires students to pay for basic necessities out of their own pockets.
Years ago, when the “dormitory business” first started, electricity was offered for free. Paul, my friend, recalled receiving the first electricity bill for the dormitory run by his NGO. It was more than $300 for the 30 students there. Surprised by the huge sum, he went to check each of the rooms. He tallied 15 rice-cookers, 10 fans and a couple of desk lamps. Many of the students also confessed that they would sometimes forget to turn the fan off when they left for school. Other times, they would forget to switch off the corridor or bathroom lights in the night.
During the following year, the dormitory lacked funding to continue. A few months after the students had moved out, Paul went to visit them around the city. Casually, he asked about their electricity bills. It was just $2 per person each month. They shared only one desk lamp and woke up early to take advantage of the morning sunlight. They cooked together and avoided turning on the fan unless it was above 33 degrees Celsius. The lesson then is that even poor Cambodian students, like any others, have a tendency to be “free riders.” When electricity and water are given for free, there is little incentive to conserve.
Food costs are also not paid for in the dormitories. Dormitories which used to provide food found that the per person food cost can be $10 each week. However, students can bring in rice from their own villages at a much cheaper price. Also, for each meal, students can buy cooked food to be shared among three or four people. From roadside vendors, such freshly fried meat and vegetables cost only 4,000 riels (one dollar). In other words, without compensating the students’ health, the facility and the centre can save $7 for each person altogether.
Hence, in economic terms, it is more socially desirable to leave students with their utility and food bills. At the same time, to make sure that these expenses do not exclude the poorest qualified students from education, subsidized rent can be offered for students with special needs.
This system of subsidized rent can also come in several tiers. In one case, I heard that dormitory managers would charge $6 for students with a motorbike, $4 for those with bicycles and $2 for those who has no means of transportation. Physical property is a good proxy for wealth. In rural areas, in particular, transactions are more likely conducted through a barter system than through fiat money. Possessions, such as acres of land, motorbikes, houses, cows, chickens and coconut trees, are the best “currency” for exchange. It is based on these assumptions that those with motorbikes are judged to be “wealthier” and should be able to afford a higher rent.
Dormitories, surely, are not the only type of non-free pro-poor services. In the rural areas, pilot programmes with self-help groups, community lending schemes and social insurance have tremendously boosted communal wealth. With a community fund, villagers who have contributed money can also draw out sums for starting businesses. Hence the “community lending scheme.” Including repayments and interest, some community funds in Cambodia have already saved thousands of dollars for their community!
This surplus of money then serves to provide public goods and social services to the villagers. When their family members get sick, for instance, they can withdraw money for medicines. This mechanism is referred to as “social insurance.” Surplus funds can also be used for promoting children’s education and for hiring trainers to upgrade the entrepreneurship and agricultural skills of the adults. In these cases, the fund has facilitated “self-help groups” in support of income generation.
These stories remind me of the debate on whether to hand poor people fish or to teach them to fish. Sometimes the government and the donor community must give out fish, in such cases as providing free access to primary education and affordable maternal health care. However, in other circumstances, it is more important to be innovative than to offer everything for free.
One of my colleagues, when speaking of poor people obtaining vocational and technical training, commented, “Even for poor people, they get what they have paid for. If they value training at zero, then they learn nothing. But when they invest a bit on their education, the benefits are far beyond what they have initially struggled to pay for.” This statement may sound counterintuitive, but its truth resonates in the cases of dormitories and community funds and possibly more examples in the developing world.
But from the point of view of practitioners, pro-poor programmes should not always deliver “free lunches.”
I know a few people in Phnom Penh operating dormitories (cum student centres) for young students from the provinces. More than roofed shelters, these dormitories offer a peer support network for the students. In the morning, they eat breakfast together. In the afternoon, they go to school together. In the evening, they chat with each other. In the night, they study together. Before they sleep, they say goodnight to each other. For many young Cambodians who travelled alone to the city for their education, the dormitories are where they find their first friends.
