A sustainability assessment of a health equity fund initiative in Cambodia

All but one of the health equity funds (HEFs) currently operating in Cambodia, introduced to address the adverse effects of low user fee exemption rates, rely heavily on external funding and have high administrative overheads. This article reports on a study of one type of HEF, based in Kirivong Operational Health District (KOD) and operated through local pagoda structures, which demonstrates minimal reliance on external funding and low administrative overheads. We utilize an adapted sustainability assessment framework to assess the ability of pagoda structures to enable financial access for the poorest to public sector health services. We further analyse the strengths and limitations of the pagoda-managed equity fund initiative, with a view to assessing not only its sustainability but its potential for replication in other settings.Our study shows that, against key sustainability indicators (health service utilization and health outcomes; management capacity and financial viability; community mobilization and government support), the pagoda-managed equity fund initiative scores well. However, it is evident that some external financial support is needed to allow the HEFs to function effectively. We conclude with recommendations for replicating the initiative, which include working innovatively with indigenous grassroots organizations to enhance community HEF ownership and to keep administrative overheads low.

Community and school-based health education for dengue control in rural Cambodia: a process evaluation

Dengue fever continues to be a major public health problem in Cambodia, with significant impact on children. Health education is a major means for prevention and control of the National Dengue Control Program (NDCP), and is delivered to communities and in schools. Drawing on data collected in 2003–2004 as part of an ethnographic study conducted in eastern Cambodia, we explore the approaches used in health education and their effectiveness to control dengue. Community health education is provided through health centre outreach activities and campaigns of the NDCP, but is not systematically evaluated, is under-funded and delivered irregularly; school-based education is restricted in terms of time and lacks follow-up in terms of practical activities for prevention and control. As a result, adherence is partial. We suggest the need for sustained routine education for dengue prevention and control, and the need for approaches to ensure the translation of knowledge into practice.

Health education is essential for the control of diseases such as dengue, ensuring that community members understand the mechanisms of infection and the key behaviours or activities that need to be addressed to prevent transmission, reduce severe disease and avoid fatalities. In Cambodia, health education for dengue control is provided in primary schools, at village health centres and by the National Dengue Control Program. However, these educational programs are accorded low priority, strategies and materials are not evaluated on a routine basis, messages are sometimes confusing, and health staff and teachers lack the training, time and opportunities to deliver educational messages. Recommendations to villages are not always practical or effective in preventing mosquito bites, and funds are not available to provide new educational materials. While school children and their parents therefore have some familiarity with the behaviour and habitat of the aedes mosquito and the environmental factors that contribute to dengue fever, their knowledge is uneven and knowledge is rarely translated to reduce the risk of infection. Community involvement in the prevention and control of dengue is essential, but will not be effective while health education is poorly resourced and irregular and lessons on prevention do not result in action.

Use of soft law to address HIV/AIDS in Southeast Asia

Non-binding agreements, or "soft law," have played a role in influencing government policy and reducing HIV vulnerability among construction workers in the Greater Mekong Subregion of Southeast Asia. In this article, David Patterson et al state that soft law sometimes offers advantages over treaty law, but that challenges remain in the implementation of soft law.

Etiology and resistance patterns of respiratory isolates in Kenyan adults with AIDS from slum population

We investigated regularly swabs of adults dispenzarised at Mary Immaculate Clinic of Trnava University in Nairobi providing free health care for about 50 000 population of Mukuru Slums. 20 patients who were treated for AIDS by our clinic (those who started HAART before Free National AIDS Cooperation Programme - NASCOP) were assessed after 1, 2 and 3 years (18 of 20 completed the survey, other 2 loss of follow up, probably died. Exposure to other molecules can select resistant mutants. Previous exposure to TMP/SMX was similar in both groups and therefore was not responsible for the difference between resistance patterns.

[Lip, jaw, and palate clefts. Analysis of unilateral cleft lip using 3-D laser topometry]

INVESTIGATION

In most cases it is not sufficient to use photographs and plaster casts to document and analyze the three-dimensional morphology of lip, jaw, and palate clefts. The aim of this study was to evaluate the applicability of surface scanning with a 3-D laser topography scanner in patients with unilateral cleft lip.

PATIENTS AND METHODS

Three-dimensional surface scans of the face were performed pre- and postoperatively in 20 patients (3-35 years of age) with a 3-D laser topography scanner. All patients were suffering from nonoperated, one-sided cleft lip, cleft lip-jaw, or cleft lip-jaw and palate. The digital data sets were metrically analyzed and expressed on the basis of quotients, independent of size factors.

