With just under 15 million people, Cambodia is a small and vibrant country in Southeast Asia. While economic growth has increased in recent years, many Cambodians continue to live in poverty. In 2012, Cambodia ranked 138th out of 187 countries assessed in the Human Development Index, a measure of well-being composed of education, income, and health. Among the biggest health challenges facing Cambodia today are high rates of maternal, infant, and child mortality, and infectious diseases such as HIV and malaria which also pose a significant threat.
PSI/Cambodia was established in 1993 when it launched a social marketing campaign for Number One condoms, a brand that still has a significant market share in Cambodia. Since then, PSI/Cambodia has expanded to include HIV prevention, reproductive health and family planning, child survival (diarrhea prevention and treatment and pneumonia treatment), and malaria prevention, diagnosis and treatment.
In 2013, with funding from USAID, PSI/Cambodia supported the formation of Population Services Khmer (PSK). PSK is an independent, local non-governmental organization that is registered with the Cambodian Ministry of Interior, that maintains close technical collaboration with PSI. Most program implementation in Cambodia is now led by PSK, with PSI/Cambodia providing technical support and assistance. PSK’s mission is to improve the health of low-income and vulnerable Cambodians through affordable, market-driven solutions, in collaboration with the Royal Government of Cambodia. PSK harnesses the strength of the private sector through a portfolio of interventions that includes provider behavior change, training programs, quality assurance, and other targeted support initiatives.
PSK is committed to evidence-based program interventions and engages in cutting-edge research throughout all health areas. Continual studies aim to understand supply and demand-side behaviors, such as drivers of healthy actions, and factors that encourage quality service provision by providers. In addition, PSK tracks the progress of interventions, ensuring measurable and positive results. Using innovative approaches as a foundation for all its programs, PSK continually strives to have more lasting and cost-effective impact throughout its health interventions.
PSI/Cambodia and PSK also have a range of quality health products that strike a balance between affordability and cost-recovery. PSK has a strong local network that expands access to health information and provides referrals for a variety of services. This empowers Cambodians to access the health care they want, when they need it.
PS/Khmer estimates that in 2015, its products and services helped avert 196,229 DALYs, including, by health area:
- 8,842 Malaria DALYs
- 73,764 HIV DALYs
- 87,664 FP DALYs
- 22,628 MNCH DALYs
- 3,332 Safe Abortion DALYs
PS/Khmer’s family planning programs also provided 671,548 couple-years of protection.
Since 1997, PSI/Cambodia has worked to improve the reproductive health status of poor and vulnerable women, with a focus on reducing unintended fertility and maternal mortality. Since launching the OK Pill oral contraceptive in 1997, PSI/Cambodia and now PSK have introduced a comprehensive mix of family planning products, including both short and long-term methods, thereby providing women with a wide range of options to meet their family planning needs. PSK uses behavior change communications materials, mass media, and an extensive network of community mobilizers and interpersonal communication workers to inform women of their family planning options, and refer them to appropriate healthcare facilities. To ensure that increased demand is met by high-quality health services, PSK invests in capacity building of providers and pharmacists through training and support.
In addition to its work with local partners, PSI/Cambodia started its own social franchise of private sector providers, the Sun Quality Health Network (SQHN), in 2002. Creating the SQHN further harnessed private sector potential, increasing access to high-quality health services, with a special focus on reproductive health. SQHN providers receive training on family planning counseling and service provision, supportive supervision and quality assurance visits, and support for the management of adverse events and complications. In addition, PSK creates demand for providers through its outreach programs and offers family planning products at a subsidized rate. In return, providers agree to adhere to certain quality and reporting standards. Since 2010, with the approval of the Ministry of Health, other health areas – especially child survival and malaria – have been integrated into several SQHN clinics. Additionally, 10 SQHN members were also trained in a cervical cancer screening and treatment pilot program. Since its founding, the social franchise network has grown to include approximately 230 members in 22 provinces.
PSK also supports private sector providers who do not offer all birth spacing methods. This includes those who work at polyclinics, maternity homes and referrers of other providers, for services such as IUD insertion. These providers have not entered into an SQHN agreement, but can receive training, demand generation and provision of subsidized product. They also benefit from supportive supervision, quality assurance and assistance with the management of adverse events and complications.
