Medical injection and infusion practices among HIV-seronegative people and people living with HIV: a behavioural survey of 10 HIV testing and opportunistic infections/antiretroviral therapy sites in Cambodia.

OBJECTIVES: In late 2014, an HIV outbreak occurred in rural Cambodia among villagers who received medical injections from unlicensed medical providers, justifying the need to assess medical injection practices among those who are at risk of acquiring and/or transmitting HIV. This study examined medical injection/infusion behaviours among people living with HIV (PLWH) and those who were HIV negative in Cambodia. These behaviours should be properly assessed, especially among PLWH, as their prevalence might influence a future risk of other outbreaks. DESIGN: A cross-sectional survey was conducted in order to examine injection behaviours and estimate injection prevalence and rates by HIV status. Unsafe injections/infusions were those received from village providers who do not work at a health centre or hospital, or traditional providers at the participant's (self-injection included) or provider's home. Logistic regression was performed to examine the relationship between unsafe injection/infusion and HIV, adjusting for sex, age, education, occupation, residence location and other risk factors. SETTING: The survey was conducted in 10 HIV testing and treatment hospitals/clinics across selected provinces in Cambodia, from February to March 2017. PARTICIPANTS: A total number of 500 volunteers participated in the survey, 250 PLWH and 250 HIV-negative individuals. OUTCOME MEASURES: Measures of injection prevalence and other risk behaviours were based on self-reports. RESULTS: Both groups of participants reported similar past year's injection/infusion use, 47% (n=66) among PLWH and 54% (n=110) HIV-negative participants (p=0.24). However, 15% (n=11) of PLWH reported having received unsafe last injection compared with only 7% (n=11) of HIV-negative participants. In logistic regression, this association remained numerically positive, but was not statistically significant (adjusted OR 1.84 (95% CI: 0.71 to 4.80)). CONCLUSIONS: The inclination for medical injections and infusions (unsafe at times) among PLWH and the general population in Cambodia was common and could possibly represent yet another opportunity for parenteral transmission outbreak.

Challenges and opportunities in addressing social determinants of child health in Cambodia: perspectives and experience of frontline providers in two health districts.

OBJECTIVES: Other forces related to socio-economic and cultural factors, besides biomedical and behavioural fields, also influence health but receive little attention in health research. This study aims to illuminate social determinants of health and to identify challenges and opportunities in addressing social determinants of child health (SDCH) in rural Cambodia. METHODS: This is a qualitative study based on interviews of frontline primary health care providers, health officials, local authorities and community volunteers in two health districts in Cambodia. The data were supplemented by secondary data on different aspects of the districts and Cambodia. RESULTS: Poverty, lack of basic commodities and adverse social conditions remained problems for population health. While access to health services was considered adequate, households and communities had several major risk exposures. Challenges in addressing SDCH were the high prevalence of social and household adverse conditions, and the lack of training of providers, of information about social services, of effective coordination and of trust in public services. Opportunities were present, including social services being existent albeit poor functioning, the traditional practice of social inquiry, existing frontline providers being open to further information and training, existing subnational coordination bodies at district and provincial levels, and use of evidence in planning and resource allocation. CONCLUSION: Addressing SDCH requires broad and coordinated efforts of stakeholders from multiple sectors. Among the prerequisites are to leverage the existing structures and mechanisms, training primary health care providers and providing them with adequate information about local resources and available supports. Improving social care services and infrastructures requires strong coordination, planning and adequate resource allocation.

