Cambodia's health professionals and the ASEAN Mutual Recognition Arrangements: registration, education and mobility.

BACKGROUND: From 2006, the Association of South East Asian Nations (ASEAN) has been developing Mutual Recognition Arrangements (MRAs) across key professions, including medicine, dentistry and nursing, that would facilitate the development of an ASEAN Economic Community, with shared regional standards and easier mobility of the workforce. This paper examines the interface between those agreements and the registration, professional education and mobility of health personnel in Cambodia. METHODS: This qualitative health policy analysis combined documentary and policy review with key informant interviews with 16 representatives of agencies relevant to the development and implementation of the MRAs in health. Thematic analysis identified three themes: registration, education and mobility. RESULTS: Cambodia is an active participant in the ASEAN MRA processes for doctors, dentists and nurses reporting progress annually. Education of health professionals has been increasingly formalised in the past 25 years, with nursing moving towards a 4-year bachelor degree. The private university sector has substantially increased, with English increasingly used as a language of instruction. Recent legislation provides for enforcement through fines and/or imprisonment to ensure all practising health professionals hold initial registration as a health professional and a renewable licence to practise as a health practitioner. Continuing Professional Development is a mandatory requirement for licence renewal. This is consistent with the MRA guidelines, though the capacity for enforcement appears limited. The Medical Council of Cambodia (MCC), and more recently, the Dental and Nursing Councils, have introduced continuing professional development initiatives, using them strategically as a positive reinforcer of registration. Midwifery education and registration in Cambodia does not conform with ASEAN guidelines. In education, course durations in medicine and dentistry are longer than regional counterparts, though anxiety around maintaining clinical standards has resulted in the introduction of a National Exit Examination and reluctance to abbreviate courses. The introduction of reforms appears to reference regional standards, though parity is still some way off. Mobility at present is infrequent and more likely to result from informal mechanisms than through the MRA mechanisms. CONCLUSION: The Royal Government of Cambodia is committed to the ASEAN MRA process. Developments in registration appear to use regional standards as benchmarks, as do reforms in the education of health professionals, though domestic factors appear to more directly impact on developments. Informal mechanisms facilitate the limited mobility currently occurring, with little formal application of the MRA provisions evident at this point.

What did the Go4Health policy research project contribute to the policy discourse on the sustainable development goals? A reflexive review.

BACKGROUND: In 2012, the European Commission funded Go4Health-Goals and Governance for Global Health, a consortium of 13 academic research and human rights institutions from both Global North and South-to track the evolution of the Sustainable Development Goals (SDGs), and provide ongoing policy advice. This paper reviews the research outputs published between 2012 and 2016, analyzing the thematic content of the publications, and the influence on global health and development discourse through citation metrics. FINDINGS AND DISCUSSION: Analysis of the 54 published papers showed 6 dominant themes related to the SDGs: the formulation process for the SDG health goal; the right to health; Universal Health Coverage; voices of marginalized peoples; global health governance; and the integration of health across the other SDGs. The papers combined advocacy---particularly for the right to health and its potential embodiment in Universal Health Coverage-with qualitative research and analysis of policy and stakeholders. Go4Health's publications on the right to health, global health governance and the voices of marginalized peoples in relation to the SDGs represented a substantial proportion of papers published for these topics. Go4Health analysis of the right to health clarified its elements and their application to Universal Health Coverage, global health governance, financing the SDGs and access to medicines. Qualitative research identified correspondence between perceptions of marginalized peoples and right to health principles, and reluctance among multilateral organizations to explicitly represent the right to health in the goals, despite their acknowledgement of their importance. Citation metrics analysis confirmed an average of 5.5 citations per paper, with a field-weighted citation impact of 2.24 for the 43 peer reviewed publications. Citations in the academic literature and UN policy documents confirmed the impact of Go4Health on the global discourse around the SDGs, but within the Go4Health consortium there was also evidence of two epistemological frames of analysis-normative legal analysis and empirical research-that created productive synergies in unpacking the health SDG and the right to health. CONCLUSION: The analysis offers clear evidence for the contribution of funded programmatic research-such as the Go4Health project-to the global health discourse.

