Demand-Side “Carelessness”

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.


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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).