New Funding Model
Malaria continues to be a major contributor to public health and economic burden in Cambodia with high rates of morbidity and mortality, hence malaria control is a priority for Cambodia. The National Strategic Plan for Elimination of Malaria (2011-2025) aims to ensure that no artemisinin-resistant malaria parasites are detected in Cambodia by 2015, to eliminate falciparum malaria as well as malaria deaths by 2020, and to eliminate of vivax malaria by 2025, in line with the global call for elimination and eradication of malaria.
Program implementation in Kampot, Koh Kong, Preah Sihanouk, Kampong Chhnang, Kampong Speu, Pursat, Kep and Takeo provinces. The program focuses on information, education and communication (IEC)/ Social Behavior Change Communication (SBCC) interventions, particularly through community mobilization: raising awareness of malaria among at-risk populations, increases use of bed nets (particularly for children) and other prevention measures, and promotes individual awareness and self-protective changes for the general population. PfD is building the capacity of community health workers in effective IEC/SBCC tools and skills to effectively identify Key Affected Population (KAP) in or near their villages and to mobilize their communities toward health goals to achieve long-term sustainability.
- Train, inform, and educate key village members (e.g., maternal and child health and mobile/ migrant population (MMP) key persons) about malaria risk, prevention, diagnosis, and treatment.
- Mobilize communities through strengthening relationships between VMW/health facilities and key community members for prevention and referral to VMWs/health facilities including tracking of case referral from community to VMW/HC
- Conduct BCC Impact Assessment (KAP Survey) and develop BCC interventions, IEC/BCC toolkits, and training materials; build capacity of existing sub-national health systems and staff.
Result of the program is on-going, but as of July 2017:
- Trained 253 health center staff on ToT approach for participatory community mapping and group identification and BCC approach
- Trained 11 Village Malaria Workers (VMW) on participatory community mapping and group identification and BCC
- Conducted the World Malaria Day in seven target provinces with average of 300 participants in each event
- Co-organized two kick – off workshop for consortium members and government health partners and national consultation workshop on BCC message and approach.
- Carried out Knowledge, Attitude and Practice (KAP) survey in eight target provinces with the results:
- Proportion of population that slept under an insecticide-treated net* the previous night in target districts (77%)
- Proportion of children under five years old who slept under an insecticide-treated net* the previous night in target districts (76%)
- Proportion of pregnant women who slept under an insecticide-treated net* the previous night in target districts (73%)
- Percentage of population at risk of malaria living in the targeted VMW/VHSGs villages who go to a VMW/VHSGs/MMW when they have a fever (5%)
- Percentage of population at risk of malaria living in the targeted villages who correctly identify symptoms of malaria (79%)
- Percentage of population at risk of malaria living in the targeted villages who correctly identify cause of malaria (83%)
- Percentage of forest goers living in targeted villages who slept under an ITN the last time they were in the forest (71%)
PfD is piloting an early warning system in Kratie province to improve tracking the emergence and spread of drug resistant parasites. The approach combines the experience of PfD in implementing interventions towards mobile migrant populations (MMP) and at community level, the expertise of the London School of Hygiene & Tropical medicine (LSHTM) in conducting operational research in Cambodia on MMPs and on drug resistance and the technical skills and expertise of Pasteur Institute in Cambodia (IPC) in molecular epidemiology. The project focuses on the Cambodia-Vietnam border where recent research results have documented the emergence of artemisinin resistant strains in Bin Phuoc province in Vietnam and delayed parasite clearance time in Snuol area in Kratie province (with the potential threat to spread to neighboring Kratie province in Cambodia).
- Conduct research to inform surveillance of drug resistance and establish an “early warning system”
- Measure drug resistance focusing on K13 (a protein that is strongly linked to artemisinin resistance)
- Strengthen tracking and information systems for MMPs
- Implementation of Plasmodium Falciparum (Pf.) Day 28 follow up and admission of Pf. Day 28 positive patients by health facilities to track drug resistance (train health staff on early diagnosis and treatment (EDAT) and second line treatment based on national treatment guideline; train VMW on EDAT)
PfD is piloting an early warning system in Kratie province to improve tracking the emergence and spread of drug resistant parasites. The approach combines the experience of PfD in implementing interventions towards MMP and at community level, the expertise of LSHTM in conducting operational research in Cambodia on MMPs and on drug resistance and the technical skills and expertise of IPC in molecular epidemiology. The project focuses on the Cambodia-Vietnam border where recent research results have documented the emergence of artemisinin resistant strains in Bin Phuoc province in Vietnam and delayed parasite clearance time in Snuol area in Kratie province (with the potential threat to spread to neighboring Kratie province in Cambodia).