RESULTS

Using this 3-D laser scanner it was possible to acquire good quality three-dimensional data sets. Measurements were in the dimension of millimeters. Based on the data sets it was possible to provide the three-dimensional cleft morphology with reproducible landmarks and analyze the data. The postoperative symmetry of the face was controlled and objectively quantified. It is disadvantageous however that numerous views need to be taken to get the full image of the face and that the scanning process takes about 2 s.

CONCLUSION

The presented 3-D laser scanner renders a precise 3-D surface analysis of the lip and nose region in cleft patients. For lively infants or uncooperative adults, the system is suitable only to a limited extent due to the time-consuming scanning process.

Probing the biogeochemistry of arsenic: response of two contrasting aquifer sediments from Cambodia to stimulation by arsenate and ferric iron

Many millions of people worldwide are at risk of severe poisoning through exposure to groundwater contaminated with sediment-derived arsenic. An ever-increasing body of work is reinforcing the link between microbially-mediated redox cycling in aquifer sediments and the mobilisation of sorbed As(V) into groundwaters as the potentially more mobile and toxic As(III) anion. However, to date, few studies have examined the biogeochemical cycling of Fe and As species by microbes indigenous to Cambodian sediments. In this study two contrasting sediments, taken from a shallow As-rich reducing aquifer in the Kien Svay district of Cambodia, were used in a laboratory microcosm study. We present evidence to show that microbes present in these sediments are able to reduce Fe(III) and As(V) when provided with an electron donor, and that the two sediments respond differently to stimulation with Fe(III) and As(V). Shifts in the community composition of the two sediments after stimulation with As(V) suggest a potential role for members of the beta-Proteobacteria in As(V) reduction, a phylogenetic grouping known to contain microorganisms capable of As(III) oxidation, but not previously implicated in As(V) reduction. PCR-based analysis of the sediment microbial DNA using primers specific to the arrA gene, (a gene essential for microbial As(V) respiration), indicates the presence of microorganisms capable of dissimilatory As(V) reduction.

Predicting factors for the experience of HIV testing among women who have given birth in Cambodia

HIV testing and counselling is an entry point for the prevention of mother-to-child transmission of HIV (PMTCT) services, and it is important to determine predictors for HIV testing to improve the acceptance of HIV testing. The aim of this study was to assess predictive determinants for HIV testing asking mothers who had already given birth. Mothers who came to a childhood immunization in Phnom Penh, Cambodia with a child (children) aged 6-24 months were randomly selected in January and February 2006. A cross-sectional survey with a semi-structured questionnaire including a question about the experience of HIV testing was conducted to the mothers at the clinic by trained interviewers. Of the 315 respondents, 193 mothers (61.3%) had ever been tested for HIV and 265 mothers (84.1%) showed the necessary of permission by partners before HIV testing. In a multivariate logistic regression analysis, basic knowledge about HIV transmission [adjusted odd's ratio (aOR): 2.875, 95% CI: 1.668-4.956] as the best predictor, the number of children (aOR: 2.186, 95% CI: 1.241-3.852) and partner's education level (aOR: 1.950, 95% CI: 1.044-3.641) remained statistically significant, however the necessity of permission by partners did not (aOR: 1.691, 95% CI: = 0.859-3.328). Since some mothers ever tested might have obtained the permission with the perception of their partners before tested, it should be still highlighted that involvement of partners is an important strategy. Education on HIV transmission to young women and men through communication and health education strategies involving partners seems to lead PMTCT services to be more acceptable.

Resistance and renewal: health sector reform and Cambodia's national tuberculosis programme

Following the destruction of Cambodia's health infrastructure during the Khmer Rouge period (1975-1979) and the subsequent decade of United Nations sanctions, international development assistance has focused on reconstructing the country's health system. The recognition of Cambodia's heavy burden of tuberculosis (TB) and the lapse of TB control strategies during the transition to democracy prompted the national tuberculosis programme's relaunch in the mid-1990s as WHO-backed health sector reforms were introduced. This paper examines the conflicts that arose between health reforms and TB control programmes due to their different operating paradigms. It also discusses how these tensions were resolved during introduction of the DOTS strategy for TB treatment.

Socioeconomic considerations regarding a land mine victim with maxillofacial injuries

This article describes a case we experienced while doing volunteer medical work in Cambodia for six months in 2002. By examining treatment of a 14-year-old female land mine victim with maxillofacial injuries, we report on the present socio-medical situation in Cambodia. This case suggests the lack of infrastructure, facilities, human resources, and patient education make it extremely difficult to provide patients with proper treatment, including general anesthesia. A comparison of land mine victim statistics between 2002 and 2005 reveals significant problems.