The Medical Detailing Program assists both healthcare and outlet providers, such as pharmacists, in counseling clients effectively on all family planning products. Through regular visits and trainings, medical detailing officers encourage provider behavior change and ensure high-quality prescribing and counseling services. Reproductive health products are distributed to healthcare providers and retail outlets throughout all of Cambodia. Working with a national distributor as well as its own sales and distribution team, PSK was responsible for 45% of the Cambodian family planning product market in 2016.
As one of the largest NGOs in Cambodia dedicated to promoting access to high-quality family planning services and supplies, PSK works closely with the Royal Government of Cambodia (RGC) to ensure consistency of protocols, transfer of skills from the private sector to the public sector, and support of national efforts to increase the use of modern methods, particularly long-term methods. In order to assist in determining the need for family planning commodities in Cambodia, PSK works with the national Contraceptive Security Working Group to develop and update a Total Market Approach Calculator. Using this tool, the RGC can forecast future family planning commodity needs, by method and by supply sector.
In response to the high abortion rates and related maternal mortality in Cambodia, PSI provides a safe medication abortion product that is both legally registered and included in Cambodia’s National Essential Drugs List. While only clinics certified by the Ministry of Health as Comprehensive Abortion Care sites can provide medication abortion, PSK ensures that all SQHN members are prepared to counsel women who have accessed medication abortion and have questions, concerns or are experiencing negative consequences. In addition, hotline counselors follow up with callers seeking information on safe abortion, in order to ensure that they have received safe treatment and post-abortion services as needed. PSK recognizes that women have a particularly strong need for family planning after an abortion or delivery.
- OK Pill oral contraceptive
- Eva Marvelon oral contraceptive
- OK injection
- Jadelle implant
- OK IUD
- Next 72emergency contraceptive pill
- Medabonmedication abortion pills
To strengthen HIV prevention in Cambodia, PSK aims to sustainably increase the accessibility, affordability and availability of condoms throughout the country, and to grow demand for and consistent use of condoms among most-at-risk populations, using a total market approach (TMA).
PSI/Cambodia began its work in this health area in 1993, when it partnered with the RGC to implement the 100% Condom Use program, and began social marketing of Number One condoms. In 2005, PSI/C introduced OK condoms as a part of its OK-branded family planning products and services. That same year, PSI/Cambodia launched co-packaged condoms and lubricant sachets, now branded as OK Plus, to offer a product specifically designed for men who have sex with men (MSM) and for entertainment workers who engage in commercial sex.
IRecently, in coordination with the National Center for HIV/AIDS, Dermatology and STDs (NCHADS), the Core Group on Sustainability of Condom Supply was established. Its aim is to achieve the strategic vision of a sustainable condom market that meets Cambodia’s universal need for condoms, increases contraceptive prevalence rates (CPR) and reduces new HIV infections. To accomplish this, all sectors of the condom market – public, non-profit private, such as PSI/Cambodia and PSK, and commercial – need to be well aligned and coordinated to meet the needs of the Cambodian people. Over time, the goal is to increase the total number of people using condoms – growing the total market – regardless of the source. Yet, as the earning power of many Cambodians grows and disposable income rises, the commercial sector can successfully sell their brands and increase their volumes.
PSK’s social marketing sector products – OK and Number One – appeal to lower income groups and more vulnerable populations with highly targeted distribution at venues that are frequented by key populations (i.e., guesthouses). PSK has also upgraded its Number One brand by introducing flavor variants, to appeal to consumers at a slightly higher price point. This kind of segmentation helps the market transition from higher to lower amounts of subsidy over time. At the same time, PSK engages with the RGC to support policies on free distribution of condoms for outreach demonstration, and for those least able to pay for and access condoms.
To avoid new infections and reduce HIV risk, PSK is working as a consortium partner with KHANA and FHI 360. The objective is to introduce innovations that support the RGC’s Cambodia 3.0 goals and Continuum of Prevention, Care, and Treatment guidelines developed under the leadership of NCHADS. This USAID-funded HIV flagship project runs for five years. To achieve PSK’s target of creating demand for condoms and reach those most at-risk of HIV (entertainment workers, MSM and male clients), PSK employs several models of evidence-based communication, outreach and innovative sales techniques. These include:
- Integrated mass media and outreach campaigns.
- Peer-to-peer condom promotion and sales at entertainment establishments.
- Condom merchandising by mobile street vendors near high-risk venues.
- Use of GPS to map high-risk venues and product availability at nearby sales outlets.
- Messaging that focuses on high-risk ‘sweetheart’ relationships, in which condom use is low.
- Integration of family planning into HIV programming for entertainment workers.