RéSUMé: OBJECTIFS: D'autres forces liées aux facteurs socio-économiques et culturels, en plus des domaines biomédicaux et comportementaux, influencent également la santé mais reçoivent peu d'attention dans la recherche en santé. Cette étude vise à éclairer les déterminants sociaux de la santé et à identifier les défis et les opportunités pour aborder les déterminants sociaux de la santé infantile (SDCH) dans les régions rurales du Cambodge. MéTHODES: Il s'agit d'une étude qualitative basée sur des entretiens avec des prestataires de soins de santé primaire de première ligne, des responsables de la santé, des autorités locales et des volontaires communautaires dans deux districts de santé au Cambodge. Les données ont été complétées par des données secondaires sur différents aspects des districts et du Cambodge. RéSULTATS: La pauvreté, le manque de produits de base et les conditions sociales défavorables restent des problèmes pour la santé de la population. Bienque l'accès aux services de santé est considéré suffisant, les ménages et les communautés sont exposés à plusieurs risques majeurs. Les défis liés à la lutte contre la SDCH étaient la prévalence élevée de conditions sociales et domestiques défavorables, ainsi que le manque de formation des prestataires, d'informations sur les services sociaux, de coordination efficace et de confiance dans les services publics. Des opportunités étaient présentes, y compris des services sociaux existants bienque fonctionnant mal, la pratique traditionnelle de l'enquête sociale, les prestataires de première ligne existants étant disposés à encore d'informations et de formation, les organes de coordination sous-nationaux existants au niveau des districts et des provinces, et l'utilisation des preuves dans la planification et l'allocation des ressources. CONCLUSION: Aborder la SDCH nécessite des efforts larges et coordonnés des parties prenantes de plusieurs secteurs. Parmi les conditions préalables, il faut tirer parti des structures et mécanismes existants, former les prestataires de soins de santé primaire et leur fournir des informations adéquates sur les ressources locales et soutiens disponibles. L'amélioration des services et des infrastructures de protection sociale nécessite une coordination, une planification et une allocation adéquate des ressources.

Assessment of dual practice among physicians in Cambodia.

BACKGROUND: Dual practice and multiple job holding are widespread among health workers throughout the world. Although dual practice can help the financially strained public sector retain skilled workers, there are also potential negative consequences if it is not regulated. In Cambodia, there is substantial anecdotal evidence of dual practice among physicians but there is very little data on the extent and prevalence of the practice. This study was conducted by the University of Health Sciences (UHS) to gain insight in to the employment practices of UHS alumni. Results from this survey may help to inform policymakers in rational planning for future health system development related to capacity building and regulation of human resources for health. METHODS: Data were collected from a self-administered survey of UHS graduates who graduated between 1999 and 2012. A total of 162 medical graduates were randomly sampled from a total of 1867 medical graduates between 1999 and 2012. Contacted individuals were asked to complete a written structured questionnaire regarding demographic characteristics, current employment and types of employment, compensation, and job satisfaction. The response rate of graduates sampled was 49% (79 completed questionnaires). The low response rate was primarily due to the difficulty in locating individuals. RESULTS: Of 79 respondents, 96% were currently employed at the time of the survey. However, only 63 of the respondents (80%) were working in the healthcare sector. The 16 respondents (20%) not working in healthcare were excluded from further analyses since they are not relevant to dual practice analysis. The vast majority (87%) of respondents are public sector employees (61.9% in public sector only and 25.4% in both public and private sector). 12.7% of respondents only work in the private sector. Almost half (47.6%) of respondents hold more than one job. For income satisfaction, physicians employed in both sectors have higher satisfaction than physicians employed in the public sector only. CONCLUSIONS: As policymakers in Cambodia consider new approaches to regulation of the practice, it is important to know the context of the practice, the benefits to the healthcare system, and the costs. Recognizing the high prevalence of multiple job holding in Cambodia, as evidenced in our survey of UHS medical graduates, contributes to the discussion as important information that can be used toward meaningful reform.

Protecting the poor? Impact of the national health equity fund on utilization of government health services in Cambodia, 2006-2013.