In Cambodia, malaria is a health risk for an estimated 2.13 million people who live or work in close proximity to the tropical forests; and malaria remains one of the leading causes of death in Cambodia. Results from a 2007 large-scale survey indicate that mosquito net coverage (people sleeping under a net) was 80% in most high risk areas, but Insecticide-Treated Nets (ITN) coverage remained low (25%) despite re-treatment efforts. Due to poor health care coverage in endemic provinces, especially in remote locations, access to and use of quality malaria diagnosis and recommended treatment remains a challenge. This issue is inappropriately addressed by the informal and unregulated private sector currently used by 60-70% of Cambodian patients with fever cases. The program aimed to strengthen and scale up the most successful control activities.
In Phase 1 (GF-RCC Round 9), PfD conducted community-based interventions focusing on geographical and strategic areas where gaps have been identified and where government or other organizations have difficulty reaching. PfD focused on reaching out to mobile and migrant population (MMPs) by developing a strategy to work with MMPs, private companies, land development companies, owners of plantations and relevant local authorities at all levels including communities. PfD piloted the design and development of a forest package containing prevention, diagnosis and treatment products to be distributed through various channels to mobile and migrant population and local forest goers. In phase 1, PfD implemented programs in Stung Treng, Kratie, Koh Kong and Kampot provinces. In addition, PfD managed one international NGO sub sub-recipient (SSR) (Equal Access, now localized to Media One), and managed four Provincial Health Department (PHD) SSR in the four provinces. In Phase 2 (GF-SSF), PfD expanded these community-based interventions within Kratie and Koh Kong provinces.
Key Activities for GF-RCC/R9 (phase 1) and GF-SSF (phase 2):
- Case management: trained health staff, Village Malaria Workers (VMW), Mobile Malaria Workers (MMW), and Plantation Malaria Workers (PMW) on early diagnosis and treatment (EDAT), focused on MMPs
- Vector control: supported PHD/OD development of a mass distribution plan and mapped MMP; supported net distribution; designed and piloted forest package distribution for forest goers
- Surveillance: Performed Day 3 follow up of malaria cases to combat drug resistance by ensuring proper treatment
- Behavior Change Communication: created radio programming and community based malaria education; trained school teachers on malaria health education
- Trained 182 MMW and PMW on malaria diagnosis, treatment and health education; 888 Village Health Volunteers (VHV) on malaria health education; 441 School Teachers on malaria school health education using Child–To–Child methodology.
- Tested 4,285 patients suspected of malaria and treated 939 patients diagnosed with malaria; reached 121,354 individuals and 17,218 school children with community – based malaria health education;
- Distributed forest packages which could prevent malaria to 389 forest goers who were at risk malaria.
Final result: PfD achieved 91.4% of company/plantation workers who slept under an insecticide-treated net the previous night; 97.73% of school children who disseminated malaria prevention messages to their friends, families and other community members through various activities; and the forest package helped reduced malaria cases by 64% among forest goers.
The Agricultural Development Program exceeded its original objectives and close coordination with both the Provincial governments and Departments of Agriculture ensured successful implementation of the field programs. The four objectives of this program, improving agricultural productivity, enhancing household nutrition, supporting the Provincial Agricultural Extension Service, and improving access to markets, are interlinked and many of the activities completed by PfD spanned across more than one objective.
The first objective of the program was to improve agricultural productivity. PfD undertook a number of activities to accomplish this objective, including the introduction of new plant varieties, planting demo plots for farmer education, working with village veterinary workers and other volunteers to improve pig and poultry rearing, and introducing fish farming to households. Activities undertaken to achieve the second objective, to improve household nutrition, included introducing alternative farming techniques to combat cultivation difficulties during the dry season, incorporating fish farmed by the household into their diet, and the distribution of clay water filters. The third objective, to support provincial departments of agriculture was achieved through engaging associate staff to conduct field activities, conducting study tours to expose field personnel to developments abroad, training and providing support for field operations, and developing extension and training materials designed specifically for ADP activities. For the final objective, to improve access to markets, PfD designed, modified, and tested farm equipment for local manufacturing and commercialization and also collected information on market prices for a wide range of agricultural commodities.