PSK also builds the capacity of local NGOs to implement effective interpersonal communication (IPC) and social marketing activities through the United Health Network and sub-grants. The IPC activities help to address the reasons people do not adopt healthy behaviors: i.e. they do not feel they are at risk, they trust their partners, or they need ways to negotiate condom use.
Finally, PSK has recently expanded efforts to integrate family planning products and counseling into its HIV prevention program for entertainment workers. Innovative approaches include community distribution of oral and emergency contraceptives, and referrals for long-term methods.
- OK Plus condom (includes lubricant sachet)
- Number 1condom
PSI/Cambodia launched its malaria program in 2003 with the introduction of malaria test kits and anti-malarial drugs, branded as Malacheck and Malarine, respectively. In 2006, long lasting insecticide treated nets (LLINs), or Malanets, were added to complete the portfolio of products made available through private-sector outlets across the country. Today, the program operates across all 21 malaria endemic provinces and continues to work in close partnership with the National Malaria Control Program. In recent years, several exciting new approaches have also been added, including the worksite program (2013), quality assurance (2014), and electronic data collection (2016).
Since 2004, PSI/Cambodia and now PSK have provided an annual one-day early diagnosis and treatment training to ensure providers are equipped with the skills and confidence to correctly diagnose and treat patients with malaria symptoms. Using proven adult participatory learning techniques to reinforce correct case management skills, this course is routinely reviewed to ensure it reflects current Ministry of Health policies. In addition to the training sessions, PSK deploys a provider behavior change communication force. Comprised of medical doctors and pharmacists who are on the road seven days a week, these teams visit providers at their place of work to ensure that they are routinely supported with technical advice and regular updates. Patients are reached through mass media channels including TV and radio.
In 2009, PSI/Cambodia launched a unique malaria prevention approach called the Bundling Program. Based on data showing that approximately 1 million untreated nets are imported into Cambodia every year, PSI/Cambodia re-evaluated its LLIN distribution campaign and decided to change track. Rather than compete with this vibrant market, PSI/Cambodia started to work directly with the net importers to improve the nets that were already being delivered. For every conventional net imported, PSI/Cambodia provided a net retreatment kit which net importers attached to the nets before moving them to provincial markets. PSI/Cambodia provided the kits for free and aired TV and radio spots to create demand. In less than one year, 70% of the markets across Cambodia were selling bundled nets.
An estimated 60 to70% of Cambodians visit their nearest private sector outlet for their health care needs, and malaria is no exception. However, with no routine system to collect caseload data from the private sector, there is a clear data gap which makes it challenging for the National Malaria Program to plan strategically. To address this, PSK and the Cambodian National Malaria Center began running mirror-image public-private mix (PPM) programs in 2013. The goal of this new initiative is to first map all registered private sector outlets and second, to train the providers to improve early diagnosis and treatment (EDAT). It is also to strengthen their record-keeping systems and to ensure that all severe cases are referred to the nearest public facility. PSK also asks that providers keep their used-rapid diagnostic tests, which are collected by provider behavior change communication officers (PBCCOs) during their monthly visits. The tests are brought back to Phnom Penh where the data is extracted and used as a cross-check. As of January 2017, PSK has signed a memorandum of agreement with 657 private providers.
Due to their link with the development of drug resistance, mobile migrant workers are high on the radars of both the National Malaria Program and the international health community. Often employed in remote worksites and frequently on the move, these workers are notoriously difficult to reach with health services. In 2013, PSK completed the first national survey to map the location of these worksites and collected a range of data including the number of workers employed by season, the availability of services and net usage. By the end of 2013, PSK signed a memorandum of understanding (MoUs) with 45 worksites and 77 mobile malaria workers (MMWs) in five provinces. Since then, the program has expanded to 131 worksites and 203 MMWs in seven provinces. All plantation owners/managers and MMWs were invited to join an orientation workshop to formally introduce the Worksite Program and all MMWs were subsequently trained on malaria testing and treatment, diarrhea treatment, and condom distributions. The MMW then provided free services and products to all workers and family members residing on their associated worksite. PSK staff provide monthly technical and material support to MMWs in exchange for data on the malaria caseload and the treatment of diarrhea, which is reported directly to local health authorities and the National Malaria Program.
