PHNOM PENH, Cambodia — Neglected tropical diseases (NTDs) afflict more than one billion people around the world. This group of infections often accompanies poverty, as they usually arise from inaccessibility to water, malnutrition, poor hygiene and inadequate sanitation.
Many countries today struggle to fight these diseases that claim lives and chronically debilitate millions. Poverty-reduction tactics are attempted, foreign aid pours in and yet, progress remains slow.
But some countries have succeeded by way of widespread behavioral change.
A new report by the Overseas Development Institute (ODI) has revealed that Cambodia is one such country. Despite its poverty, the country has found success in combating its three most prevalent NTDs: intestinal worms, snail fever and elephantiasis.
In 2004, the country became the first to reach the World Health Organization’s (WHO) target of providing 75 percent of school-aged children regular treatment for intestinal worms. Cambodia achieved this goal six years ahead of schedule by undertaking a nationwide mass drug administration (MDA) program.
The pilot program began in 1997 before it became nationwide in 2003. In 1990, hookworms — a type of intestinal worm — were the seventh most common cause of child disability. In 2010, it was the 53rd. Roundworms similarly fell from ninth to 111th.
Meanwhile, in 1995, the prevalence of snail fever hovered near 75 percent. That year, MDA programs began and were progressively expanded and improved to better target endemic villages. By 2003, that number crashed to 0.5 percent. Today, snail fever has been virtually eliminated.
Because of these programs, Cambodian policymakers became increasingly aware of which regions were most endemic. So in 2004, Cambodia unveiled an MDA program for elephantiasis. It enjoyed unparalleled efficiency from its inception and by 2010, prevalence rates were close to zero. If transmission tests confirm these low prevalence rates, Cambodia could be certified by the WHO in 2015 as being elephantiasis-free.
How Did Cambodia Do It?
The ODI lists five factors that have driven this change: strong collaboration between education and health sectors, cost-efficiency, global partnerships, effective fundraising and general progress in the education and health sectors.
Cambodia’s deworming program demonstrates how all of these factors brought about its success.
Because school-aged children are the most likely to suffer from intestinal worms, Cambodia shrewdly targeted them through a nationwide school deworming program. This was one of the largest deworming programs ever undertaken, and it succeeded because of the enthusiastic cooperation between the Ministry of Health (MoH) and the Ministry of Education (MoE). The MoE took on additional responsibilities without hesitation, as teachers — serving the goals of the deworming program — essentially became pharmacists twice a year.
The program was also cost-efficient. The pilot program cost 12 cents per student. As the program was expanded nationwide, it only cost six cents. And when it continued to become more efficient and only endemic villages were targeted, the cost dropped to a paltry three cents.
Such cost-effectiveness was achieved because Cambodia relied on pre-existing channels; routine outreach activities and special village meetings were modified to incorporate NDT education and treatment. This circumvented the costs of training more staff and allowed more remote locations to be reached by the deworming program.
Partnerships of all types were essential to the deworming program’s efficacy. The MoH partnered with a sub-department, the National Malaria Center Helminths Sub-Unit (CNM/HSU), which itself partnered with the MoE in delivering treatment to students. The CNM/HSU was set up only after gaining knowledge from development partners specializing in nutrition.
Since other countries have taken similar steps as Cambodia in fighting NTDs, the WHO — a key partner — developed a Regional Action Plan for Neglected Tropical Diseases in the Western Pacific Region so that countries of the region could learn from each other’s mistakes and successes.
Globally, Cambodia partnered with Children Without Worms (CWW), which — alongside with the WHO and NGOs — donated medications to the deworming program to ensure its continuation.
Funding for the deworming program arrived from two sources: external donors and the Cambodian government.
Pharmaceutical donations by organizations like the aforementioned CWW allowed Cambodia to offer free treatments. But operational costs still weighed down the program. In this regard, the MoH received small but essential funds from the Asian Development Bank’s Communicable Diseases Control Project and the World Bank’s Second Health Sector Support Program.
Since the market price for medications is often seven to ten times higher than the production price, the Cambodian government incurred a significant burden by undertaking such an expansive program. But some of that cost has been lessened by the CNM/HSU’s proactive fundraising and the willingness of salaried employees to take on more tasks without additional financial compensation.
Progress in Health & Education
Progress in the broader health sector has also contributed to the success of the massive deworming program. In 1990, the government spent $30 million on health; by 2012, expenditure soared to $134 million. Similarly, expenditure per capita increased from $4 in 2000 to $9.36 in 2009, resulting in better facilities, improved staff and a larger health infrastructure.
Education has seen a similar surge in quality. Since the fall of the Khmer Rouge, more and more students have been attending primary school. Now, nearly all school-aged children attend school. As the deworming program was mostly conducted through schools, this progress in the education sector ensured that the maximum number of children were being treated and reached by the health education curriculum.
– Shehrose Mian