Tuberculosis active case finding in Cambodia: a pragmatic, cost-effectiveness comparison of three implementation models.

BACKGROUND: Globally, almost 40% of tuberculosis (TB) patients remain undiagnosed, and those that are diagnosed often experience prolonged delays before initiating correct treatment, leading to ongoing transmission. While there is a push for active case finding (ACF) to improve early detection and treatment of TB, there is extremely limited evidence about the relative cost-effectiveness of different ACF implementation models. Cambodia presents a unique opportunity for addressing this gap in evidence as ACF has been implemented using different models, but no comparisons have been conducted. The objective of our study is to contribute to knowledge and methodology on comparing cost-effectiveness of alternative ACF implementation models from the health service perspective, using programmatic data, in order to inform national policy and practice. METHODS: We retrospectively compared three distinct ACF implementation models - door to door symptom screening in urban slums, checking contacts of TB patients, and door to door symptom screening focusing on rural populations aged above 55 - in terms of the number of new bacteriologically-positive pulmonary TB cases diagnosed and the cost of implementation assuming activities are conducted by the national TB program of Cambodia. We calculated the cost per additional case detected using the alternative ACF models. RESULTS: Our analysis, which is the first of its kind for TB, revealed that the ACF model based on door to door screening in poor urban areas of Phnom Penh was the most cost-effective (249 USD per case detected, 737 cases diagnosed), followed by the model based on testing contacts of TB patients (308 USD per case detected, 807 cases diagnosed), and symptomatic screening of older rural populations (316 USD per case detected, 397 cases diagnosed). CONCLUSIONS: Our study provides new evidence on the relative effectiveness and economics of three implementation models for enhanced TB case finding, in line with calls for data from 'routine conditions' to be included in disease control program strategic planning. Such cost-effectiveness comparisons are essential to inform resource allocation decisions of national policy makers in resource constraint settings. We applied a novel, pragmatic methodological approach, which was designed to provide results that are directly relevant to policy makers, costing the interventions from Cambodia's national TB program's perspective and using case finding data from implementation activities, rather than experimental settings

Are health workers motivated by income? Job motivation of Cambodian primary health workers implementing performance-based financing

Background: Financial incentives are widely used in performance-based financing (PBF) schemes, but their contribution to health workers’ incomes and job motivation is poorly understood. Cambodia undertook health sector reform from the middle of 2009 and PBF was employed as a part of the reform process. Objective: This study examines job motivation for primary health workers (PHWs) under PBF reform in Cambodia and assesses the relationship between job motivation and income. Design: A cross-sectional self-administered survey was conducted on 266 PHWs, from 54 health centers in the 15 districts involved in the reform. The health workers were asked to report all sources of income from public sector jobs and provide answers to 20 items related to job motivation. Factor analysis was conducted to identify the latent variables of job motivation. Factors associated with motivation were identified through multivariable regression. Results: PHWs reported multiple sources of income and an average total income of US$190 per month. Financial incentives under the PBF scheme account for 42% of the average total income. PHWs had an index motivation score of 4.9 (on a scale from one to six), suggesting they had generally high job motivation that was related to a sense of community service, respect, and job benefits. Regression analysis indicated that income and the perception of a fair distribution of incentives were both statistically significant in association with higher job motivation scores. Conclusions: Financial incentives used in the reform formed a significant part of health workers’ income and influenced their job motivation. Improving job motivation requires fixing payment mechanisms and increasing the size of incentives. PBF is more likely to succeed when income, training needs, and the desire for a sense of community service are addressed and institutionalized within the health system

Strengthening the management and provision of public health services: an investigation of the recent healthcare reform using internal contracting in Cambodia

© 2013 Dr. Keovathanak KhimIntroduction: Contracting, regarded as one of innovative approaches, has been used to address these issues. As part of larger national reform strategies to address poor public services, Cambodian government has piloted internal contracting as an approach to improve the management of district health system and services. The approach means parties from the same legal entity enter into a contract that is relational and based on trust and existing relationship. In Cambodia, a third of health districts, nominated as “Special Operating Agency - SOA”, are granted a semi-autonomous status with a greater degree of flexibility for decision-making. They receive additional funding to provide staff with financial incentives, recruit additional staff and engage communities and users. Using the Cambodian reform as a case study, this thesis examines the effectiveness of this approach in improving the management and provision of district health services. The effectiveness is judged by its being appropriate to and implementable in the context and able to overcome constraints and improve the conditions of staff and organisations, and the performance of service provision. It describes the design of the internal contracting arrangement, examines the implementation, changes in staff income and motivation, and assesses changes in the provision of primary health services. Methods: I reviewed the literature and available documents related to the reform, analysed data from interviews with officials and from a cross-sectional survey of 266 primary health care staff. Routine service data on child immunisation, antenatal care at second visit, newborn delivery by trained staff and outpatient consultation from four SOA districts were used to assess changes in primary care services before and after the reform. Findings: The implementation of internal contracting enabled facilities to maintain service delivery outputs elevated through other forms of contracting before the introduction of the current reform. The additional funding, carefully managed and utilised, made it possible to pay staff incentive; it along with performance contract made it possible to improve accountability addressing their underperformances and the functioning of health facilities. The incentive, albeit low, contributed to staff income and motivation. Coupled with job monitoring, incentive dissuaded many from private practice. Several challenges remained. System, tools and resources for management of performance and incentive and for contract monitoring were inadequate. Resource provision has been improved, but transparency of funding flow and information sharing was insufficient to tackle delays and cuts. Improvement in working conditions and organisational conditions was not optimal and their deficiencies continued to constrain staff performance. Analysis of provision primary care services (outpatient consultation, child immunisation, antenatal care and newborn delivery) showed mixed results, with most of the services increasing and stabilising after the introduction of the internal contracting. Conclusions: Internal contracting, when carefully packaged and designed, is effective in enhancing and sustaining service delivery for the long term. Adequate systems and tools for implementing performance contracts and managing resources are pre-requisites for improving staff performance and service delivery. Fine-tuning of the governance structure and the arrangements to ensure integrity of resource management and improve monitoring function would likely result in increased effectiveness of the local health system and service provision

