With just under 15 million people, Cambodia is a small country in Southeast Asia, sharing borders with Vietnam, Thailand and Laos.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 challenges facing Cambodia in the realm of public health today are high maternal, infant and child mortality; infectious diseases such as HIV and malaria also pose a significant threat.
PSI/Cambodia (PSI/C) was established in 1993 when it launched a social marketing campaign for Number One condoms, supporting the Royal Government of Cambodia’s (RGC) 100 percent Condom Use Program. Since then, PSI/C has expanded its health programs to include HIV prevention, reproductive health and family planning, child survival (diarrhea prevention and treatment and pneumonia treatment), and malaria prevention, diagnosis and treatment. As a key partner of the RGC, PSI/C’s support strengthens Cambodia’s health systems by harnessing the private sector to improve the health of the poor and vulnerable. It does so through a portfolio of interventions that includes medical detailing, training programs, and targeted outlet support to improve the behaviors of the private sector. In addition, PSI/C makes quality and affordable products and services accessible and available and encourages Cambodians to seek quality health care through its extensive network of community outreach workers and demand generation activities.
In line with its institutional development vision, PSI/C has evolved into a Cambodian organization, Population Services Khmer (PSK). Launched in 2013, PSK is an independent, local non-governmental organization that is registered with the Cambodian Ministry of Interior. PSK has an organic and sustained connection with PSI and benefits from the global network to promote life-saving products, services and communications to help Cambodians lead healthier lives.
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 behaviors and factors that encourage quality service provision by providers. In addition, PSK’s management information system department tracks the progress of interventions, ensuring measurable and positive results. Using innovative approaches as a foundation for all of its programs, PSK encourages healthier behaviors by ensuring people have the opportunity, ability and motivation they require to make healthier choices and seek quality health services.
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/C and now PSK have introduced a comprehensive mix of family planning products, including both short- and long-term methods, and 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/C started its own social franchise of private sector providers, the Sun Quality Health Network (SQHN) in 2002. Creating the SQHN further supported the harnessing of private-sector potential to increase 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. Finally, in the coming months, a select number of SQHN members will become part of a cervical screening and treatment pilot program. Since its founding, the social franchise network has grown to include more than 230 members in 17 provinces.
PSK also supports private sector providers who do not offer all birth spacing methods, including those who work at polyclinics and maternity homes and refer to other providers for services such as IUD insertion. These providers have not entered into an SQHN agreement, but can receive support including training, demand generation and provision of subsidized product, as well as supportive supervision, quality assurance and assistance with the management of adverse events and complications.
While PSK’s Training Teams instruct and its Supportive Supervision Teams supervise healthcare providers in their technical skills, PSK’s Medical Detailing Program assists health care providers as well as outlet providers, such as pharmacists, in counseling clients effectively on all family planning products. Through regular visits and trainings, medical detailing officers work to encourage provider behavior change and ensure high-quality prescribing and counseling services. PSK’s reproductive health products are distributed to health care 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 56 percent of the Cambodian family planning product market in 2012.
In order to further support both clients and providers, PSK operates a provider hotline that enables providers to access technical information and order stock, while clients can call a consumer hotline to receive information about family planning and reproductive health options, including referrals for services.
In response to the high abortion rates and related maternal mortality in Cambodia, PSK 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. PSK recognizes that women have a particularly strong need for family planning after an abortion or delivery. In order to address this, PSK began in 2013 to train SQHN providers as well as hotline counselors to answer questions and counsel women on post abortion and port partum family planning, as well as refer to appropriate product and service provision outlets.
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 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. Furthermore, in order to ensure that policy initiatives become a reality on the ground, PSK has begun assisting provincial health departments in determining their reproductive health needs and goals and training supervisors to ensure quality service provision at public health centers.
- OK Pill
- OK Injection
- Jadelle Implant
- OK IUD
- Next 72 Emergency Contraceptive Pill
- Medabon Medication Abortion
- Marvelon Oral Contraceptive
For HIV prevention in Cambodia, PSK aims to increase 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/C began its work in this health area in 1993, when it partnered with the Royal Government of Cambodia 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 itsOK-branded family planning products and services. That same year, PSI/C launched co-packaged condoms and lubricant sachets, now branded as OK Plus, to offer a product specifically designed for MSM and for entertainment workers who engage in commercial sex.
To reduce new HIV infections sustainably, all sectors of the condom market – public, social marketing and commercial – need to be well aligned and coordinated to meet the need 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 they have more disposable income, 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 itsNumber One brand by introducing flavor variants, to appeal to consumers at a slightly higher price point. This kind of market 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 development of policies on targeted free distribution of condoms for outreach demonstration and for those least able to pay for and access condoms.
