Cambodia turns a TB health crisis into an opportunity
Twenty years ago, Cambodia had one of the world’s highest tuberculosis (TB) rates and a health system weakened by decades of conflict and economic hardship. Over the past decade, however, new approaches that provide universal access to TB care through primary health centres have halved the number of new cases and helped the country meet global targets for detection and treatment.
“These results are a major achievement for TB control. They prove that in low-income settings persistence, commitment and competence do succeed in saving lives,” says Dr Mario Raviglione, Director of WHO’s Stop TB Department. Cambodia’s success story is highlighted in the Global Tuberculosis Report 2012 published by WHO.
Health system in tatters
In the early 1990s, Cambodia was struggling with a health system left in tatters after decades of civil war and Khmer Rouge rule. Much of the infrastructure had been destroyed and fewer than 50 doctors were left practicing from a former workforce of around 600.
Cambodia had one of the highest TB infection rates in the world. Diagnosis and treatment services were only available in hospitals, and many people did not seek care because they could not afford the cost of travel and accommodation for the 12–18 months of treatment required at that time. Others waited until they were very sick before going to hospital, infecting many more people in the meantime and making treatment much more challenging.
A new approach
In 1993, the global focus on the resurgence of TB worldwide triggered the newly elected government to relaunch its national TB programme with strong support from the recently re-established WHO country office.
Five years later, a radical reconfiguration of the Cambodian health system cut the number of hospitals and created decentralized health services for the communities. “This reform provided the perfect opportunity to change the way TB services were delivered,” says Dr Pieter van Maaren, WHO Representative in Cambodia.
Cambodia has now transformed its TB programme from a hospital-based system to one that provides free, universal access to TB care at the grassroots level. At the core of the new approach was the WHO-recommended DOTS (Directly Observed Therapy – Short Course), with its emphasis on supporting TB patients as they follow a six-month treatment regimen.
Rapid DOTS expansion
Since the turn of the century, health system reforms have dramatically expanded access to primary health care. The number of community-based health centres providing free, DOTS-based TB services surged from 60 in 2000 to around 1000 across the country by 2005. Over the same timeframe, the number of health workers trained in TB control increased from 800 to 2500. By 2005, Cambodia had achieved global TB targets of 70% case detection rate and 85% treatment success.
“Cambodia changed a health crisis into an opportunity,” says Dr Ikushi Onozaki, from WHO’s Stop TB Department.
An evidence-based approach
“The new approach was firmly based on scientific evidence,” he says. In 2002, a survey of more than 30 000 people confirmed that Cambodia had one of the highest TB prevalence rates in the world, with more than 1500 cases per 100 000 people. Onozaki says this survey gave TB “visibility” within and outside the country – and helped to define the problem, map out local conditions, guide resource allocation and attract international attention.
As this and other surveys gathered evidence to measure disease, they also provided the impetus to generate “know-how” in the more than 50 villages where they were conducted. Health workers and affected people saw X-ray imaging and evaluation on-the-spot, best practices to collect and evaluate sputum samples, and learnt when to refer samples to hospitals for further analysis.
Experts from WHO and Japan International Cooperation Agency (JICA) worked closely with the Ministry of Health to adapt the global strategy for TB control to meet local needs and conditions. Pilot studies tested interventions in targeted communities before they were expanded on a national scale. These studies were instrumental in training village “DOTS watchers” who could help detect TB early so that people could be treated effectively at home, with local support and reduced spread of infection.
A second national survey in 2011 found TB prevalence had fallen from the 2002 rate of more than 1500 cases to 820 cases per 100 000 people – a 45% reduction in nine years.
“Starting from a baseline of zero, within five years DOTS was being used to treat TB virtually everywhere, which is quite an achievement,” says van Maaren. “But TB control is about more than just getting pills into patients. A lot of aspects must come together to achieve sustainable success. ”
Keys to success
Dr Mao Tan Eang, national TB programme manager in the Cambodian Ministry of Health, says that the TB programme owes its success to a clear evidence-based policy and plan, strong technical expertise, government commitment and leadership, as well as sustained support from international donors and partners, including WHO, JICA, the World Bank, United Nations World Food Programme, the United States Agency for International Development, United States Centers for Disease Control and Prevention and the Global Fund to Fight AIDS, Tuberculosis and Malaria.
“Cambodia’s success in providing universal access to TB care and treatment is remarkable but there is still a long way to go,” says van Maaren. “Many people are infected and public health work to detect and treat the disease will be needed for a long, long time.”