A comprehensive archaeological map of the world's largest preindustrial settlement complex at Angkor, Cambodia

The great medieval settlement of Angkor in Cambodia [9th-16th centuries Common Era (CE)] has for many years been understood as a "hydraulic city," an urban complex defined, sustained, and ultimately overwhelmed by a complex water management network. Since the 1980s that view has been disputed, but the debate has remained unresolved because of insufficient data on the landscape beyond the great temples: the broader context of the monumental remains was only partially understood and had not been adequately mapped. Since the 1990s, French, Australian, and Cambodian teams have sought to address this empirical deficit through archaeological mapping projects by using traditional methods such as ground survey in conjunction with advanced radar remote-sensing applications in partnership with the National Aeronautics and Space Administration (NASA)/Jet Propulsion Laboratory (JPL). Here we present a major outcome of that research: a comprehensive archaeological map of greater Angkor, covering nearly 3,000 km2, prepared by the Greater Angkor Project (GAP). The map reveals a vast, low-density settlement landscape integrated by an elaborate water management network covering>1,000 km2, the most extensive urban complex of the preindustrial world. It is now clear that anthropogenic changes to the landscape were both extensive and substantial enough to have created grave challenges to the long-term viability of the settlement.

Treatment of frontoethmoidal meningoencephalocele in Cambodia: a low-cost procedure for developing countries

OBJECT

Frontoethmoidal meningoencephaloceles (MECs) are a relatively common abnormality in southeast Asia, with disastrous consequences for the sufferer. In Cambodia, a lack of skilled neuro- and craniofacial surgeons, and the cost of surgery limit the possibilities for appropriate treatment of patients with these lesions. The authors developed a low-cost humanitarian program with the goals of treating frontoethmoidal MECs, ensuring careful postoperative follow-up, and teaching Khmer surgeons how to treat these malformations.

METHODS

This program was facilitated by two nongovernmental organizations: Rose Charities Cambodia provided the facilities, patients, and local staff, and "Médecins du Monde" provided visiting surgeons and anesthesiologists. All operations were free of charge for all patients. A strict follow-up program was organized to evaluate the surgical results, the social impact of the surgery, and the satisfaction levels of the children and their parents.

RESULTS

Forty-five children and seven young adults with MECs were treated using a rather simple surgical technique. Of the three types of MECs encountered, the most frequent was the nasoethmoidal type (43 cases). The most common postoperative issue was a temporary CSF leak (in 16 patients). Cosmetic results were considered excellent or good in 40 patients, average in nine, and poor in one; two patients were lost to follow-up. The overall cost of each operation was estimated to be $380 (US dollars), far less than a standard MEC operation would cost in a more developed country. At the end of this humanitarian program, Khmer surgeons were able to treat standard cases of frontoethmoidal MECs without the help of foreigners.

CONCLUSIONS

Patients in developing nations who have limited access to standard neurosurgical care can be treated for frontoethmoidal MECs with few complications and a satisfactory cost-to-benefit ratio.

An economic evaluation of thermostable vaccines in Cambodia, Ghana and Bangladesh

This paper evaluates the incremental health and programmatic cost impacts of new vaccine products, as compared to the standard vaccine products in multi-dose vials in Cambodia, Ghana, and Bangladesh. The authors use a cost-effectiveness model to estimate the impacts of introducing four thermostable vaccines with single-dose presentations: measles, yellow fever, bacille Calmette-Guérin, and diphtheria-tetanus-pertussis-hepatitis B. The effectiveness of all of the vaccines increases with the thermostable formats. The incremental costs associated with the introduction of thermostable vaccines increases for three out of four vaccines. Single-dose presentations of thermostable vaccines are potentially cost-effective interventions to reduce childhood deaths and disability in low-resource settings in Asia and Africa.