Evaluation of Diabetes Care Performance in Cambodia Through the Cascade-of-Care Framework: Cross-Sectional Study.

BACKGROUND: Cambodia has seen an increase in the prevalence of type 2 diabetes (T2D) over the last 10 years. Three main care initiatives for T2D are being scaled up in the public health care system across the country: hospital-based care, health center-based care, and community-based care. To date, no empirical study has systematically assessed the performance of these care initiatives across the T2D care continuum in Cambodia. OBJECTIVE: This study aimed to assess the performance of the 3 care initiatives-individually or in coexistence-and determine the factors associated with the failure to diagnose T2D in Cambodia. METHODS: We used a cascade-of-care framework to assess the T2D care continuum. The cascades were generated using primary data from a cross-sectional population-based survey conducted in 2020 with 5072 individuals aged ≥40 years. The survey was conducted in 5 operational districts (ODs) selected based on the availability of the care initiatives. Multiple logistic regression analysis was used to identify the factors associated with the failure to diagnose T2D. The significance level of P<.05 was used as a cutoff point. RESULTS: Of the 5072 individuals, 560 (11.04%) met the definition of a T2D diagnosis (fasting blood glucose level ≥126 mg/dL and glycated hemoglobin level ≥6.5%). Using the 560 individuals as the fixed denominator, the cascade displayed substantial drops at the testing and control stages. Only 63% (353/560) of the participants had ever tested their blood glucose level in the last 3 years, and only 10.7% (60/560) achieved blood glucose level control with the cutoff point of glycated hemoglobin level <8%. The OD hosting the coexistence of care displayed the worst cascade across all bars, whereas the OD with hospital-based care had the best cascade among the 5 ODs. Being aged 40 to 49 years, male, and in the poorest category of the wealth quintile were factors associated with the undiagnosed status. CONCLUSIONS: The unmet needs for T2D care in Cambodia were large, particularly in the testing and control stages, indicating the need to substantially improve early detection and management of T2D in the country. Rapid scale-up of T2D care components at public health facilities to increase the chances of the population with T2D of being tested, diagnosed, retained in care, and treated, as well as of achieving blood glucose level control, is vital in the health system. Specific population groups susceptible to being undiagnosed should be especially targeted for screening through active community outreach activities. Future research should incorporate digital health interventions to evaluate the effectiveness of the T2D care initiatives longitudinally with more diverse population groups from various settings based on routine data vital for integrated care. TRIAL REGISTRATION: International Standard Randomized Controlled Trials Number (ISRCTN) ISRCTN41932064; https://www.isrctn.com/ISRCTN41932064. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/36747.

Diabetes care components effectively implemented in the ASEAN health systems: an umbrella review of systematic reviews.

OBJECTIVES: Association of Southeast Asian Nations (ASEAN) is among the hardest hit low-income and middle-income countries by diabetes. Innovative Care for Chronic Conditions (ICCC) framework has been adopted by the WHO for health system transformation towards better care for chronic conditions including diabetes. We conducted an umbrella review of systematic reviews on diabetes care components effectively implemented in the ASEAN health systems and map those effective care components into the ICCC framework. DESIGN: An umbrella review of systematic reviews and/or meta-analyses following JBI (Joanna Briggs Institute) guidelines. DATA SOURCES: Health System Evidence, Health Evidence, PubMed and Ovid MEDLINE. ELIGIBILITY CRITERIA: We included systematic reviews and/or meta-analyses which focused on management of type 2 diabetes, reported improvements in measured outcomes and had at least one ASEAN member state in the study setting. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted the data and mapped the included studies into the ICCC framework. A narrative synthesis method was used to summarise the findings. The included studies were assessed for methodological quality based on the JBI critical appraisal checklist for systematic reviews and research syntheses. RESULTS: 479 records were found of which 36 studies were included for the analysis. A multidisciplinary healthcare team including pharmacists and nurses has been reported to effectively support patients in self-management of their conditions. This can be supported by effective use of digital health interventions. Community health workers either peers or lay people with necessary software (knowledge and skills) and hardware (medical equipment and supplies) can provide complementary care to that of the healthcare staff. CONCLUSION: To meet challenges of the increased burden of chronic conditions including diabetes, health policy-makers in the ASEAN member states can consider a paradigm shift in human resources for health towards the multidisciplinary, inclusive, collaborative and complementary team.

