Twenty years ago, Cambodia had one of the world’s highest tuberculosis (TB) rates and a health system weakened by decades of conflict and economic hardship. Over the past decade, however, new approaches that provide universal access to TB care through primary health centres have halved the number of new cases and helped the country meet global targets for detection and treatment.
“These results are a major achievement for TB control. They prove that in low-income settings persistence, commitment and competence do succeed in saving lives,” says Dr Mario Raviglione, Director of WHO’s Stop TB Department.
Health system in tatters
In the early 1990s, Cambodia was struggling with a health system left in tatters after decades of civil war and Khmer Rouge rule. Much of the infrastructure had been destroyed and fewer than 50 doctors were left practicing from a former workforce of around 600.
Cambodia had one of the highest TB infection rates in the world. Diagnosis and treatment services were only available in hospitals, and many people did not seek care because they could not afford the cost of travel and accommodation for the 12–18 months of treatment required at that time. Others waited until they were very sick before going to hospital, infecting many more people in the meantime and making treatment much more challenging.
A new approach
In 1993, the global focus on the resurgence of TB worldwide triggered the newly elected government to relaunch its national TB programme with strong support from the recently re-established WHO country office.
Five years later, a radical reconfiguration of the Cambodian health system cut the number of hospitals and created decentralized health services for the communities. “This reform provided the perfect opportunity to change the way TB services were delivered,” says Dr Pieter van Maaren, WHO Representative in Cambodia.
Cambodia has now transformed its TB programme from a hospital-based system to one that provides free, universal access to TB care at the grassroots level. At the core of the new approach was the WHO-recommended DOTS (Directly Observed Therapy – Short Course), with its emphasis on supporting TB patients as they follow a six-month treatment regimen.