Students also have to pay a fee – the rent (most probably inclusive of an “activity fee”) – and to support their own daily expenditures on food, electricity, water and transportation. These sums may become a financial burden for those from poor rural villages.
Practitioners say, nonetheless, that there is greater utility, for both the facility and the students, when the centre charges rent and requires students to pay for basic necessities out of their own pockets.
Years ago, when the “dormitory business” first started, electricity was offered for free. Paul, my friend, recalled receiving the first electricity bill for the dormitory run by his NGO. It was more than $300 for the 30 students there. Surprised by the huge sum, he went to check each of the rooms. He tallied 15 rice-cookers, 10 fans and a couple of desk lamps. Many of the students also confessed that they would sometimes forget to turn the fan off when they left for school. Other times, they would forget to switch off the corridor or bathroom lights in the night.
During the following year, the dormitory lacked funding to continue. A few months after the students had moved out, Paul went to visit them around the city. Casually, he asked about their electricity bills. It was just $2 per person each month. They shared only one desk lamp and woke up early to take advantage of the morning sunlight. They cooked together and avoided turning on the fan unless it was above 33 degrees Celsius. The lesson then is that even poor Cambodian students, like any others, have a tendency to be “free riders.” When electricity and water are given for free, there is little incentive to conserve.
Food costs are also not paid for in the dormitories. Dormitories which used to provide food found that the per person food cost can be $10 each week. However, students can bring in rice from their own villages at a much cheaper price. Also, for each meal, students can buy cooked food to be shared among three or four people. From roadside vendors, such freshly fried meat and vegetables cost only 4,000 riels (one dollar). In other words, without compensating the students’ health, the facility and the centre can save $7 for each person altogether.
Hence, in economic terms, it is more socially desirable to leave students with their utility and food bills. At the same time, to make sure that these expenses do not exclude the poorest qualified students from education, subsidized rent can be offered for students with special needs.
This system of subsidized rent can also come in several tiers. In one case, I heard that dormitory managers would charge $6 for students with a motorbike, $4 for those with bicycles and $2 for those who has no means of transportation. Physical property is a good proxy for wealth. In rural areas, in particular, transactions are more likely conducted through a barter system than through fiat money. Possessions, such as acres of land, motorbikes, houses, cows, chickens and coconut trees, are the best “currency” for exchange. It is based on these assumptions that those with motorbikes are judged to be “wealthier” and should be able to afford a higher rent.
Dormitories, surely, are not the only type of non-free pro-poor services. In the rural areas, pilot programmes with self-help groups, community lending schemes and social insurance have tremendously boosted communal wealth. With a community fund, villagers who have contributed money can also draw out sums for starting businesses. Hence the “community lending scheme.” Including repayments and interest, some community funds in Cambodia have already saved thousands of dollars for their community!
This surplus of money then serves to provide public goods and social services to the villagers. When their family members get sick, for instance, they can withdraw money for medicines. This mechanism is referred to as “social insurance.” Surplus funds can also be used for promoting children’s education and for hiring trainers to upgrade the entrepreneurship and agricultural skills of the adults. In these cases, the fund has facilitated “self-help groups” in support of income generation.
These stories remind me of the debate on whether to hand poor people fish or to teach them to fish. Sometimes the government and the donor community must give out fish, in such cases as providing free access to primary education and affordable maternal health care. However, in other circumstances, it is more important to be innovative than to offer everything for free.
One of my colleagues, when speaking of poor people obtaining vocational and technical training, commented, “Even for poor people, they get what they have paid for. If they value training at zero, then they learn nothing. But when they invest a bit on their education, the benefits are far beyond what they have initially struggled to pay for.” This statement may sound counterintuitive, but its truth resonates in the cases of dormitories and community funds and possibly more examples in the developing world.
