Cambodia achieved nationwide DOTS coverage at district level in 1998, at a time when the health services were still relatively centralized. Since then, a policy of progressive decentralization has been followed, designed to improve the access of the population to health care. With the establishment of peripheral health centres, the NTP has gradually introduced its activities in these settings, resulting in substantially improved access to TB control services. By the end of 2004, the remaining health centres will be included. A national TB prevalence survey in 2002 yielded a great deal of valuable information, which continues to be applied in strengthening the programme. Results will be published and will serve as an important basis for the assessment of the burden of TB and the impact of DOTS services on the TB epidemic. The shortage of staff to support the expanding programme is now being addressed, and there are plans to tackle the urgent need for better coordination between the TB and HIV control programmes.
System of TB control
Cambodia’s NTP operates under the responsibility of the National Center for Tuberculosis and Leprosy Control (CENAT) and within the overall national health system. It comprises TB referral hospitals, provincial TB centres and district TB units. In 1994, TB control was decentralized from provincial hospitals to district hospitals, and in 1999 to health centres. As of 2003, more than 145 TB units and 700 health centres are implementing the DOTS strategy.
There are 180 laboratories in the country including the TB reference laboratory of CENAT, which is responsible for the development of training materials, training of laboratory technicians, and supervision and quality assurance of the provincial laboratories. The reference laboratory carries out culture of mycobacteria and HIV testing but not regular drug susceptibility testing, which will be started in the near future. There are 24 provincial laboratories with responsibility for the supervision and training of health centre staff in sputum smear microscopy and quarterly reporting to CENAT.
Surveillance and monitoring
Cambodia’s case detection rate under DOTS was 60% in 2003, after the noticeable upturn in case detection since 2001. This assessment of the case detection rate is based on an estimate of incidence that pre-dates the 2002 prevalence survey. Analysis of the results of that survey will allow a reassessment of the burden of TB in the country and of the case detection rate. The proportion of all cases diagnosed as smear-positive in 2003 was 67%, falling from the highest recorded level of 82% in 1999, possibly because of improvements in diagnosis (fewer false-positives).
The treatment success rate reported among new smear-positive cases has exceeded 90% since 1995, which is unusually high given that 13% of TB patients were thought to be coinfected with HIV in 2003. The success rate for re-treatment patients in 2002 was also remarkably high (89%). Despite some uncertainty about case detection and treatment success, Cambodia is in a strong position to evaluate the future impact of the expanding DOTS programme on TB prevalence, incidence and deaths. As found in population-based surveys in other countries, the 2002 survey in Cambodia has yielded much more than an estimate of prevalence, including data that suggest numerous ways improving routine diagnosis and treatment.
Improving programme performance
The strong commitment of the Cambodian government to poverty elimination and health infrastructure development will have a positive effect on the control of TB in the future. Capacity building for DOTS expansion in all areas of the NTP continues to be a leading priority for the programme. In response to the low access to health services and DOTS in some areas, DOTS services were expanded to 320 additional health centres in 2003. There are plans to implement DOTS in the remaining 150 health centres by the end of 2004. A six-month short-course chemotherapy regimen has been introduced in pilot studies in three operational districts, and training in the new regimen for health-care workers will continue into 2005. A follow-up study of TB suspects detected during the 2002 prevalence survey has started and will be completed during 2004. A drug resistance survey conducted in 2000–2001 found that the prevalence of MDR-TB was negligible among new cases and 3% among re-treatment cases.
The lack of human resource capacity remains a challenge for the NTP. At the request of CENAT, a representative from KIT met with key personnel and staff focus groups to assess human resource development needs in 2003. A workshop was subsequently organized to develop an outline for management training; training activities have been intensified and new staff have been recruited. There is still an urgent need for both in-country and international training for staff (including managers), and to recruit more staff. The NTP is planning to address these issues through recruitment of staff from outside the NTP with the aid of partners, making use of additional funding from the GFATM and the World Bank.
Other areas where programme performance needs to be improved are diagnostic and laboratory services, TB/HIV coordination and links with other health-care providers and the community.
Diagnostic and laboratory services
Two of 24 provincial laboratories have been upgraded during 2003 to perform culture and drug susceptibility testing. The EQA system, introduced in 2002, is still under development and must be strengthened and expanded. There are too few staff with sufficient training to run the laboratory and diagnostic services in Cambodia. During 2005, training programmes will improve technical knowledge and enhance staff motivation. Drug susceptibility testing is not available in Cambodia, but its introduction is considered a priority.
A national TB/HIV prevalence survey in 2003, carried out by the VCT service at CENAT, estimated HIV seroprevalence among TB patients at 12% (similar to the WHO estimate of 13% among adult TB patients). As yet, there are no data on TB incidence or mortality among PLWHA. TB/HIV collaborative pilot studies in four provinces included screening and treatment for TB among PLWHA, isoniazid preventive treatment for PLWHA who are infected with M. tuberculosis, surveillance of HIV in TB patients and ART for HIV-infected TB patients. A workshop to assess the pilot projects concluded that TB/HIV collaboration is hampered by the disease-specific focus of the individual programmes, the quality of TB/HIV counselling and lack of joint IEC material. IEC materials and standardized reporting and recording forms for TB/HIV activities are being developed.
Links with other health-care providers
The 2002 prevalence survey showed that among people with TB symptoms who sought any type of health care, 89% went first to the private sector (pharmacies and doctors). However, the private sector has not yet been formally involved in the NTP in Cambodia. The majority of private providers diagnose and treat TB but the quality of the services provided by them is generally poor, as shown in a study carried out by CENAT in collaboration with the Quality Assurance Project of Cambodia’s University Research Corporation. However, many private providers are interested in collaborating with the NTP, and a pilot project involving private practitioners and pharmacies will be launched in 2005.
Links with the community
Community-based DOTS has been introduced in four districts, and training started in 2004 for community-based DOT workers.
Cambodia has a diverse group of technical partners including CDC (TB/HIV pilot programme activities), JICA (training and supervision, laboratory technical support, IEC, procurement, operational research, TB/HIV), KNCV (training and workshops, community DOTS) and WHO (training and supervision, laboratory technical support, IEC, procurement, TB/HIV). The main financial partners are CIDA, GFATM, JICA, USAID, WHO and the World Bank.
Budgets and expenditures
The NTP budget has increased from about US$ 4 million in 2002 to almost US$ 7 million in 2005, in line with planned increases in case detection. Available funding almost doubled between 2002 and 2005, from about US$ 3 million in 2002 to almost US$ 6 million in 2005. This improvement is becasue of a large increase in grant funding, including from the GFATM. However, funding gaps have persisted in each year from 2002 to 2005. In both 2004 and 2005, the gap is about US$ 1 million, equivalent to about 15% of the total budget requirement. The increased budgets in 2004 and 2005 are mainly a result of higher proposed spending on TB/HIV collaborative activities, and initiatives to increase case detection and cure rates (e.g. implementation of community-based care in remote areas and active case-finding).
Reported expenditures were lower than available funding in both 2002 and 2003. On a per patient basis, the NTP budget has varied from between US$ 175 (in 2002) and US$ 220 (for 2004), while actual expenditures per patient were US$ 134 and US$ 77 in 2002 and 2003, respectively. When costs not covered by the NTP budget are included (i.e. 1200 dedicated TB hospital beds and visits to clinics for DOT and monitoring during treatment), the cost per patient treated is estimated to range from around US$ 220 to US$ 360. The total cost of TB control was about US$ 7 million in 2002. Provided the 2005 budget is fully funded and spent and the projected number of cases are treated, this will rise to almost US$ 12 million in 2005.