The four focal areas of PfD’s community development work for the Allen Foundation in Stung Treng and subsequently Kratie province were: 1) economic development, particularly supporting rural livelihoods; 2) public health and sanitation; 3) public education and local capacity building, particularly improving community knowledge of health, nutrition, and agricultural practices; and 4) assessing and addressing problems in community infrastructure. A silk weaving training program was added to the project in 2001 with help from Veterans International. The World Food Program contributed rice to rice banks PfD built in Stueng Treng as part of its agricultural development support activities.
The project goal was to facilitate community development and quality of life within the eight communities. More specifically, through working with local structures such as Village Development Committees (VDCs), the project aimed to support community-initiated activities in: (a) economic development; (b) public health and sanitation; (c) public education and local capacity building; and (d) community infrastructure and communications.
The project completed “rice banks” in five villages across Stung Treng and Kratie. The banks have improved food security for poor farming households that are at risk of going in to debt or losing their land during periodic food shortages. Working through PfD, World Food Programme provided the rice stock for the banks to these community-constructed facilities. Members of the bank may then borrow from this stock during seasonal shortages; after harvest, borrowers then repay the bank with rice plus an extra 10% “interest” payment in rice. PfD also convinced local banks to provide credit for fertilizer and other key agricultural inputs.
With additional funding from the Allen Foundation, PfD also completed 100 latrines benefitting 567 community members, and provided sanitation education to families throughout the community.
PfD’s malaria prevention and control program, funded by The Global Fund to Fight AIDS, Tuberculosis and Malaria, and in partnership with the Ministry of Health’s National Center for Malaria and Dengue, worked at a community level to prevent and control malaria. Engaging village volunteers, primary school students, teachers, village authorities, commune councils and local elected officials, PfD worked to encourage behavior change focused on prevention and treatment among rural populations. PfD trained 1,345 teachers, benefiting 57,132 primary school students in health education. In 2014 alone, PfD trained 267 primary school teachers, reached over 57,000 individuals through community based malaria health education, and provided training for 500 new and existing Village Health Volunteers. Over the eight years that PfD has partnered with the Global Fund, PfD provided over 65,000 people with bed nets. This program improved access to early malaria diagnosis and treatment services, with an emphasis on detecting all new malaria cases (including among mobile/migrant populations) and ensuring effective treatment and P. falciparum gametocyte clearance. Also, PfD combated drug-resistant malaria parasites by improving access to appropriate treatment and educating the public against using sub-standard drugs and therapies. This was part of a larger strategy to promote awareness of malaria and change community understandings of how best to treat this endemic parasitic disease. PfD worked closely with local governments and health facilities to improve local capacity to fight malaria.
In 2011, with a $250,000, 2-year seed grant from USAID, Partners for Development (PfD) implemented its “Providing Rural Communities Equal Care through Commercial Transport” (PROTECT) initiative in Kratie province. PROTECT was funded and implemented as part of USAID’s Saving Lives at Birth partnership to test an innovative approach to overcoming transportation barriers to maternal and newborn services in rural Cambodia.
The PROTECT project aimed to develop a replicable and financially sustainable model to ensure access to ante/postnatal care, and delivery and emergency obstetric care in remote, rural villages of Kratie province, in northeastern Cambodia. With local government guidance and management, PfD tested a model designed to leverage the strong local demand for reliable motor transportation to benefit the area’s pregnant women and new mothers. In addition to ensuring low trip costs, PfD negotiated 24-hour emergency transport service for these women by establishing fixed rates for emergency transport, guaranteeing the availability of transport providers, and creating a revolving village loan fund to provide immediate micro-credit to pay for the emergency travel.
In the 13 month period August 2012 – August 2013, a total of 584 emergency loans were made out of the VLF in the 25 villages. 248 of these (42.5%) were for maternal/newborn care.The remaining 336 loans (57.5%) were for other illnesses or accidents, particularly malaria or diarrheal diseases.
Between September 2011 and September 2013, PfD implemented PROTECT in all villages within two Health Center catchment areas, Prek Prasob and Kanchor, with an estimated combined population of 33,115. The members of each area’s villages are subject to the annual floods that make travel by road arduous and hazardous during monsoon season every year. PfD purchased seven remorque motorbike taxis and two stronger koyun tractor-esque taxis to navigate the steep and muddy hills surrounding Prek Prasob and Kanchor’s villages, and established contracts with the local Commune Councils to ensure their continued functioning in each community.