Tuesday, 13 October 2009
Alas, The Language Genius
“Jae reh peep… saa haa jip… oo saa haa gaam… gaa vee peet… joh jaa…”
One by one, I read out these Khmer words which caught my attention at a recent tripartite meeting involving government officials, trade union representatives and factory managers.
“Sustainability… trade union… industry… schedule… negotiate…”
One by one, also, Savon, my Khmer friend, patiently explained to me the words’ meaning.
I continued to read from my list, including words which did not make any “Khmer sense,” and in the end, Savon commented, “Phoebe, you are so smart! You have caught such big words!”
“Oo-goon,” I said. Looking at her eager face, I repeated more earnestly, “Oo-goon jeraan.”
Thank you. Thank you very much. Ironically, of all the big words I have learned, “thank you” is the only phrase which came across my mind at that moment. Secretly, I asked myself, “Where is my daily life vocabulary?” Yes, I can listen and understand, but I cannot make any verbal comments. In fact, the more Khmer I get to understand, the more I realize my inability to speak.
Having lived in several countries, I know how it feels to enter a strange land and think that “foreign peoples” (from my point of view), speaking in foreign languages, are always talking about me. When my eyes meet those of a street vendor, and then when she turns around and speak with someone else, I would instinctively feel that I am their topic of discussion. To save myself from such anxiety, I would like to be able to understand and also be able to speak enough so that people know that I understand. But learning to speak is really easier said than done.
These thoughts remind me of a recent conversation with a missionary couple from Hong Kong who spent ten years in the Philippines with their three kids. They sent their eight-year-old son to a Christian international school which used English, Mandarin and Filipino as the languages of instruction. Hakka, a southern Chinese dialect, is sometimes used by the ethnic Chinese teachers as well. From day to day, the boy would return home, do his homework neatly and get good grades at tests and exams in all three languages. In fact, in their prayer letter back to their home church in Hong Kong, the missionaries cited with grace their son’s “smooth transition.” In response, the congregation wrote back in excitement, “Your son must be a language genius!”
Alas, their son was the “language genius” only until the parent-teacher day.
Sitting the classroom, the teacher looked at the boy’s excellent results but sternly commented, “This is all good… but is your son dumb?” Before the missionaries could talk back in protest, the teacher added, “He has not spoken one word in class or in recess time with us or his classmates.”
Puzzled, the parents insisted that the teacher visit their home for dinner one night. To the teacher’s surprise, at home, the son behaved just like any other kid. He played with his siblings, argued over toys, fought over the TV remote control and yelled for daddy and mammy when his older brother bullied him. Yes, he could listen and understand Mandarin, English and Filipino; but he just could not speak them. He could only speak Cantonese, the language the family spoke at home.
The son, from then on, got back on track with his speaking abilities. The point of this story, though, is that I sometimes feel like that poor little boy – understanding what people are saying but cannot make any verbal response.
Yesterday night, I returned home from a choir practice with my Singaporean neighbour. We spoke with the landlord’s mother, which I respectfully call yaay (grandmother in Khmer). Or, more accurately, she spoke with yaay; I listened. I knew they were talking about yaay’s health, an old shoulder injury which has started to che (hurt) again. I understood that she has been to the pheet (doctor) and that she has nyam tnam (take medicine). But medicines have not worked. My friend told her to haat braan (exercise) by swinging her arms, from bon dtik bon dtuuik (small actions) to klang klang (large movements). To start with, she advised yaay to repeat the motion bpram dong (five times) and then gradually do deeut deeut hi (more and more). I stood there and nodded to show that I understood. But really, I hope I could echo my friend’s advice and be part of this conversation.
One by one, I read out these Khmer words which caught my attention at a recent tripartite meeting involving government officials, trade union representatives and factory managers.
“Sustainability… trade union… industry… schedule… negotiate…”
One by one, also, Savon, my Khmer friend, patiently explained to me the words’ meaning.
