Cambodia

Cambodia ranks 21st on the list of 22 high-burden tuberculosis (TB) countries in the world. An estimated 64 percent of Cambodians are infected with TB, and a substantial number of cases remain undetected. As of 2006, around 13,000 Cambodians die annually from the disease. There were more than 70,000 new TB cases in Cambodia in 2006, with an estimated incidence rate of 500 cases per 100,000 population. The National TB Control Program (NTCP) began DOTS (directly observed treatment, short course) implementation in 1994 and by 2004, DOTS coverage reached 100 percent. Although there is a high burden of disease, the TB situation in Cambodia has remained relatively stable over the past five years. The country has maintained a TB case detection rate of nearly 60 percent and a treatment success rate of more than 90 percent, although cure rates vary dramatically across provinces. Case detection has fallen after reaching 68 percent in 2005. It is not clear if the decline is due to a drop in incidence or problems with case finding. Increasing the participation of community members to refer and supervise TB patients and collaborating with the private sector will likely improve case finding.

The 2008 World Health Organization (WHO) Anti-Tuberculosis Drug Resistance in the World Report does not report multidrug-resistant (MDR) TB, although preliminary results from the ongoing second National Tuberculosis Drug Resistance Survey show that cases of MDR-TB have appeared and around 60 patients are being treated for MDR-TB. HIV prevalence among new TB cases is 9.6 percent, very high compared with the national HIV prevalence of 0.8 percent. HIV co-infection among new cases is also high compared with the WHO regional average but just below the average of 11.0 percent for the high-burden countries.

USAID Approach and Key Activities

USAID, through the Tuberculosis Control Assistance Program (TB CAP); the Program for Appropriate Technology in Health (PATH); the Reproductive and Child Health Alliance (RACHA); and the Reproductive Health Association of Cambodia (RHAC), works closely with the NTCP and ground-level partners to implement the government’s National Health Strategic Plan for TB Control in Cambodia, 2006–2010. USAID support began in 2001; funding for TB programming between 2001 and 2006 averaged $2 million per year and increased to $3.4 million in fiscal year (FY) 2007. TB CAP implements targeted interventions that address the major challenges and gaps identified by the NTCP, particularly focusing on strengthening the quality of DOTS and TB-HIV/AIDS collaborative activities. PATH supports a public-private mix (PPM) strategy, which aims to strengthen both the public and private sectors in TB case management and case detection, since approximately 60 percent of people with suspected TB first visit private sector providers. RHAC and RACHA focus on increasing community participation in TB control through community-based DOTS (C-DOTS). USAID activities include:

• Developing new approaches for engaging all care providers, including staff in pharmacies, private consultation offices, clinics, and laboratories, in TB control
• Supporting the nationwide scale-up of PPM activities that builds on a successful model that uses providers to increase TB case detection
• Supporting the expansion of C-DOTS programs to increase access to DOTS at the community level and in rural areas
• Investing in technical assistance for drug management and logistics
• Strengthening collaborative TB-HIV/AIDS activities and improving services for people with co-infection
• Increasing laboratory capacity for high-quality drug susceptibility testing and supporting external quality assessment of sputum microscopy, helping to ensure that MDR-TB can be diagnosed
• Strengthening links between PPM pharmacies, DOTS formal health services, and communities by increasing the skills of pharmacy staff in private and public sectors to identify and refer suspected TB cases to DOTS service centers
• Developing a case management model for HIV-positive patients to ensure linkages to TB screening and treatment
• Supporting the design and implementation of advocacy, communication, and social mobilization activities in order to create political, public, and community-level support for TB control
• Identifying and sharing innovative ways in which communities and nongovernmental organizations (NGOs) can expand DOTS to increase referral of suspect TB cases

USAID Program Achievements

Cambodia has made significant progress in its TB control program. USAID program achievements include the following:

• Increased C-DOTS coverage in 26 operational districts to 299 health centers, one-third of all health centers in Cambodia in FY 2007
• Increased the number of villages with trained DOTS watcher networks from 2,393 to 3,686 between FY 2006 and FY 2007
• Trained more than 7,128 health center staff, private providers, and volunteers in DOTS in FY 2007
• Supported the initial pilot and expansion of the TB PPM network from zero to 11 provinces between FY 2005 and FY 2007, resulting in more than 400 private providers, more than 40 private laboratories, and 884 pharmacies being engaged, and 777 new TB cases being identified
• Provided technical support to the NTCP for laboratory improvements and treatment guidance, which has helped maintain high levels of treatment success rates
• Helped the Ministry of Health improve the collaboration of TB-HIV/AIDS programs at the national and provincial levels and expand implementation of TB-HIV/AIDS co-infection activities
• Supported the National TB-HIV Workshop in May 2007, which brought together NTCP and National AIDS Program staff, NGOs, and other development partners, to develop the revised national TB-HIV framework
• Developed TB-HIV/AIDS clinical guidelines and a training curriculum package that will strengthen capacity for clinical management of TB-HIV/AIDS co-infected patients and will be disseminated nationally

Case Detection and Treatment Success Rates Under DOTS

Note: DOTS treatment success rate for 2006 will be reported in the 2009 Global Report. Source: Global Tuberculosis Control: Surveillance, planning, financing:WHO Report 2008.

Partnerships

USAID works in close collaboration with the NTCP, the Japan International Cooperation Agency, WHO, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. WHO leads the technical collaboration of external partners in Cambodia. TB CAP is implemented by the KNCV Tuberculosis Foundation and its partners in the Tuberculosis Coalition for Technical Assistance. The Japanese Anti-Tuberculosis Association is the coordinating partner for TB CAP in Cambodia. Other USAID supported partners which contribute to work in TB include PATH, RACHA, and RHAC. The World Food Programme contributes food to a nutritional support intervention for TB patients. The Global Fund awarded Cambodia a $6.2 million grant in Round 2 for DOTS expansion and a $3.7 million grant in Round 5 for TB and TB-HIV/AIDS co-infected patients in underserved areas. Funding for Round 7 has been approved and will be used to expand C-DOTS and improve TB-HIV/AIDS coordination and treatment services.

January 2009

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Related Links

• USAID Overview of Cambodia