In order to create 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 builds the capacity of local NGOs to implement effective 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 Condom
- OK+ Condom and Lubricant Sachets
- Number 1 Condom
PSI/C 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, 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 20 malaria endemic provinces and continues to work in close partnership with the National Malaria Control Program. In recent years, two exciting new approaches have also been added, the net bundling strategy and the plantations program which started in 2013.
To ensure providers are equipped with the skills and confidence to correctly diagnose and treat patients who present with malaria symptoms, PSI/C and now PSK have provided an annual one-day “Early Diagnosis and Treatment” training since 2004. 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 medical detailing 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/C 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/C re-evaluated its LLIN distribution campaign and decided to change track. Rather than compete with this vibrant market, PSI/C started to work directly with the net importers to improve the nets that were already being delivered. For every conventional net imported, PSI/C provided a net retreatment kit which net importers attached to the nets before moving them to provincial markets. PSI/C 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 60-70 percent 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 strategically plan. To address this, PSK and the Cambodian National Malaria center began running mirror-image Public Private Mix 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 their record-keeping systems and ensure that all severe cases are referred to the nearest public facility. PSK also asks that providers keep their used-rapid diagnostic tests, which medical detailers collect during their monthly visits. The tests are brought back to Phnom Penh where the data is extracted and used as a cross check.
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 plantations 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 plantations 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 will have signed MoUs with 40 plantations to allow PSK staff access to provide malaria health services to the workers from inside these enterprises in exchange for data on the number of cases tested and treated, which will be reported directly to the local health authorities and the National Malaria Program.
- Malacheck: Malaria Test. Differentiates between P. falciparum, P.vivax and mixed infections. Provides a result in 20 minutes.
- Malarine: An effective 3-day Malaria treatment using DHA-pip. Manufactured in three age doses – for children, adolescents and adults.
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/C introduced the world’s first commercially available diarrhea treatment kit, branded OraselKIT and combining ORS and zinc, in a pilot project in two Cambodian provinces. Since then, distribution has been expanded to 15 provinces. OraselKIT is distributed through commercial retailers, village shopkeeper networks, rural outlets, community health workers and the SQHN.Pneumox250, an antibiotic designed to treat pneumonia and ARI in children under five, was introduced in 2012. It is distributed through private providers that are legally registered and appropriately trained, including providers from the SQHN network, doctors and nurses working in Health Care Rooms/Consultation Cabinet Rooms, and outlet providers at pharmacies and drug depots.
In order to increase demand for these lifesaving products, PSK and its local NGO partners in the UHN use interpersonal communications activities. Outreach workers make household visits, organize community educational sessions and reach caregivers at public gathering places. In the case of the OraselKIT, United Health Network workers directly distribute treatment kits to caregivers and provide instructions on symptom and danger signs recognition and home management of childhood diarrhea. For pneumonia/ARI, caregivers are taught symptom and danger signs recognition, and are provided with contact information for the nearest qualified healthcare providers who can provide treatment with Pneumox250.
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 MoH policies.
Finally, in order to improve diarrheal disease prevention, PSI/C introduced a safe water program in 2010. This project, currently present in 15 provinces, focuses on distribution and correct use of household water treatment tablets and safe hygiene practices. Products are supported with intensive community-based communications focusing on holistic hygiene behavior change messages.
- Orasel KIT®: Contains two sachets of new low-osmolarity oral rehydration salts (ORS) and one course of dispersible zinc treatment (10 tablets of 20mg).
- Toeuk Sovatepheap: Contains ten tablets of chlorine-based active ingredient sodium dichloroisocyanurate (NaDCC). Each 67mg Toeuk Sovatepheap tablet contains 40mg free available chlorine and treats 20L of water.
- Pneumox250: Contains one full dose of antibiotic for a child under five years old.
- U.S. Agency for International Development
- The Global Fund To Fight AIDS, Tuberculosis and Malaria
- Bill and Melinda Gates Foundation
- Royal Government of Cambodia
- United Health Network
- Family Health International 360
- 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).
- Improving Provider Behavior Change Communication and IPC: Best Practices from the Women’s Health Project
This brief describes the challenges faced, strategies developed, and lessons learned by the Women's Health Project. It also proposes a set of best practices for improving productivity of interpersonal communications (IPC) agents and increasing providers' skills and motivation.
- Increasing LARC Provision in Cambodia through Improved Provider Selection and Motivation Strategies
This brief describes the challenges faced, strategies developed, and lessons learned to improve uptake of long-acting reversible contraception through the Sun Quality Health Network in Cambodia.
- Approaches to Measuring Equity: Methods & Pilots from 12 Franchise Programs
PSI's presentation at the iHEA conference highlighted equity results from social franchising programs and introduced standard methods for the collection and analysis of equity data.