Cambodia (2004): MAP Study Evaluating the Coverage and Quality of Coverage of Malaria Prevention, Diagnostic, and Treatment Products. First Round.

In June 2004, Population Services International in Cambodia (PSI/Cambodia) conducted a Project MAP survey to identify the baseline coverage of Malaria diagnosis, prevention, and treatment products. Coverage indicates geographic access by users from retail outlets. The fundamental goal of this process was to assist in refining and expanding an existing social marketing program by clarifying the status of product placements and exposing strengths and weaknesses in the market. The survey investigated all available malaria treatments, including Malarine for Children (called Malarine-3 at the time of fieldwork) and Malarine for Adults (called Malarine-4 at the time of fieldwork), Rapid Diagnosis Tests (RDTs; including Paracheck/Malacheck), untreated bednets, insecticide treated bednets, and insecticide treatment kits. Lot Quality Assurance Sampling (LQAS) was used for data analysis. LQAS is a statistical method that combines a sampling framework and one-sided hypothesis testing for data analysis that allows for the sample selected from each lot to be quite small, while still providing valid and useful results

Cambodia (2005): MAP Study Evaluating Coverage and Quality of Coverage of Hormonal Contraceptives and Condoms in Urban and Rural Areas First Round

Project Measuring Access and Performance (MAP) aims to assess or gauge the coverage, quality, equity of access and efficiency of product social marketing and service delivery systems. Project MAP was undertaken to determine the coverage and quality of coverage of PSI/Cambodia's HIV and birth spacing (BS) products (Number One Condom, Number One-Plus Condom, OK Condom, OK Pill and OK Injection) in rural, urban, and Phnom Penh areas. Lot Quality Assurance Sampling (LQAS) was used to draw a sample of 19 areas within each geographic category. Geographic categories in which data were collected are: Rural areas (nineteen villages), an urban area (Kampong Cham provincial town; selected randomly from among all provincial capitals, and divided into nineteen zones) and a hyper urban area, Phnom Penh (nineteen Sangkats)

Medical injection and infusion practices among HIV-seronegative people and people living with HIV: a behavioural survey of 10 HIV testing and opportunistic infections/antiretroviral therapy sites in Cambodia

ObjectivesIn late 2014, an HIV outbreak occurred in rural Cambodia among villagers who received medical injections from unlicensed medical providers, justifying the need to assess medical injection practices among those who are at risk of acquiring and/or transmitting HIV. This study examined medical injection/infusion behaviours among people living with HIV (PLWH) and those who were HIV negative in Cambodia. These behaviours should be properly assessed, especially among PLWH, as their prevalence might influence a future risk of other outbreaks.DesignA cross-sectional survey was conducted in order to examine injection behaviours and estimate injection prevalence and rates by HIV status. Unsafe injections/infusions were those received from village providers who do not work at a health centre or hospital, or traditional providers at the participant's (self-injection included) or provider's home. Logistic regression was performed to examine the relationship between unsafe injection/infusion and HIV, adjusting for sex, age, education, occupation, residence location and other risk factors.SettingThe survey was conducted in 10 HIV testing and treatment hospitals/clinics across selected provinces in Cambodia, from February to March 2017.ParticipantsA total number of 500 volunteers participated in the survey, 250 PLWH and 250 HIV-negative individuals.Outcome measuresMeasures of injection prevalence and other risk behaviours were based on self-reports.ResultsBoth groups of participants reported similar past year's injection/infusion use, 47% (n=66) among PLWH and 54% (n=110) HIV-negative participants (p=0.24). However, 15% (n=11) of PLWH reported having received unsafe last injection compared with only 7% (n=11) of HIV-negative participants. In logistic regression, this association remained numerically positive, but was not statistically significant (adjusted OR 1.84 (95% CI: 0.71 to 4.80)).ConclusionsThe inclination for medical injections and infusions (unsafe at times) among PLWH and the general population in Cambodia was common and could possibly represent yet another opportunity for parenteral transmission outbreak