A strong TB programme embedded in a developing primary healthcare system is a lose-lose situation: insights from patient and community perspectives in Cambodia.

As exemplified by the situation in Cambodia, disease specific (vertical) health programmes are often favoured when the health system is fragile. The potential of such an approach to impede strengthening of primary healthcare services has been studied from a health systems perspective in terms of access and quality of care. In this bottom-up, qualitative study we investigate patient and community member experiences of health services when a strong tuberculosis (TB) programme is embedded into a relatively underutilized primary healthcare system. We conducted six gender-stratified community focus group discussions (n = 49) and seven mixed-gender focus group discussions with TB patients (n = 45) in three provinces located in urban, peri-urban and rural areas of Cambodia. Our analysis of health-seeking behaviour and experiences for TB and TB-like illness indicates that building a strong vertical TB control programme has had numerous benefits, including awareness of typical symptoms and need to seek care early; confidence in free TB services at public facilities; and willingness to complete treatment. However, there was a clear dichotomy in experiences and behaviour with respect to care-seeking for less severe illness at primary health services, which were generally avoided owing to access barriers and perceived poor quality. The tendency to delay seeking health care until the development of severe symptoms clearly indicative of TB is a major barrier to early diagnosis and treatment of TB. Our study indicates that an imbalance in the strength of vertical and primary health services could be a lose-lose situation as this impedes improvements in health system functioning and constrains progress of vertical disease control programmes.

Decentralized DOTS shortens delay to TB treatment significantly in Cambodia.

SETTING: Rural districts in Cambodia with and without decentralized health center based DOTS program. OBJECTIVE: To compare delays to treatment and behavior of patients up to diagnosis, between the pilot districts where DOTS is decentralized through the health centers, and the control districts where DOTS is provided through hospitals. DESIGN: A cross sectional study with structured questionnaire interviews to all new smear-positive TB patients aged 15 years or older who were registered in the study sites from May 1st to July 31st in 2002. RESULTS: The total delay in the pilot districts was significantly shorter than that in the control districts (median 58 days vs. 232 days, p < 0.01). The median doctors' delay within TB service in the pilot districts was 10 days and that in the control was 6 days. The period between first consultation to any health care provider and first visit to a TB service center, subsequent contact delay, was longer than any other type of delay and significantly different (24 days in pilot vs. 185 days in control, p < 0.01). The distance and travel costs to a TB service center were the factors associated with delay in seeking diagnosis of tuberculosis. No other variables had any significant association with the delay. CONCLUSION: Decentralizing DOTS to primary care health centers is highly effective in reducing the delay to TB treatment in Cambodia.