I continued to read from my list, including words which did not make any “Khmer sense,” and in the end, Savon commented, “Phoebe, you are so smart! You have caught such big words!”
“Oo-goon,” I said. Looking at her eager face, I repeated more earnestly, “Oo-goon jeraan.”
Thank you. Thank you very much. Ironically, of all the big words I have learned, “thank you” is the only phrase which came across my mind at that moment. Secretly, I asked myself, “Where is my daily life vocabulary?” Yes, I can listen and understand, but I cannot make any verbal comments. In fact, the more Khmer I get to understand, the more I realize my inability to speak.
Having lived in several countries, I know how it feels to enter a strange land and think that “foreign peoples” (from my point of view), speaking in foreign languages, are always talking about me. When my eyes meet those of a street vendor, and then when she turns around and speak with someone else, I would instinctively feel that I am their topic of discussion. To save myself from such anxiety, I would like to be able to understand and also be able to speak enough so that people know that I understand. But learning to speak is really easier said than done.
These thoughts remind me of a recent conversation with a missionary couple from Hong Kong who spent ten years in the Philippines with their three kids. They sent their eight-year-old son to a Christian international school which used English, Mandarin and Filipino as the languages of instruction. Hakka, a southern Chinese dialect, is sometimes used by the ethnic Chinese teachers as well. From day to day, the boy would return home, do his homework neatly and get good grades at tests and exams in all three languages. In fact, in their prayer letter back to their home church in Hong Kong, the missionaries cited with grace their son’s “smooth transition.” In response, the congregation wrote back in excitement, “Your son must be a language genius!”
Alas, their son was the “language genius” only until the parent-teacher day.
Sitting the classroom, the teacher looked at the boy’s excellent results but sternly commented, “This is all good… but is your son dumb?” Before the missionaries could talk back in protest, the teacher added, “He has not spoken one word in class or in recess time with us or his classmates.”
Puzzled, the parents insisted that the teacher visit their home for dinner one night. To the teacher’s surprise, at home, the son behaved just like any other kid. He played with his siblings, argued over toys, fought over the TV remote control and yelled for daddy and mammy when his older brother bullied him. Yes, he could listen and understand Mandarin, English and Filipino; but he just could not speak them. He could only speak Cantonese, the language the family spoke at home.
The son, from then on, got back on track with his speaking abilities. The point of this story, though, is that I sometimes feel like that poor little boy – understanding what people are saying but cannot make any verbal response.
Yesterday night, I returned home from a choir practice with my Singaporean neighbour. We spoke with the landlord’s mother, which I respectfully call yaay (grandmother in Khmer). Or, more accurately, she spoke with yaay; I listened. I knew they were talking about yaay’s health, an old shoulder injury which has started to che (hurt) again. I understood that she has been to the pheet (doctor) and that she has nyam tnam (take medicine). But medicines have not worked. My friend told her to haat braan (exercise) by swinging her arms, from bon dtik bon dtuuik (small actions) to klang klang (large movements). To start with, she advised yaay to repeat the motion bpram dong (five times) and then gradually do deeut deeut hi (more and more). I stood there and nodded to show that I understood. But really, I hope I could echo my friend’s advice and be part of this conversation.
Thursday, 8 October 2009
So You Have Graduated.... Be a Cleaning Lady
Back in high school, I remember spending one night with Lena, my family’s Filipino domestic helper, and watching a movie starred by Matt Damon. About half an hour into the movie, Lena exclaimed, “I remember this story! It is in your book!”
With a puzzled face, I replied, “Which book?”
She immediately ran to the shelf and pulled out John Grisham’s THE CHAMBER. She has recently finished the book. I felt so ashamed of myself, for although I bought shelves full of books, I have not found the determination and energy to read all of them. While I was lazing around, though, Lena has probably read all the books and remembered well the details of my English fiction and non-fiction books.