INTRODUCTION: Cambodia's health equity fund (HEF) is the country's most significant social security scheme, covering the poorest one-fifth of the national population. During the last two decades, the HEF system was scaled up from an initial two health districts to national coverage of public health facilities. This is the first national study to examine the impact of the HEF on the utilisation of public health facilities. METHODS: We first investigated the level of national HEF population coverage and health service use made by HEF eligible members using an administrative HEF operational dataset. Second, through multilevel interrupted time series analysis of routine monthly utilisation statistics during 2006-2013, we evaluated the impact of the HEF on hospital and health centre utilisation. RESULTS: The proportion of HEF beneficiaries using hospital services in a given year (4.6%) appeared to exceed rates in the general population (3.3%). The introduction of the HEF was associated with: a significant level change in the monthly number of consultations at HCs followed by a gradual slope increase in time trend and a significant level change in the monthly number of deliveries. Overall, this was equivalent to a 15.6% net increase in number of consultations and 5.3% in deliveries in the first year. At RHs: a significant level change in the number of RH inpatient cases, followed by a sustained slope increase; a significant slope increase in the number of outpatient consultations and in the overall number of newborn deliveries. Overall, this was equivalent to a 47.9% net increase in inpatient cases, 24.1% in outpatient cases and 31.4% in deliveries in the first year. CONCLUSION: The implementation of the HEF scheme was associated with increased utilisation of primary and secondary care services by the poor.

Administrative reform and pay-for-performance methods of primary health service delivery: A comparison of 3 health districts in Cambodia, 2006-2012.

Since 1999, performance-based financing or pay-for-performance (P4P) methods have been piloted in the Cambodian public health sector, first as one part of external contracting approaches with international nongovernment organizations and from 2009 as a part of internal contracting arrangements between units within the Ministry of Health under a wider public sector administrative reform. This study analyses these reforms and compares outcomes in 3 health districts. The study analysed routine quantitative data for primary care service delivery by using the interrupted time series method. Qualitative data were collected from key informant interviews. Both the level and the trend line of key service delivery indicators during earlier contracting/P4P models were at least maintained and in most cases increased with the move to internal contracting. The results of the interrupted time series analysis were mixed, mainly due to contextual issues. Qualitative results indicated an increased sense of local ownership and financial sustainability. Despite the gains, the management of personnel and the implementation and the integrity of contract monitoring were found to be compromised in this case. To be fully effective, contracting and P4P approaches must be accompanied by changes in the structure and culture of government administration.

Tuberculosis active case finding in Cambodia: a pragmatic, cost-effectiveness comparison of three implementation models.

BACKGROUND: Globally, almost 40% of tuberculosis (TB) patients remain undiagnosed, and those that are diagnosed often experience prolonged delays before initiating correct treatment, leading to ongoing transmission. While there is a push for active case finding (ACF) to improve early detection and treatment of TB, there is extremely limited evidence about the relative cost-effectiveness of different ACF implementation models. Cambodia presents a unique opportunity for addressing this gap in evidence as ACF has been implemented using different models, but no comparisons have been conducted. The objective of our study is to contribute to knowledge and methodology on comparing cost-effectiveness of alternative ACF implementation models from the health service perspective, using programmatic data, in order to inform national policy and practice. METHODS: We retrospectively compared three distinct ACF implementation models - door to door symptom screening in urban slums, checking contacts of TB patients, and door to door symptom screening focusing on rural populations aged above 55 - in terms of the number of new bacteriologically-positive pulmonary TB cases diagnosed and the cost of implementation assuming activities are conducted by the national TB program of Cambodia. We calculated the cost per additional case detected using the alternative ACF models. RESULTS: Our analysis, which is the first of its kind for TB, revealed that the ACF model based on door to door screening in poor urban areas of Phnom Penh was the most cost-effective (249 USD per case detected, 737 cases diagnosed), followed by the model based on testing contacts of TB patients (308 USD per case detected, 807 cases diagnosed), and symptomatic screening of older rural populations (316 USD per case detected, 397 cases diagnosed). CONCLUSIONS: Our study provides new evidence on the relative effectiveness and economics of three implementation models for enhanced TB case finding, in line with calls for data from 'routine conditions' to be included in disease control program strategic planning. Such cost-effectiveness comparisons are essential to inform resource allocation decisions of national policy makers in resource constraint settings. We applied a novel, pragmatic methodological approach, which was designed to provide results that are directly relevant to policy makers, costing the interventions from Cambodia's national TB program's perspective and using case finding data from implementation activities, rather than experimental settings.

