Just as real progress was being made, Cambodia is experiencing a tuberculosis funding gap at precisely the wrong time
By Leigh Ferguson Photography by Lucas Veuve and Leigh Ferguson
It is a particularly hot day on the outskirts of Phnom Penh, with no shade to provide some respite for Nhean Sophana during a trip to one of his patients’ homes in Choum Chao district. Kicking up a cloud of rust-coloured dust as he arrives on a motorbike, Nhean steps off and turns his gaze toward a familiar shack fashioned out of rusted metal and crooked wooden sticks.
Nhean is a locally based employee of Operation Asha, or OpASHA, an organisation established in 2010 and dedicated to making treatment for tuberculosis (TB) available to some of Cambodia’s most disadvantaged patients. With the highest mortality rate and second-highest prevalence of TB in the world, after South Africa, the disease is one of Cambodia’s biggest health issues.
Rummaging through his bag, Nhean pulls out a small, yellow card and a container of medicine for his patient, 33-year-old Soung Ratanak, for whom extra pulmonary tuberculosis was first diagnosed six months ago, causing his health to decline rapidly. Nhean asks Soung various questions, ticking and crossing boxes on the yellow card as he goes. He then repacks his heavy backpack, which is brimming with paperwork, and heads out to begin the tiring journey back to the OpASHA medical centre to input the data, which will later be transferred to the NGO’s headquarters.
This cumbersome record-keeping and paperwork will soon become a thing of the past for Nhean and his colleagues. OpASHA is currently piloting innovative information and communications technology (ICT) tools to integrate the process of TB services from diagnosis to cure. The ICT trials include a case-finding and contact-tracing app, lab alerts to improve early access and a biometrics system called ECompliance that uses a fingerprint reader attached to a tablet to improve patient monitoring.
Field supervisors such as Nhean will go door-to-door, using ECompliance to register new patients’ fingerprints and access existing patients’ medical histories. Their medical condition and history will be screened and their geographical location will be retained in a GPS system. If field supervisors notice an excessive number of ‘red dots’ in an area, indicating an outbreak, OpASHA can go there and intervene.
The organisation successfully implemented this same system in India three years ago, and figures have shown a decrease in the percentage of patients receiving incorrect medication. A finger scanner costs $70 and a tablet goes for about $250, meaning these new ICT tools could revolutionise the fight against TB in the Kingdom.
“Everything is synchronised with the central database every day and this creates an electronic medical record,” says Jacqueline Chen, country director for OpASHA Cambodia. “It’s web-based, so it can be accessed anywhere.”
In a developing country such as Cambodia, paper-based record systems are still widely used, allowing for human error and omissions to be made that can result in patients missing follow-up appointments for weeks at a time.
“It gets really tedious having to transport [the files] everywhere,” says Chen. “By the end of the month when you actually have the data, the patient could have misdosed for two weeks. This new technology is real-time data and allows us to make sure the patient is always getting what is required.”
Chen stresses the importance of regular and correct treatment to ensure patients do not develop multi-drug-resistant TB, or MDR-TB. This new disease is a growing concern, and the World Health Organisation (WHO) predicts there could be as many as two million drug-resistant cases worldwide by next year.
So far, the Kingdom has seen a steady decrease in TB infection rates, thanks in part to free screenings and treatment provided by the government. By 2012, mortality rates had been reduced by 50% – three years earlier than the target set by the WHO. Despite such progress, there have also been large funding cuts. From 2011 to 2013, Cambodia was receiving a steady $12 million per year in overall TB funding, which has dropped to $8 million this year.
In a speech last year that pushed for funding post-2014, WHO director Margaret Chan said: “We are treading water at a time when we desperately need to scale up our response to MDR-TB.”
It is not only Cambodia that is feeling the repercussions of this reduced support, much of which came from the Global Fund to Fight Aids, Tuberculosis and Malaria. The Global Fund and the WHO have identified an anticipated gap of $1.6 billion worldwide in annual international support for the fight against TB in low- to middle-income countries. According to Dr Rajendra Yadav, a medical officer for the WHO’s Stop TB programme, Cambodia’s government needs to step up to the plate with funding for TB cure and prevention. To illustrate the situation with a comparison, the Philippine government gives $25 million per year to combating TB, while the Cambodian government pledges
$1.5 million. “Cambodia has been doing well despite its low budget… but it’s just not good enough,” says Yadav, adding that the Kingdom is in great need of assistance from external resources.
Grant cuts may see the spread of the contagious disease spiral out of control and send the country back down a deadly path. “TB is very funding-dependent, and cuts in funding will have repercussions,” says Chen.
Yadav agrees, saying that the current cash shortage is one of the key factors that has caused the diagnosis of cases to drop by a staggering 8-10% each year. “The funding is going down, and so, proportionately, case finding is going down too. This then creates more cases, and when we are not finding and treating these cases, the disease is then spreading and transferring to the rest of the community,” he explains.
Current screening methods are inadequate, with 30% of TB cases being missed globally every year, according to the WHO. Yadav argues this is largely due to microscopy equipment being outdated. “We are basically using the same equipment as a hundred years ago,” he says, referring to Robert Koch’s first use of the microscope to diagnose TB in 1882. Yadav also mentions the difficulty in reaching the “poorest of the poor” and notes that these individuals’ lack of access to screening centres is also hindering Cambodia’s fight against TB.
Alongside the spread of the regular TB strain, MDR-TB is proving to be a growing concern amid gaps in the treatment process. It is a “dangerous global threat”, according to Momcilo Orlovic, communications officer at Unitaid, a non-profit organisation that assists with financing for HIV/Aids, malaria and tuberculosis. “Only 50% of those who endure the gruelling two-years of treatment are cured,” he says.
Innovative and more accurate treatment and diagnosis technology is readily available, if funding can be sourced. Alongside the biometrics system, state-of-the-art GeneXpert machines – technology that shortens the diagnosis time for MDR-TB from weeks to just a few hours – are slowly being introduced to Cambodia. So far, the WHO’s Stop TB programme has distributed 18 GeneXpert machines across the Kingdom – 11 of them are ‘fixed’ in the largest referral hospitals and seven are mobile. Yadav hopes that with more funding they can increase this number to 82 machines, ideally having one in every referral hospital. “The improvements in testing are encouraging, although we need to do better as access to MDR-TB testing is still very low at around 20%,” said Philippe Duneton, executive director at Unitaid. “But the challenge is also to have simpler, shorter, more affordable drug regimens against MDR-TB,” he added.
OpASHA’s model for patient monitoring is a cost-effective one, with expenses sitting at about $87 for a full six-month round of tuberculosis treatment, and there are already four finger scanners and tablets being successfully utilised in various regions throughout Cambodia. The finger-scanning system is also being improved upon already, undergoing revision to increase its sensitivity, as TB prevalence is high among the impoverished, who are often manual workers and therefore have less distinct fingerprints.
ICT tools in TB screening, diagnosis and treatment will ensure that people such as Nhean’s patient Soung have a greater chance of a full recovery through a more regulated treatment process and home visits. “I feel tired, but I have courage now that I can afford to get daily treatment,” explains Soung. “I look forward to going back to work and selling shellfish, and being able to care for my two sons.”
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