TB key populations to be prioritized
The decision on what key populations would be included in this assessment were first guided by the groups delineated in the National Strategic Plan for Tuberculosis Control [6]. Figure 1 summarizes the votes among the 70 participants (five groups) at the consultative stakeholder workshop.
The estimated population size of the prioritized key populations was collated separately and presented in Table 3. In addition to the top five key populations prioritized through the stakeholder workshop, PWUD and PWID were added to the list after a thorough discussion with the project steering committee and the sub-technical working group (Table 2). Therefore, seven TB key populations were proposed to be included in this assessment and prioritized for national TB response.
Table 3 Estimated population size of tuberculosis key populations in Cambodia
Key Populations
|
Size Estimate (median)
|
Estimate reliability
|
Source
|
People living with HIV
|
72,607
|
High
|
NCHADS, 2016
|
TB contacts (household contact)
|
79,585
|
Medium
|
Average household size: 4.6 (CDHS, 2015)
Index case for the last two years of Smear+ (2015 and 2016): 22,107 (CENAT, 2017)
|
TB contacts (close contact)
|
Lower bound: 221,070
Upper bound: 331,605
|
Medium
|
A person with active TB may have interaction with on average 10-15 people if untreated (WHO, 2017)
Index case of Smear+: 22,107 (CENAT, 2017)
|
Elderly people
|
1,795,415
|
High
|
NIS, 2017
|
People with diabetes
|
Lower bound: 205,502
Upper bound: 418,090
|
Medium
|
2.9% of 25-64 (UHS/WHO, 2010)
5.9% of 30-69 (WHO, 2016)
7,086,277 aged 25-64 (NIS, 2017)
|
Prisoners
|
22,801
|
High
|
GDP, 2016
|
PWUD
|
13,000
|
High
|
NACD, 2012
|
PWID
|
1,303
|
High
|
NACD, 2012
|
Abbreviations: CDHS, Cambodia Demographic and Health Survey; CENAT, National Center for Tuberculosis and Leprosy Control; GDP, General Department of Prison; NACD, National Authority for Combating Drugs; NCHADS, National Center for HIV/AIDS, Dermatology and STD; NIS, National Institute of Statistics; PWID, people who inject drugs; PWUD, people who use drugs; TB, tuberculosis; UHS, University of Health Science; WHO, World Health Organization.
Barriers to TB services
Lack of knowledge and awareness about TB
Participants described the lack of TB knowledge and awareness as one of the major barriers to TB services. Among people living with HIV, the lack of knowledge regarding TB as a common opportunistic infection was highlighted, and they recommended that all individuals newly diagnosed with HIV should undergo TB screening. The stakeholders identified the lack of knowledge about TB services and misconception of TB risks among elderly as barriers for elderly people to access TB services. The general lack of awareness of TB was also raised by the participants when they discussed barriers faced by people with diabetes, prisoners, and PWUD/PWID.
Generally, TB is easy to spread because first of all, elderly people don’t understand about TB. Most of them said that they are coughing because of just severe cold. Then, they don’t protect themselves, because they think that their body is strong, therefore they wouldn’t have TB. (IDI with a male operational district staff)
Distance to the nearest TB clinic
A major barrier to TB services was the long travel distance between home and the closest clinic for TB services. In rural areas, IDI participants reported that it was difficult for people who do not have a motorbike or money to hire a vehicle to visit a TB clinic for screening and treatment services, although the services are free of charge, as they live far away from the nearest health center.
We treat all TB patient for Free. They only need transportation to get medication every morning at the health center. The most common issue related to the patients themselves is that they said it’s hard for them to come to the health center every morning to get medication because they don’t have transportation. Some of them live far away from the health center. (IDI with a female health center staff)
Lack of economic means
The lack of time and financial means to travel to a TB clinic may limit access to quality TB services, particularly for key populations. People with other chronic co-morbidities such as diabetes may feel demotivated to seek TB services due to financial burden as treatment and care for diabetes are mostly out-of-pocket. Participants highlighted competing work and family commitments, and some people with TB symptoms cannot afford to take time off to go to a TB clinic for screening, even if they know that TB services are 100% free.
While they are taking that TB medication or when they get side effects from the drugs, how do they have energy to work for their family’s income? Therefore, they would decide to abandon the medication. Whether they are cured or not, it’s no longer important. They would give it up to work to support their family, meaning that their treatment has already failed. They said they would die for their family’s living. (FGD with a female people living with HIV)
The competition was more apparent among women to be evaluated for TB.
Our women at home have 10 types of work, while men only go to do only one construction work. When they come back in afternoon, they say they are very tired. So women have to take care all the housework (FGD with a female people living with HIV)
Lack of implementation of TB screening guidelines and resources at health centers
While TB service providers and stakeholders noticed that prisoners have little knowledge of how to prevent TB in prisons, FGDs with prisoners and other stakeholders reported that prisoners were not always screened for TB as stated in the guidelines when they entered the prison. They reported that prisoners with TB would only get noticed by correctional officers only when they got very sick.