Factors Driving Changes in the Design, Implementation, and Scaling-Up of the Contracting of Health Services in Rural Cambodia, 1997-2015.

Abstract-Contracting approaches have been used in various forms to improve the delivery of public health services in low- and middle-income countries. Cambodia has embarked on a public-sector reform that includes a model of internal contracting of health care through the Ministry of Health, supported by incentive payments for staff and facilities. Contracting for health care in Cambodia has evolved through three phases during 1997-2015, each with particular design features, arrangements, and structures; different levels of involvement of local and international stakeholders; and modifications based on evidence from operational research. Based on a review of published and gray literature and interviews with 29 local and international key informants, we identify national ownership, financial sustainability, and the need to strengthen service delivery institutions as the major forces that have shaped contracting in Cambodia, culminating in the move to internal contracting arrangements for public health care delivery. There remains a need to strengthen contracting governance arrangements.

Are health workers motivated by income? Job motivation of Cambodian primary health workers implementing performance-based financing.

BACKGROUND: Financial incentives are widely used in performance-based financing (PBF) schemes, but their contribution to health workers' incomes and job motivation is poorly understood. Cambodia undertook health sector reform from the middle of 2009 and PBF was employed as a part of the reform process. OBJECTIVE: This study examines job motivation for primary health workers (PHWs) under PBF reform in Cambodia and assesses the relationship between job motivation and income. DESIGN: A cross-sectional self-administered survey was conducted on 266 PHWs, from 54 health centers in the 15 districts involved in the reform. The health workers were asked to report all sources of income from public sector jobs and provide answers to 20 items related to job motivation. Factor analysis was conducted to identify the latent variables of job motivation. Factors associated with motivation were identified through multivariable regression. RESULTS: PHWs reported multiple sources of income and an average total income of US$190 per month. Financial incentives under the PBF scheme account for 42% of the average total income. PHWs had an index motivation score of 4.9 (on a scale from one to six), suggesting they had generally high job motivation that was related to a sense of community service, respect, and job benefits. Regression analysis indicated that income and the perception of a fair distribution of incentives were both statistically significant in association with higher job motivation scores. CONCLUSIONS: Financial incentives used in the reform formed a significant part of health workers' income and influenced their job motivation. Improving job motivation requires fixing payment mechanisms and increasing the size of incentives. PBF is more likely to succeed when income, training needs, and the desire for a sense of community service are addressed and institutionalized within the health system.

Strengthening district health service management and delivery through internal contracting: lessons from pilot projects in Cambodia.

Following a decade of piloting different models of contracting, in mid-2009 the Cambodian Ministry of Health began to test a form of 'internal contracting' for health care delivery in selected health districts (including hospitals and health centers) contracted by the provincial health department as Special Operating Agencies (SOAs) and provided with greater management autonomy. This study assesses the internal contracting approach as a means for improving the management of district health services and strengthening service delivery. While the study may contribute to the emerging field now known as performance-based financing, the lessons deal more broadly with the impact of management reform and increased autonomy in contrast to traditional public sector line-management and budgeting. Carried out during 2011, the study was based on: (i) a review of the literature and of operational documents; (ii) primary data from semi-structured key informant interviews with 20 health officials in two provinces involved in four SOA pilot districts; and (iii) routine data from the 2011 SOA performance monitoring report. Five prerequisites were identified for effective contract management and improved service delivery: a clear understanding of roles and responsibilities by the contracting parties; implementation of clear rules and procedures; effective management of performance; effective monitoring of the contract; and adequate and timely provision of resources. Both the level and allocation of incentives and management bottlenecks at various levels continue to impede implementation. We conclude that, in contracted arrangements like these, the clear separation of contracting functions (purchasing, commissioning, monitoring and regulating), management autonomy where responsibilities are genuinely devolved and accepted, and the provision of resources adequate to meet contract demands are necessary conditions for success.