From 2007 to 2011, with support from USAID and in collaboration with University Research Corporation (URC) and Cambodia’s MOH, PfD designed and implemented activities in: capacity-building; information, education and behavior change communication (IEC/BCC); formative and operational research; malaria case management and vector control in the northwest provinces of Battambang, Pailin, Banteay Meanchey and Oddar Meanchey.
PfD developed various innovative IEC/BCC strategies and materials, including the “taxi drivers” pilot project targeting mobile and migrant populations (MMP), based on PfD’s initial research and assessment of MMP travel tendencies. On this premise, PfD recruited and trained local taxi drivers on malaria prevention and treatment, and gave them IEC materials to distribute to their customers. Over 20,000 migrant workers received health education and IEC materials. Due to the success of the pilot, the Battambang provincial health department adopted it as one of its community-based malaria interventions.
Working in collaboration with the Provincial Education Offices in Kratie and Koh Kong, PfD designed a curriculum for educating children on malaria transmission and prevention for its School Health Education programs. Based on the Child-to-Child Methodology, this program enables school children to become peer educators and disseminate key messages to siblings, parents and the community through games, songs, activities and community theater productions. Over 55,700 children have been trained as peer educators in Malaria Health Education. PfD leveraged its expertise in school health education and child-to-child methodologies to work with the Ministry of Education, Youth and Sports (MoEYS) to develop a standardized national curriculum for malaria education in primary schools. The MoEYS approved the curriculum and integrated it into primary school classrooms. PfD trained 32 trainers from provincial and district education offices on how to work with teachers to disseminate and integrate the curriculum into school programs.
PfD, in partnership with the Pasteur Institute of Cambodia, the Institute of Research for Development and with support from the National Malaria Control Program, designed and conducted the “Malaria, Mobile Population and Migrants in the Context of Drug Resistance in Cambodia” study which shed light on the relationship between population movement, land development, malaria and the issue of drug resistance. As a result of this study, PfD developed a conceptual and operational framework using proxy indicators to define areas of concern for potentially imported malaria; emergence; and spread of drug resistance. By using this framework and geographical information systems (GIS), PfD was able to identify geographical areas of concern and to estimate the number of people in each of the three categories. PfD continues to refine this framework and develop it as an operational tool.
PfD played a critical role in building capacity among health professionals and community health workers. It designed and facilitated training workshops for health center and hospital staff in malaria prevention and health education; diagnosis and treatment, including severe case clinical management; logistics/drugs management; proposal writing and project cycle management, and selected and trained over 1,500 community members as Village Malaria Workers and Village Health Workers. PfD’s innovative interventions and research contributed to the development of strategies to address multi-drug resistant malaria in Cambodia, and the underlying challenge of mobile and migrant populations in this context.
In 2007-2008, with support from the UN Family Planning Agency, PfD adapted its youth-focused behavior change curriculum to address issues of sexual and reproductive health in Cambodia. As in the United States, youth sex education is a difficult topic in Cambodia, and many teenagers are unaware of safe sex practices and HIV/AIDS prevention.
Working together with the Provincial AIDS Office, the Department of Women’s Afairs, and local health clinics, PfD organized a variety of community activities to educate young people in Kratie on safe sex practices. Activities included a sports tournament, community theater, parent education sessions, and teacher training workshops, and were designed to reach members of the community at all stages of life to promote a culture of responsible and healthy sexual behavior. PfD also hosted a youth forum on sexual and reproductive health, allowing young leaders the opportunity to educate their peers on safe behaviors and HIV/AIDS prevention. These young leaders were also invited to create community education dramas themselves. At the end of the project, the majority of youths surveyed expressed feeling confident in their awareness of safe sex practices and how to prevent HIV/AIDS, thanks in large part to PfD’s peer education initiatives.
As a part of the USAID-funded Northeast Cambodia Community Development Program, PfD took an integrated approach to community health and well-being to improve the quality of life throughout Stung Treng. Specific initiatives targeted local water supplies, community environmental sanitation (particularly human waste management), HIV/AIDS education (particularly for members of the military and sex workers), and improving local government structures.