From 2011 to 2015, Cambodia began to shift programming to malaria pre-elimination, to prepare for full elimination by 2025. In response, PSK has made sure that all private malaria providers (both PPM and MMW) have the necessary knowledge and skills to provide high-quality care to all patients. To this end, PSK established the quality assurance (QA) program in 2014 to ensure patients receive the highest possible level of care by identifying areas of weakness, and providing structured support to address underlying problems. The QA team works closely with the provider behavior change communication team who visits providers every month to provide this support based on provider performance during the QA assessments. Results from the QA program indicate that providers consistently improved year to year as the quality of care metric has improved from 72.2% in 2014 to 78.4% in 2016.
In 2016, the government launched the Malaria Elimination Action Framework 2016 – 2020, which identified a number of steps necessary to move Cambodia towards malaria elimination. Particularly crucial was its recognition of required updates to the data entry and surveillance systems, which often take up to two months for malaria case data to reach those responsible for making programmatic decisions. In response, PSK established a surveillance program in 2016 to upgrade the data collection system in the private sector. PSK launched the Malaria Case Surveillance (MCS) app in July 2016 and began rolling out phones and apps to all its providers, allowing them to enter a wealth of information on each patient in a simplified, intuitive manner. Data input by providers via the app is automatically uploaded to PSK’s District Health Information Software (DHIS2). This significantly reduces the number of steps involved in data collection and allows PSK, the government, and partners to pivot more quickly based on what is happening on the ground. In the near future, the hope is to link the application with the National Center for Parasitology Entomology and Malaria Control’s (CNM) malaria information system (MIS), so both the government and PSK can access and utilize real-time private sector data on demand.
- DS Standard Diagnostics, ONE STEP Malaria HRP-II (P.f) and pLDH (P.v) Antigen Test. Provides a result in 15 minutes with 4 drops of buffer solution.
- ACT: Eurartesim (DHA-PPQ), an effective 3-day treatment in three age-specific dosages – child, adolescent, and adult.
Artesunate Mefloquine (ASMQ), also an effective 3-day treatment in one age-specific dosage – child.
In its child survival program, PSK works to address two of the most serious health threats to children ages five and under in Cambodia: diarrheal disease and pneumonia/acute respiratory infection (ARI). In both areas, PSK aims to increase access and availability of high-quality products and service provision.
In 2006, PSI/Cambodia introduced the world’s first commercially available diarrhea treatment kit, branded OraselKIT, combining ORS and zinc, in a pilot project in two Cambodian provinces. Since then, distribution has expanded to 15 provinces. OraselKIT is distributed through commercial retailers, village shopkeeper networks, rural outlets, community health workers and the SQHN.
In order to increase demand for OraselKIT, PSK collaborated with a number of local NGOs in the United Health Network (UHN) to implement community outreach programs. Outreach workers make household visits, organize community educational sessions, and reach caregivers at public gatherings to provide information on symptoms and danger signs for the home management of childhood diarrhea. OraselKIT was directly distributed by the UHN to village shopkeepers, rural outlets, and community health workers. For pneumonia/ARI, caregivers are taught how to recognize the symptoms and danger signs, and are provided with contact information for the nearest qualified, trained healthcare providers who can provide treatment.
PSK also works to improve providers’ behavior through medical detailing and tailored training programs. PSK offers providers the skills and tools they need to correctly diagnose and treat diarrhea and pneumonia, while following Ministry of Health policies.
Orasel KIT®: Contains two sachets of new low-osmolality oral rehydration salts (ORS) and one course of dispersible zinc treatment (10 tablets of 20mg).
PSK’s WASH program started in 2016 and works to increase the clean water use in Cambodia. Currently, the program is in pilot phase and is testing strategies to improve overall use of clean water in Kampong Speu province to evaluate their potential for scale up.
The Provincial Department for Rural Development suggested that PSK, given its experience with social marketing, could complement a local partner, TS1001, which produces and distributes safe drinking water in this province.
In TS1001’s coverage area, PSK is working to increase demand for TS1001’s products through two approaches: first, PSK builds the capacity of TS staff and their kiosk management committee in marketing, sales, coverage, and service quality. This strengthens the organization’s ability to generate demand. Second, PSK participates in a number of WASH-oriented interpersonal communication activities. Outreach workers make household visits, organize community educational sessions, and work to reach caregivers at public gathering places. If local populations identify safe drinking water as a priority, the interpersonal communication (IPC) focal point refers them to TS1001’s products. In addition, caregivers are taught to identify safe sources of drinking water in the community and common water borne diseases.
