Cambodia

Cambodia is located in southeastern Asia and had 13,881,427 inhabitants, as of 2005. It is divided into 20 provinces and four municipalities. The annual population increase is 1.8 percent. Gross domestic product per capita was estimated to be US$2,200 in 2005, but 40 percent of the population lives below the poverty line. The unemployment rate is 2.5 percent.

Cambodia is one of the world’s 22 high-burden countries for TB; in the Western Pacific Region, it is ranked fourth. The 2004 WHO-estimated burden of TB was 709/100,000 population for all cases and 313/100,000 population for new smear-positive cases. The government adopted the DOTS strategy in 1994 and is strongly committed to DOTS implementation. DOTS was first introduced in all referral hospitals and TB units, and then extended to nine pilot health centers. By the end of 2004, 850 health centers and 39 health posts were providing DOTS as part of the DOTS Expansion Program, whose goal was to achieve 100 percent DOTS coverage by 2005. The trend of HIV prevalence among TB patients (all forms) has shown a decrease from 11.9 percent in 2003 to ten percent in 2005.

TB CAP Highlights Cambodia

Diagnostic Capacity Improvement
Through TB CAP, an activity called Diagnostic Capacity Improvement has been introduced to strengthen the capacity of NTP staff in TB diagnosis. The Diagnostic Capacity Improvement covers laboratory quarterly based EQA, strengthening culture and DST capacity, establishing diagnostic committees for smear negative TB cases. In 2006, before the start of this activity, only 54 of the total 201 TB laboratories were participating in quarterly based EQA, this increased to 115 laboratories by the end of 2007. With the technical assistance support from TB CAP and other partners, laboratory quarterly EQA has been successfully decentralized to provincial level and the EQA system was set up for implementation. It should be noted that no reliable data on laboratory performance is available for the baseline year 2006. The result from EQA shows that the total agreement rate is high as 97.9% in 2007 and 98.3% in 2008 and the number of laboratories performing TB microscopy with over 95% correct microscopy is 74% in 2007 and 74.3% in 2008. Furthermore, the quality of smear preparation has improved remarkably compared to baseline: quality of sputum increased from 53.4% to 68%, smear size from 39.2% to 70%, smear thickness from 36.5% to 50% and smear evenness from 32.2% to 40%.

TB CAP has also strengthened the culture and DST services. Now the NTP has 3 regional culture centers with trained staff. CENAT/NTP central laboratory has capacity to conduct DST for Drug Resistance. To strengthen the diagnosis of sputum smear negative TB cases, TB CAP has supported NTP to improve the capacity of TB physicians by developing Term of Reference for the Diagnostic Committee, a referral system and a diagnosis schedule that were not previously available. As a result, many more sputum smear negative TB suspects were referred from remote health centers to referral hospitals for diagnosis. There is 2,6 fold increase in the number of referrals and more than twice the number of TB cases diagnosed in one year.

The achievement above is the effort made by TB CAP in close collaboration with CENAT/NTP staff. To achieve this, some strategies/activities have been undertaken:

• TB CAP has been successful in bringing together partners with renowned expertise in specific areas of technical assistance to coordinate their activities in support of the NTP Cambodia
• TB CAP facilitated regular meetings of the technical working groups for laboratory, TB/HIV, and MDR-TB, which provides a good opportunity to review and coordinate activities of all partners. These technical working groups also take the lead in developing guidelines and other policy documents for the NTP through a participatory approach
• Conduct regular meeting between project staff and USAID mission to have a consensus on activities
• Joint development of EQA standard operational procedure
• Develop Terms of Reference for diagnostic committee, referral mechanism, schedule for diagnosis, referral slip
• Develop feedback sheet for improvement of quality of smear preparation
• Provide EQA training to laboratory technicians to be cross-checker and assessor
• Provide smear assessment and smear preparation training for laboratory technician and health center staff (non-laboratory technicians)
• Workshop to provide orientation for implementation
• Regular meeting with CENAT/NTP core staff to improve the implementation
• Joint regular monitoring and supervision between TB CAP staff and NTP

Despite considerable progress made by TB CAP and NTP, there are still many challenges for TB CAP to overcome such as the coordination of activities in the project that involves several partners outside Cambodia; many TB CAP activities are implemented by NTP staff with competing interests that hamper timely implementation as planned in the TB CAP work plan; TB CAP has little influence over political issues affecting NTP such as human resource planning and distribution, staff motivation and low salary.

One important challenge for TB CAP is the commitment of NTP staff towards the TB CAP. Unlike other USAID funding NGOs, TB CAP does not have many employed staff for implementation. Most of TB CAP activities have been jointly carried out by TB CAP and NTP staff. Moreover, unlike some other donors, TB CAP does not provide any incentive or salary for those who are involved in TB CAP field activities. At the same time, the salary for NTP staff is very low and cannot support the cost for their family living. And recently, the increase in inflation rate has affected the commitment of NTP staff in implementing TB CAP activities in the field since the rate of TB CAP per diem provided is still the same.

To overcome the challenge, TB CAP:

• Organizes many meetings with NTP director and his staff to explain that TB CAP is the technical assistance project that contributes to the objectives and achievement of NTP
• TB CAP provides per diem and transport cost for NTP staff to carry out activities in the fields
• Tries to coordinate for activity schedule among all TB partners so that NTP staff can implement other activities with other partners to get some earning to support their living
• Since TB CAP is the technical assistance project, in-kind incentive has been provided such as new skill training on program management, data management, laboratory, culture, DST, diagnostic capacity improvement, case management, and others.

TB CAP Project Period (2005-2010)

Expected output(s)

• Strengthened TB program leadership and management
• Improved diagnostic capacity
• Increased and strengthened TB and HIV/AIDS coordinated activities
• Strengthened and Expanded DOTS program