Strengthening of primary (horizontal) health services for TB diagnosis and treatment in Cambodia are essential to improve perceptions and trust in the wider health system and to enhance tuberculosis control.
By: Neisha Sundaram
In 1979, at the end of the Khmer Rouge regime and genocide that targeted intellectuals and professionals in Cambodia, less than 50 doctors remained to serve the country’s population of between 6 and 7 million. In addition to manpower losses, infrastructure also suffered and the country’s health system needed major rebuilding. The National Tuberculosis (TB) Programme received attention in the 1990s; treatment for tuberculosis was first made available in hospitals and later decentralized to health centres.
Remarkable progress in TB control has been made since then through concerted efforts. The country’s TB prevalence has halved since 1990 and treatment success rate of above 90% has been reported since 2000. However, Cambodia still has one of the highest TB burdens in the world and an estimated 50-70% of cases are believed to go undetected. Tackling the large remaining TB burden is challenging in a country where remote, rural areas have relatively poorer health services and disease identification relies heavily on potential patients presenting themselves to public facilities for TB diagnosis and treatment
We conducted a qualitative research study by talking to 94 community members and TB patients, to listen and understand their views and experiences with TB and seeking help for illness. We paid special attention to the local sociocultural context in order to identify ways to improve TB diagnosis and treatment. We included a remote rural study area, which has been the focus of relatively little research, in addition to peri-urban and urban study areas to gain a more complete understanding of issues affecting TB control for people in different parts of the country.
Through our research we found that general awareness of severe TB symptoms was high, as was knowledge of and trust in available TB treatment among both patients and community members. The persons we spoke with had high levels of confidence in biomedical treatment for TB, supported early treatment initiation at public health facilities and were aware of the need to complete their course of treatment, which is crucial in TB control. These findings indicate excellent progress made my public health authorities in educating community members about tuberculosis as well as gaining their trust regarding biomedical TB treatment, especially as traditional medicine is widely practiced and relied upon for many other conditions.
However, when illness did not include a characteristic sign of blood in sputum that is typically associated with TB, community members did not suspect TB and delayed seeking help from medical professionals. For what might be early stages of TB such as cough without blood, respondents said they would either do nothing at all, directly buy medicines at a pharmacy or visit a traditional healer: “We usually try many other methods first and the hospital is the last choice.”
This also had to do with a rather poor perception of primary public health services. Unlike perceptions of TB services at public facilities, which were generally good, patients and community members thought that for general illnesses public health facilities had poor service with long waiting times. Moreover, healthcare providers at these facilities were thought to be rude, have poor skills, not provide their patients enough time, not conduct thorough physical exams and be greedy in the way they charged fees; and drugs offered by way of treatment were considered unspecific, ineffective or inadequate in number. Private health services were a clear preference over public but remained unaffordable to the majority and reliance on private health services sometimes led to dire financial consequences, noted as follows by a study participant: “The most important is our lives. We can do everything including selling cows, buffaloes, land, etc. to pay for treatments.”
The result of negative perceptions of public health services and use of private health services for what are perceived to be non-specific illnesses may be delayed help-seeing for TB, as TB treatment in Cambodia is offered through public health services alone. Such diagnostic delays until the illness is severe, can lead to spread and infection of others in the community.
Other challenges for TB control uncovered by our research included lower awareness of tuberculosis, great distrust in biomedicine, more reliance on traditional medicine, lower priority for accessing public health service for TB and significant problems with accessing health facilities at the most rural site compared to the other two sites. As a respondent from this site eloquently noted: “It is not because we don’t want to go to the hospital, but because we don’t have enough money. We prefer to die at home as we are too poor and the hospital is too far”. The need for better outreach and accessible health services in this area is clear.
Broadly, our research found a dichotomy in experiences and behaviour with respect to seeking care for illnesses considered non-specific or less severe (which may be TB in its early stages), compared to seeking care for more advanced TB, identified by participants as cough with blood in sputum. This dichotomy resulted in the tendency to delay seeking appropriate care until the development of severe symptoms clearly indicative of TB, which in turn is a major barrier to early diagnosis and treatment of the disease. Our study indicates that improvements in horizontal primary health services to match the well-run vertical TB programme could lead to a better balance with significant synergies, and contribute to tackling TB control beyond what is possible in a primarily vertically-run programme.