Healthcare usage and expenditure among people with type 2 diabetes and/or hypertension in Cambodia: results from a cross-sectional survey.

OBJECTIVE: To assess usage of public and private healthcare, related healthcare expenditure, and associated factors for people with type 2 diabetes (T2D) and/or hypertension (HTN) and for people without those conditions in Cambodia. METHODS: A cross-sectional household survey. SETTINGS: Five operational districts (ODs) in Cambodia. PARTICIPANTS: Data were from 2360 participants aged ≥40 years who had used healthcare services at least once in the 3 months preceding the survey. PRIMARY AND SECONDARY OUTCOME: The main variables of interest were the number of healthcare visits and healthcare expenditure in the last 3 months. RESULTS: The majority of healthcare visits took place in the private sector. Only 22.0% of healthcare visits took place in public healthcare facilities: 21.7% in people with HTN, 37.2% in people with T2D, 34.7% in people with T2D plus HTN and 18.9% in people without the two conditions (p value <0.01). For people with T2D and/or HTN, increased public healthcare use was significantly associated with Health Equity Fund (HEF) membership and living in ODs with community-based care. Furthermore, significant healthcare expenditure reduction was associated with HEF membership and using public healthcare facilities in these populations. CONCLUSION: Overall public healthcare usage was relatively low; however, it was higher in people with chronic conditions. HEF membership and community-based care contributed to higher public healthcare usage among people with chronic conditions. Using public healthcare services, regardless of HEF status reduced healthcare expenditure, but the reduction in spending was more noticeable in people with HEF membership. To protect people with T2D and/or HTN from financial risk and move towards the direction of universal health coverage, the public healthcare system should further improve care quality and expand social health protection. Future research should link healthcare use and expenditure across different healthcare models to actual treatment outcomes to denote areas for further investment.

Generation of Cascades of Care for Diabetes and Hypertension Care Continuum in Cambodia: Protocol for a Population-Based Survey Protocol.

BACKGROUND: Cardiovascular diseases (CVDs) were accountable for 24% of the total deaths in Cambodia, one of the low- and middle-income countries, where primary health care (PHC) settings generally do not perform well in the early detection, diagnosis, and monitoring of leading risk factors for CVDs, that is, type 2 diabetes (T2D) and hypertension (HT). Integrated care for T2D and HT in the Cambodian PHC system remains limited, with more than two-thirds of the population never having had their blood glucose measured and more than half of the population with T2D having not received treatment, with only few of them achieving recommended treatment targets. With regard to care for T2D and HT in the public health care system, 3 care models are being scaled up, including (1) a hospital-based model, (2) a health center-based model, and (3) a community-based model. These 3 care models are implemented in isolation with relatively little interaction between each other. The question arises as to what extent the 3 care models have performed in providing care to patients with T2D or HT or both in Cambodia. OBJECTIVE: This protocol aims to show how to use primary data from a population-based survey to generate data for the cascades of care to assess the continuum of care for T2D and HT across different care models. METHODS: We adapt the HIV test-treat-retain cascade of care to assess the continuum of care for patients living with T2D and HT. The cascade-of-care approach outlines the sequential steps in long-term care: testing, diagnosis, linkage with care, retention in care, adherence to treatment, and reaching treatment targets. Five operational districts (ODs) in different provinces will be purposefully selected out of 103 ODs across the country. The population-based survey will follow a multistage stratified random cluster sampling, with expected recruitment of 5280 eligible individuals aged 40 and over as the total sample size. Data collection process will follow the STEPS (STEPwise approach to NCD risk factor surveillance) survey approach, with modification of the sequence of the steps to adapt the data collection to the study context. Data collection involves 3 main steps: (1) structured interviews with questionnaires, (2) anthropometric measurements, and (3) biochemical measurements. RESULTS: As of December 2021, the recruitment process was completed, with 5072 eligible individuals participating in the data collection; however, data analysis is pending. Results are expected to be fully available in mid-2022. CONCLUSIONS: The cascade of care will allow us to identify leakages in the system as well as the unmet need for care. Identifying gaps in the health system is vital to improve efficiency and effectiveness of its performance. This study protocol and its expected results will help implementers and policy makers to assess scale-up and adapt strategies for T2D and HT care in Cambodia. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number (ISRCTN) registry ISRCTN41932064; https://www.isrctn.com/ISRCTN41932064. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/36747.