In my opinion, I think we should have health check-up service for them inside the prisons because we don’t know who has it, or who doesn’t. We should check on all of them, encourage them to get health check-up. (FGD with a female member of a village health support group)
Stakeholders identified a lack of resources for TB screening and diagnosis at some health centers. In these health facilities, sputum samples have to be delivered and assessed at referral hospitals resulting in delayed diagnosis.
I think that at some health centers, we are still lacking (of resources) at this point that we deliver the smears for testing at the provincial hospital. Too late. I think this is still a problem. (IDI with a female member of a village health support group)
Indication of discriminatory or coercive practices against women and key populations
There was a consensus among the stakeholders across all sites covered in the assessment that there was no discrimination against or coercive practices on people with TB from the health service providers at all levels irrespective of the gender and towards all key populations. Stigma, especially among people with TB, reportedly exists, and there have been some instances in which some degree of discrimination within their communities, especially the immediate neighborhood, exist.
They told their child to not play with my child. I heard they talked like that, and I felt really offended when they look down on my child. (FGD with a female people living with HIV)
Service providers, NGOs working on TB, and some target key populations indicated that internal stigma is sometimes a case in point, irrespective of gender.
The assessment team attempted to examine whether there were any discriminatory or coercive practices from law enforcement officers, including local authorities, towards people with TB. No reports of discriminatory or coercive practices from them onto people with TB were found.
TB policies for gender and key populations
Inclusion and recognition of gender and key populations in the national TB response
The National Strategic Plan for Tuberculosis Control (2014-2020), the principal guiding document for program interventions for the national TB response in Cambodia, specified that ‘everyone’ residing in Cambodia is entitled to access TB services free of charges [6]. In addition to the key populations outlined in Figure 1, the technical guidelines published by the National Center for Tuberculosis and Leprosy Control provided guidance to manage other vulnerable groups such as people affected by multi-drug resistance TB, children, pregnant women, and people with liver disorders [17]. There was a consensus from the consultative workshop that no key populations were excluded from the national TB response. FGDs with both TB service recipients and providers did not reveal sentiments of gender-based discrimination and violations of rights.
There are no discriminations in TB service. We treat patients for free without forcing them. (IDI with a male operational district staff)
People can get treatment voluntarily with confidentiality and without discrimination, regardless of their nationality, or whether they are poor, elderly, or small children – doctors (providers) treat them all. (IDI with a male TB survivor)
Funding sources and allocation
In Cambodia, the national TB response was predominantly funded by foreign agencies (Figure 2 and Table 4) [18]. Domestic funding remained low, but there was a sign of increment from 11% in 2012 to 18% in 2016. From the desk review and IDIs with policy makers and implementers at the national level, there were considerations for key populations such as the elderly and prisoners in the budget planning and allocation but not based on gender. There was no systematic documentation of expenditures on TB programs by gender.
Table 4 Funding sources and amount (in USD) for the national tuberculosis response
|
2012
|
2013
|
2014
|
2015
|
2016
|
Total
|
14,108,469
|
13,549,308
|
14,607,707
|
12,370,879
|
13,533,578
|
Domestic
|
1,531,870
|
1,718,114
|
1,886,609
|
2,327,395
|
2,448,770
|
GFATM
|
4,493,802
|
3,074,528
|
3,588,712
|
2,580,342
|
5,301,266
|
United States government (USAID and US-CDC)
|
5,295,632
|
5,213,800
|
5,200,000
|
4,750,000
|
4,450,000
|
Others bi-&multi-lateral donors
|
2,787,165
|
3,542,866
|
3,932,386
|
2,713,142
|
1,333,542
|
Abbreviations: GFATM, Global Fund to Fight AIDS, Tuberculosis, and Malaria; USAID, United States Agency for International Development; US-CDC, United States Center for Disease Control; USD, United States dollar.
Community participation in the national TB response
Overall, there were coordination mechanisms and platforms that enabled non-governmental and civil society organizations, development partners, and representative of key populations to participate in the design and implementation of the national TB response [19]. For instance, former TB patients and local communities actively participated in TB activities through the village health support groups. Participants of the village health support groups were trained to refer people who might have TB, support sputum collection, and support patients on treatment in the village. This community participation in the TB response formed part of the community directly observed treatment, short-course (C-DOTS) initiative, which was started in 2002 and has expanded to 861 health centers nationwide [19]. IDI participants also reaffirmed the existence of community participation in the national TB response.
We have network from the national level to department level, to operational district level, to health center, and until the Community level. At the community level, there are authorities such as village chief, commune chief, and district chief who help support us and volunteer groups in the village. (IDI with a male operational district staff)
Needs for better documentation and understanding of TB by gender and key populations
In Cambodia, there were no official estimates of the national population size of TB key populations. The precision of the currently available estimates (Table 4) needs to be periodically verified. From the desk review and IDIs with the national policy makers and implementers, CENAT conducted two national TB prevalence surveys – the first one in 2002 [20] and the most recent one in 2011 [21] to estimate the prevalence of TB and care-seeking behaviors among the general population in the country. However, data on the prevalence and risk behaviors among TB key populations were not available. Also, the national TB response did not disaggregate financial data based on gender and age group.