World Report
The Lancet, Pages 191 – 192, 16 July 2005

Cambodia’s fight against malaria

Patralekha  Chatterjee
Cambodia is a shining example of malaria control. But colonisation by new settlers of former Khmer Rouge forest strongholds is exposing a new population to infection—and is threatening to undermine the country’s success. Patralekha Chatterjee reports from Kampot province.

Those unfamiliar with Cambodia’s health-care system may wonder why U K Phirum chose to set up a pharmacy-cum-clinic opposite the government health centre in Trapeaugreang village, Kampot province, southern Cambodia. But patients come knocking at his door at all hours, says Phirum, precisely because he is right across the road from the health centre.
Kampot boasts the best pepper, salt, seafood, and fish sauce in Cambodia. But there is a less savoury side to this province bordering Vietnam: it is one of several areas in the country with high local transmission of malaria. Many of those who knock on Phirum’s door need early diagnosis and appropriate treatment for this parasitic disease transmitted by mosquitoes. Phirum, once an assistant to a medical practitioner, charges 50 cents for Malacheck—a rapid diagnostic test that detects Plasmodium falciparum malaria—and US$2 for Malarine, a 3-day prepackaged malaria treatment combining artesunate and mefloquine, the current regimen recommended by WHO and Cambodia’s National Centre for Parasitology, Entomology, and Malaria Control (CNM). Population Services International (Cambodia) sells both at subsidised rates.
Kampot has four referral hospitals and 47 health centres. Such centres should provide free check-ups and treatment, but drugs are often in short supply. For those who have travelled long distances, places such as Phirum’s clinic, located in the front part of his home, is a convenient one-stop-shop for diagnosis and treatment.
Vong Tharith, owner of a grocery store-cum-pharmacy and clinic in Kampot, admits that his day job—a nurse at a government health centre—provides only US$20 a month. It is not enough to feed a family. Like many who work for government hospitals and clinics, Tharith has started another business. At his grocery store, one can pick up antimalaria drugs along with cans of beer and condensed milk.
Tharith’s and Phirum’s thriving practices point to a familiar situation in the country, acknowledged even by the CNM. Cambodia’s poor are likely to avoid government-run health centres. Most will self-treat, go to private practitioners, or consult traditional healers before showing up at government clinics, making it difficult to gauge the magnitude of the malaria case load in the country.
Despite a sharp drop in malaria-related deaths in recent years, the disease remains a key public-health challenge for this conflict-scarred and infrastructure-weak nation. Malaria has compounded other health problems in the country—anaemia, complications in pregnancy, low birthweight, and poor child growth—and accounts for 16% of hospital deaths, nearly 14% of admissions to hospital, and 5% of outpatient attendance. An unregulated private sector in health care and frequent use of incorrect treatments have exacerbated the problem of drug resistance in Cambodia, as elsewhere in southeast Asia, and has fuelled a flourishing trade in fake medicines.
CNM’s 2004 progress report, released earlier this year, reveals that although Cambodia has spearheaded the introduction of several evidence-based interventions, malaria morbidity and mortality is still very high compared with other countries in the region. “The main problem is that the hyperendemic areas are remote, with little or no development, and very poor”, the report notes.
101 857 people were treated for malaria by public-health services and village malaria workers last year—a decline from the 132 571 cases treated in 2003. The malaria incidence rate has also decreased to 7·5 per 1000 in 2004 from 10·8 per 1000 in 2003. But “real figures are almost certainly higher as most malaria patients are either treated first through private clinics and drug sellers or do not seek treatment at all”, says the CNM report.
As Cambodia renews its fight against malaria, there is growing recognition that close collaboration with the private sector results in better data, diagnosis, and treatment. This means multisector action, multipartner support, and a community-based approach.
One exciting initiative in this direction is the creation of The Society for Malaria Control in Cambodia (SMCC), a local NGO. Set up in 2003 with support from some of the country’s leading malaria experts, it collects, monitors, and evaluates malaria-related information from private sector health-care providers in Kampot, Pursat, Pailin, and Stung Treng provinces. The primary tool used by SMCC is the Malaria Information Register, which records name, age, sex, occupation, symptoms, severity, diagnosis, treatment dosage, and results for each patient. This is given to nearly 200 private practitioners in the selected areas. SMCC staff make regular visits to inspect the registers and check if national treatment guidelines are being followed. The visits are also used to create a greater awareness among private practitioners—many of whom lack medical degrees—about rapid diagnostic tests and correct treatment for malaria.
Mok Rot Rangsay of SMCC, who visited Kampot recently, says overdosing is the most common problem. If there are factual discrepancies in the Malaria Information Registers, explanations are sought from the private practitioners. The initiative has the support of the provincial and federal governments. The provincial health department selects the practitioners who take part.
“In future, we hope to extend the initiative to 12 provinces. Only when we start getting better information from the private practitioners, will we have a more rounded picture of the malaria situation in the country”, says V V R Seshu Babu, malaria consultant to CNM. Babu says that the CNM is aware that dependence on statistics, recorded only through the public-health facilities, may lead to wrong conclusions. That was why CNM did a pilot project in four provinces to train private providers in diagnosis, treatment according to national guidelines, and record keeping, with financial support from the German aid agency GTZ. That project ended in February, 2005, and the Canadian International Development Agency stepped in to assist SMCC to operate during a transitional phase before the initiative could be scaled up.
Cambodia’s hopes now rest on the Global Fund for AIDS, Tuberculosis, and Malaria. CNM officials hope the Global Fund will extend its support to the initiative so that some 2500 private health-care providers can be trained in diagnosis, treatment, and recording of malaria-related information.
The malaria situation in Cambodia is an indicator of achievement and of the constraints that still plague the country’s malaria-control programme. New forest settlers pose an emerging challenge. The Khmer Rouge turned Cambodia’s forests into “no go” areas and fear of mines kept most people away. Now that the situation has stabilised, a new threat has emerged. Many poor rural Cambodians, mostly men, have started venturing into forest areas to work as loggers, gem miners, or to hunt. These men are susceptible to malaria because they lack immunity.
More Cambodians are aware of the mosquito—malaria link and of the need to use insecticide-treated nets than before. “But many do not feel the need to adapt their sleeping habits to the biting times of the insects, or carry their nets with them if they venture temporarily into forests. The most dangerous time is between 6 pm and 6 am. Many who are in the forest at this time sleep under nets but remain unprotected when they sit around, chatting till late evening inside the forest. Some say it is hot to use nets and go to sleep in a hammock. So you need insecticide-treated hammock nets”, says Lon Chan Thap, a CNM technical officer.
Ker Rathavuta, vice chief of operations, Chhuk district, Kampot, is optimistic. “5 years ago, people came to the district hospital at a late stage, with severe symptoms. Sometimes they were in a coma. Many even refused to believe malaria had anything to do with mosquitoes. They thought it was caused by spirits.” But now the situation is a lot better, he says. “Superstition is gradually fading. When they come to a hospital and get treated, they are also counselled on symptoms and how to protect themselves.”
Clearly, a key reason behind the sharp decline in malaria deaths in recent years is the widespread distribution of insecticide-treated nets—a programme supported by the World Bank and WHO. Other notable innovations include the village malaria workers, a scheme piloted in 2001 to reach out to the country’s most vulnerable groups, including ethnic minorities and those living in remote villages and forested areas with almost no access to health-care facilities. In many such areas, people have to walk miles across rivers, and ride elephant-back to get treatment. The CNM’s goal is to have these workers visiting 300 of the country’s most remote villages in the near future.

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