Can mHealth and eHealth improve management of diabetes and hypertension in a hard-to-reach population? -lessons learned from a process evaluation of digital health to support a peer educator model in Cambodia using the RE-AIM framework.

BACKGROUND: The burden of non-communicable diseases (NCDs) is increasing in low- and middle-income countries (LMICs) where NCDs cause 4:5 deaths, disproportionately affect poorer populations, and carry a large economic burden. Digital interventions can improve NCD management for these hard-to-reach populations with inadequate health systems and high cell-phone coverage; however, there is limited research on whether digital health is reaching this potential. We conducted a process evaluation to understand challenges and successes from a digital health intervention trial to support Cambodians living with NCDs in a peer educator (PE) program. METHODS: MoPoTsyo, a Cambodian non-governmental organization (NGO), trains people living with diabetes and/or hypertension as PEs to provide self-management education, support, and healthcare linkages for better care management among underserved populations. We partnered with MoPoTsyo and InSTEDD in 2016-2018 to test tailored and targeted mHealth mobile voice messages and eHealth tablets to facilitate NCD management and clinical-community linkages. This cluster randomized controlled trial (RCT) engaged 3,948 people and 75 PEs across rural and urban areas. Our mixed methods process evaluation was guided by RE-AIM to understand impact and real-world implications of digital health. Data included patient (20) and PE interviews (6), meeting notes, and administrative datasets. We triangulated and analyzed data using thematic analysis, and descriptive and complier average causal effects statistics (CACE). RESULTS: Reach: intervention participants were more urban (66% vs. 44%), had more PE visits (39 vs. 29), and lower uncontrolled hypertension [12% and 7% vs. 23% and 16% uncontrolled systolic blood pressure (SBP) and diastolic blood pressure (DBP)]. Adoption: patients were sent mean [standard deviation (SD)] 30 [14] and received 14 [8] messages; 40% received no messages due to frequent phone number changes. Effectiveness: CACE found clinically but not statistically significant improvements in blood pressure and sugar for mHealth participants who received at least one message vs. no messages. Implementation: main barriers were limited cellular access and that mHealth/eHealth could not solve structural barriers to NCD control faced by people in poverty. Maintenance: had the intervention been universally effective, it could be paid for from additional revolving drug fund revenue, new agreements with mobile networks, or the government. CONCLUSIONS: Evidence for digital health to improve NCD outcomes in LMICs are limited. This study suggests digital health alone is insufficient in countries with low resource health systems and that high cell phone coverage did not translate to access. Adding digital health to an NCD peer network may not significantly benefit an already effective program; mHealth may be better for hard-to-reach populations not connected to other supports. As long as mHealth remains an individual-level intervention, it will not address social determinants of health that drive outcomes. Future digital health research and practice to improve NCD management in LMICs requires engaging government, NGOs, and technology providers to work together to address barriers.

Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium (SCUBY): a study design for a quasi-experimental multiple case study.

Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.

Social and behavioural factors associated with risky sexual behaviours among university students in nine ASEAN countries: a multi-country cross-sectional study.