For areas outside of TS1001’s coverage area, PSK also works to increase demand by improving providers’ behavior through medical detailing and tailored training programs. PSK offers providers the skills and tools they need to counsel clients, particularly those who come with diarrhea, on clean water use and various water treatment options – including water filters.
In 2017, PSK’s research team is planning to conduct a formative study and market assessment of the clean water and water filter markets as well as the attitudes and behaviors of target populations with respect to safe drinking water. The findings from these studies will inform behavior change strategies and program design moving forward. The baseline and endline surveys generated will be used to better understand the prevalence of clean water use, to determine how prevalence changes over the course of the two-year program. Results will then be used to improve the program and its approach in the future.
- Royal Government of Cambodia
- Family Health International 360
- United Health Network
- INTHANOU Association
- Mega Lifesciences
- Clinton Health Access Initiative (CHAI)
- Malaria Consortium
- University Research Co. (URC)
- 17 Triggers
- Worksite Programs for Malaria Elimination: Best Practices & Lessons Learned from Cambodia
In 2013, Population Services Khmer (PSK) launched its malaria worksite program on 45 plantations in five malaria endemic provinces of Cambodia. This document summarizes the program’s key learnings and recommendations.
- Malaria Elimination: Who is Really at Risk?
This document presents an alternative approach to thinking and talking about malaria risk factors affecting mobile and migrant populations in the Greater Mekong Subregion, and how this can be translated into strategy and action.
- The GEMS Program: Greater Mekong Subregion Elimination of Malaria through Surveillance
In 2016, PSI launched GMS Elimination of Malaria through Surveillance (GEMS) in Cambodia, Lao PDR, Myanmar and Vietnam to strengthen case management and surveillance in the private sector to accelerate malaria elimination. This project brief describes each component of GEMS project in detail.
- Shaping the Family Planning Market by Strengthening the Public Sector
PSI considers total market approaches to be critical for achieving universal health coverage, especially when it comes to contraception. This program brief presents cases, supported by several different donors, which take into consideration the total family planning market.
- Making Data Work for Malaria Elimination: Surveillance in the Private Sector
This two-page brief describes the importance and usefulness of the Malaria Case Surveillance App and provides a case study of how it has been used in Cambodia.
- Towards Subsidized Malaria Rapid Diagnostic Tests. Lessons Learned from Programmes to Subsidise Artemisinin-Based Combination Therapies in the Private Sector: a Review
Private sector subsidy programmes of ACTs have been effective in increasing availability of ACTs in the private sector and driving down average prices but struggled to crowd out antimalarial monotherapies. A subsidy of rapid diagnostic tests (RDTs) in the private sector has been recommended by governments and international donors to cope with over-treatment with ACTs and to delay the emergence of resistance to artemisinin. In order to improve the cost-effectiveness of co-paid RDTs, we should build on the lessons we learned from almost 10 years of private sector subsidy programmes of ACTs in malaria-endemic countries.
- Antimalarial Market Improvements in Cambodia from 2009 to 2015
Repeat outlet surveys in Cambodia demonstrate the success of public and private strategies to improve case management. The private sector still accounts
for the majority of antimalarial distribution. Given the continued role of the private sector in antimalarial distribution in Cambodia, there is need to scale up private sector engagement and support to ensure quality case management.
- Simplified Asset Indices to Measure Wealth and Equity in Health Programs: a Reliability and Validity Analysis Using Survey Data from 16 Countries
Many program implementers have difficulty collecting and analyzing data on program beneficiaries' wealth because a large number of survey questions are required to construct the standard wealth index. We created country-specific measures of household wealth with as few as 6 questions that are highly reliable and valid in both urban and rural contexts.
- Evidence of Successful Malaria Case Management Policy Implementation in Cambodia: Results from National ACTwatch Outlet Surveys
Cambodia has worked for over a decade to implement policies and strategies to increase access to quality malaria case management services and address the driving forces behind multi-drug resistance. This paper analyzes outlet survey trend data collected by the ACTwatch project to demonstrate how these changes in policy and strategy have led to shifts in Cambodian anti-malarial markets.
- Integrating Family Planning Services: Family Planning HIV Integration Among Entertainment Workers, Cambodia
In Cambodia, the HIV prevalence among adult populations aged 15 to 49 gradually decreased from 2% in 1998 to a projected 0.7% in 2013. Despite this decline, high prevalence still exists among members of most-at-risk populations (MARPs): female entertainment workers (FEWs), men who have sex with men (MSM), transgender people (TG), and people who inject drugs (PWID).