What surprised me in that encounter was her ability to read and understand sophisticated English. No one would expect a domestic helper who does household chores to have excellent language abilities. Upon further inquiry, she revealed that she has already completed a university degree in the Philippines. From her demonstrated English skills, I assumed that her degree was of decent quality. But why are her skills so underused?
In many developing countries in Southeast Asia, there is a misalignment between developments in the education and the industrial sectors. Consider three scenarios. In some countries, education reforms can be so successful that more and more young people completes beyond basic education and pursue tertiary degrees. Most of these students acquire general/soft skills in business and financial management, language proficiency, information technology skills, etc. These skills would be valuable in a fully urbanized and industrialized society; but in countries where agriculture remains a sizable economic sector and the industrial base is narrow, these graduates would not be able to find jobs commensurate with their skills.
In other countries, both the education and industrial sectors may be growing rapidly. However, there is little coordination between universities and vocational training institutions. In effect, training efforts may be duplicated, leading to oversupply of certain skills and a dearth other needed skills. Also, since training institutions rarely interact with private sector employers, the industry-specific skills trainees obtained may be outdated or too shallow. In the end, employers would have to waste resources re-training their new employees again.
In the third group of countries, industrial development occurs at a faster rate than education reforms. There would be an influx of unskilled workers into the workforce but they lack the qualifications to land in a decent job. At the same time, training institutions lack the human resource and infrastructural capacities to deliver high quality training. In some cases, training institutions may be established but under-utilized because few resources have been invested in publicity and outreach.
In all three cases, different forms of misaligned educational and industrial developments lead to mismatch of skills. For some countries, workers respond to this mismatch through migration. The Philippines would serve as an example where, on the one hand, many educated women would choose to work as domestic helpers overseas. On the other hand, many professionally trained Filipinos would migrate to other Southeast Asian countries, the European Union or the USA to be teachers, nurses and doctors. For other countries with handicapped education systems and a vast pool of unskilled labour, youth unemployment rate maybe very high. Idle youth can represent forgone economic productivity and also contribute to social problems, such as violence and drug abuse.
There are two additional key issues related to tackling employment creation and skills mismatch. First, the informal economy, which includes mobile food stalls, small roadside shops and motorbike repair stations, represents a large (and growing) proportion of economic activities in developing countries. Most “workers” in the informal economy are sole proprietors or “own-account workers” with small and unstable income. Since their work requires low levels of skills, there is little incentive to obtain training. As many development economists have suggested, one solution to limited wage employment in the formal sector is to “formalize the informal sector.” Take the example of newspaper sellers on the roadside. Instead of having many small independent street vendors, there can be a large newspaper distribution company that hires these vendors (and they can wear a uniform, etc.). As formal employees, their welfare, wages and work conditions can be better monitored. With clearer job descriptions as formal sector employees, then employers, workers and training institutions can better pinpoint the areas of training needed.
The second issue related to the quality of education and training necessary to facilitate decent employment. More precisely, some mechanisms for obtaining professional certifications and qualifications, either through exams or coursework, would be needed. In many developed countries and some developing countries, there is a complex National Qualifications Framework, which specifies the various levels of skills in particular professions. The process of developing the framework can take years, but such accreditation and certification procedure would be crucial for making training courses widely recognized by employers. With clear guidelines for training, vocational training institutions nationwide can standardize their curriculum and employers can also predict the level of skills their new employees possess.
All in all, this brief article puts on the table several key issues to industrial development that must be discussed in detail in the future. The skills mismatch that propelled the migration of Filipinos is not an isolated case. This mismatch is indicative of the uneven pace of industrial growth and education reform. Its solution requires such multi-faceted and coordinated policies as “formalization” and skills standards formulation.
References
Cristina Martinez-Fernandez and Marcus Powell, "Employment and Skills Strategies in Southeast Asia: Setting the Scene," OECD LEED Programme, July 2009.
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