While university students are potential human resources, this population group is particularly involved in health risk behaviours. Preventing risky sexual behaviours among them would contribute to prevention of HIV, sexually transmitted infections (STIs), and unwanted pregnancies, which have posed a great burden on population health. This study was therefore conducted to identify social and behavioural factors associated with risky sexual behaviours among university students in nine ASEAN countries. A multi-country, cross-sectional study was conducted in 2015 among university students by a network of researchers in the selected countries. A convenient sampling method and stratified random sampling procedures were employed to select universities and students, respectively. A structured questionnaire was translated into national languages of the participating countries and used to collect data from the selected students in the classrooms. Using STATA, Chi-square test was used to test differences in proportions, and multinomial logistic regression analyses were performed to obtain relative risk ratios and 95% confidence intervals. Multivariate logistic regression analysis was performed with to identify independent social and behavioural factors associated with non-condom use at last sexual intercourse. In total, 8,836 students with a mean age of 20.6 (SD = 2.0) participated in the study. Most of them (98.5%) were unmarried. In all countries, male students were significantly more likely to have two or more sexual partners in the past 12 months compared to female students (4.8% vs. 1.1%, p < 0.001). Female students were significantly more likely to report unprotected sex compared to male students (50.5% vs. 58.8%, p = 0.01). Results of multivariable logistic regression analyses showed that students who reported having two or more partners in the past 12 months were significantly more likely to be male, be aged between 20-30, be current tobacco smokers, be binge drinkers, have severe depressive symptoms, and have been in a physical fight in the past 12 months, compared to students who reported having less than two sexual partners in the past 12 months. Health intervention programmes to prevent and control STIs, especially HIV infection, should focus on university students having the social and behavioural characteristics that are associated with risky sexual behaviours.

The impact of ASEAN economic integration on health worker mobility: a scoping review of the literature.

The Association of Southeast Asian Nations (ASEAN) Economic Community (AEC) was inaugurated in December 2015 with the primary aim of achieving a strong and prosperous community through accelerating economic integration. The notion of a single market, underpinned by the free flow of trade in services and skilled labour, is integral to the spirit of the AEC. To facilitate the intra-regional mobility of health professionals, Mutual Recognition Arrangements (MRAs) were signed, for nursing in 2006 and for medicine and dentistry in 2009, and now sit within the AEC objectives. This study examines the observed and potential impact of the health-related MRAs on health worker mobility within the region, particularly with regard to qualified doctors and nurses. To explore the available evidence, the authors undertook a narrative literature and document review, consistent with the RAMESES guidelines for qualitative research in international development and policy making in the area of health. Peer-reviewed articles and the grey literature from the period beginning in 2005 were reviewed. We find that the implementation of health-related MRAs has been slow and complex due to a number of barriers and challenges, such as resistance to the inflow of health professionals by the local workforce, shortcomings in the implementing mechanisms and an individual preference among health professionals for seeking better opportunities outside the region. Despite increasing worker mobility generally within ASEAN through formal and informal mechanisms, the MRAs themselves do not appear yet to have facilitated the freer movement of health workers. To strengthen health worker mobility, the full implementation of the health-related MRAs is essential, requiring support from broader trade and immigration policies and a stronger political commitment. Policy makers in ASEAN Member States will need to manage competing national interests in order to harness support for effective implementation.

Did the right to health get across the line? Examining the United Nations resolution on the Sustainable Development Goals.

Since the new global health and development goal, Sustainable Development Goal (SDG) 3, and its nine targets and four means of implementation were introduced to the world through a United Nations (UN) General Assembly resolution in September 2015, right to health practitioners have queried whether this goal mirrors the content of the human right to health in international law. This study examines the text of the UN SDG resolution, Transforming our world: the 2030 Agenda for Sustainable Development, from a right to health minimalist and right to health maximalist analytic perspective. When reviewing the UN SDG resolution's text, a right to health minimalist questions whether the content of the right to health is at least implicitly included in this document, specifically focusing on SDG 3 and its metrics framework. A right to health maximalist, on the other hand, queries whether the content of the right to health is explicitly included. This study finds that whether the right to health is contained in the UN SDG resolution, and the SDG metrics therein, ultimately depends on the individual analyst's subjective persuasion in relation to right to health minimalism or maximalism. We conclude that the UN General Assembly's lack of cogency on the right to health's position in the UN SDG resolution will continue to blur if not divest human rights' (and specifically the right to health's) integral relationship to high-level development planning, implementation and SDG monitoring and evaluation efforts.