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COMPREHENSIVE APPROACH TO DOTS EXPANSION IN CAMBODIA

This article discusses the implementation and impact of a comprehensive approach to expanding the DOTS (Directly Observed Treatment, Short-course) strategy for tuberculosis control in Cambodia. It also highlights the achievements, challenges, and targets for the National Tuberculosis Program.

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COMPREHENSIVE APPROACH TO DOTS EXPANSION IN CAMBODIA

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  1. COMPREHENSIVE APPROACH TO DOTS EXPANSION IN CAMBODIA 4th DOTS Expansion WG Meeting Hague 7-8 / 10 / 2003Dr. Mao Tan Eang Director National Center for TB and Leprosy Control (CENAT), MoH, Cambodia

  2. I.Background A. General • Location :Western Pacific region, bordering with Thailand, Lao PDR and Viet Nam • Land area : 181 035 Km2 ( 24 provinces, 183 districts, ~1600 communes) • Population : 13 Million (in 2003) - 15.7 % in Urban & 84.3% in Rural - Under 15: 43% & Over 65 : 3.5 - Growth rate : 2.5% - Crude birth rate : 3.8% - Total fertility rate : 5.3 • GDP (1999) :US$ 310 per Capita • Adult Literacy Rate : 67.3 ( 79.5: male: 57: female )

  3. B.Tuberculosis • TB is a priority disease of MoH • High burden country among 22 in the world • NTP established since 1980 • High incidence and prevalence - Incidence rate of Sm+ TB (BK+) : 241/100,000 pop. - Incidence rate of all forms : 540/100,000 pop. • Death rate : 90/100,000 pop. ~ 10,000 deaths • HIV among TB patients: also high:8.4% in 2002 • TB cases will increase in the coming years,

  4. Before the reform(1995) 4 Levels: Central, Province, Disrict & Commune Based on administrative criteria Facilities: - Central MoH, Centers and Institutions - 8 Nat. Hosp. - 23 Prov. Hosp. - 164 Dist. Hosp. - 1267 Commune clinics After the reform New Health System: 3 Levels: Central, Province,Operational District (OD) Based on population & geography : Health Coverage Plan73 ODs Planned Facilities: - Central MoH, Centers and Institutions - 8Nat. Hosp. - 23 Prov. Referral Hosp. - 44 Dist. Referral Hosp. - 946 Health Centers II. Health Sector Reform

  5. III. DOTS Expansion in Cambodia DOTS started in Cambodia since 1994 • 3 Types of DOT: Hospitalization, Ambulatory and At home • From 1994 till 1999 • mainly DOT hospitalization • up to 1999 there were 145 TB Units in RH and HC former district public hospitals • Home care DOT:pilot in Phnom Penh since ‘ 97 • DOTS expansion to HC level: Why ? Start from Pilot project: • in September 1999 started in 9 HCs (CENAT/JICA):Ambulatory DOT  Evaluation  good result

  6. Comprehensive Approach for DOTS Expansion to HC: Systematic process: * Establishment of DOTS Expansion teams * Activities - Preparation visit: situation analysis - Sensitizing workshop: to get consensus - Technical training : to HC staff - Meeting before implementation: technique & logistics - Implementation: monitoring & supervision - Assessment workshop: after 3 month implementation - Routine monitoring and evaluation : biannual, yearly..

  7. Implementation Status • in 2000, expanding to 60 HCs (in 4 Model ODs) • 2001, National DOTS Expansion Plan adopted as part of Global DOTS Expansion Plan • By the end of 2001: 264 HC were providing DOTS • By the end of 2002: 386 HC were providing DOTS • Now 700 HC provide DOTS on top of 78 HC/FDH and out of 814 HC MPA ( 82%) • Plan for 2004 and 2005: cover all remaining health centers

  8. Impact of DOTS Expansion to HC • Increase case detection from 51 % to 57% • Economic impact: • reduction treatment related cost (e.g travel cost…) : amount ? • Increase income of patient family: amount ? • Impact on general health service utilization: may be increasing • Others :…..

  9. V . Other NTP Achievements • Policies & Strategies for TB Control 2001-2005 • Strategic Plan for TB Control 2001-2005 • TB Multi-Drug Resistance Survey • TB Prevalence Survey • TB/HIV Service in CENAT • Inter-agency Coordination Committee for TB Control (ICC)

  10. VI. Main Targets 2001-2005

  11. VII. Challenges for DOTS Expansion • Staff capacity and motivation • Service Quality VS free -of- charge services • Resources implication: human, $, material • TB/HIV • TB in children & Extra-pul. TB • Involvement of community, private sector including NGO and other institutions • IEC activities

  12. Thank You

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