The prevalence of cariogenic salivary micro-organisms in children of various ages

The objective of the research was to obtain data on the values of salivary Streptococcus mutans and Lactobacillus spp. in 12 years old children and teenagers (13 - 18 years old children), and to compare the values of these cariogenic microoorganisms in children of various ages, for the purpose of valuating the risk of caries. The sample comprised 32 persons divided into two groups. The first group included 17 children of the age of 12. The second group included 15 teenagers. The specimen of stimulated saliva, needed for the purpose of establishing the quantities of Streptococcus mutans and Lactobacillus spp., was taken by the method of CRT-bacteria, according to manufacturers instruction. In the group of 12 years old children, the distribution of salivary Lactobacillus spp. was as follows: very low values 41,1%, low values 35,2%, high values 17,6%, very high values 5,8%, while in the group of teenagers, the results were the following: very low values 26,66%, low values 33,33%, high values 40%, very high values 0%. The levels of Streptococcus mutans were the following: 12 years old children had very low values in 41,7% cases, low values in 11,7% cases, high values in 41,7% cases, very high values in 5,8% cases, while the group of teenagers had very low values in 0%, low values in 33,3%, high values in 33,3%, and very high values in 33,3% cases. The levels of Streptococcus mutans are higher in our teenage children than in younger children, while the differences in levels of Lactobacillus spp. among children of various ages do not exist. In terms of global distribution, the levels of Streptococcus mutans and Lactobacillus spp. are higher in our population than in other countries in both control groups.

Freshwater Bryozoa of Tonle Sap, Cambodia

We identified a collection of freshwater bryozoans from Tonle Sap (meaning Tonle Lake), Cambodia, a body of water fed by the Mekong River and characterized by extreme fluctuations in water level between the wet and dry seasons. The collection also included specimens from the moat of Angkor Wat, located at the north end of the lake. We found four phylactolaemate species (Plumatella bombayensis, Plumatella casmiana, Plumatella vorstmani, Hyalinella lendenfeldi) and one ctenostome species (Hislopia cambodgiensis) from the lake, and only a single, additional phylactolaemate species (Plumatella javanica) from the moat. We provide brief descriptions of these species, photographs of colonies for some, and photomicrographs by light and scanning electron microscopy (SEM) of statoblasts. None of the species encountered in this study is endemic to Cambodia, and the wide distributions of the species are possibly related to the dispersability of floatoblasts by birds. We briefly discuss some of the taxonomic problems surrounding Hislopia cambodgiensis.

Mercury in hair and blood from residents of Phnom Penh (Cambodia) and possible effect on serum hormone levels

High concentration of mercury (Hg) in hair has been reported for Cambodians. To confirm the Hg contamination occurring through intake, Hg concentrations were determined in both hair and blood of residents (n=20) from Phnom Penh, Cambodia. Mercury concentrations in the hair and blood were 0.69-190microg g(-1) dry wt and 5.2-58microg l(-1), respectively, which were lower than those from Hg contaminated or high fish intake regions, but were higher than those from non-contaminated regions. Some female subjects had hair and blood Hg levels exceeding the threshold values for neurotoxic effects. Interestingly, serum estrone and estradiol levels were positively correlated with blood Hg level for both males and females, indicating possible induction of female hormones by Hg exposure in Cambodians.

Improving access to hospital care for the poor: comparative analysis of four health equity funds in Cambodia

There is a large body of evidence that user fees in the health sector create exclusion. Health equity funds attempt to improve access to health care services for the poorest by paying the provider on their behalf. This paper reviews four hospital-based health equity funds in Cambodia and draws lessons for future operations. It investigates the practical questions of 'who should do what and how'. It presents, in a comparative framework, similarities and differences in objectives, the actors involved, design aspects and functional modalities between the health equity funds. The results of this review are presented along the lines of identification, hospitalization rates and relative costs. The four schemes had a positive impact on the volume of utilization of hospital services by the poorest patients. They now account for 7 to 52% of total hospital use. The utilization of hospitals by paying patients has remained constant in the same period. The comparative review shows that a range of operational arrangements may be adopted to achieve the health equity fund objectives. Our study identifies essential design aspects, and leaves different options open for others.

Klebsiella pneumoniae necrotizing fasciitis and septic arthritis: an appearance in the Western hemisphere

BACKGROUND

Necrotizing fasciitis caused by Klebsiella pneumoniae is rare, with 11 documented cases in the literature, all occurring in Asia and the Middle East. These reports have become more frequent in recent years in association with the emergence of the highly virulent K1 capsular serotype of Klebsiella. We report a case of Klebsiella necrotizing fasciitis and con-current septic arthritis in the Western hemisphere.

METHODS

Case report and review of the literature.

RESULTS

Our patient, a 50-year-old Cambodian man with advanced hepatitis B-associated cirrhosis, who had last visited an endemic area six months prior to presentation, was hospitalized after several days of left knee and thigh pain. He was hypotensive, tachycardic, and bacteremic with K. pneumoniae. A computed tomography scan showed gas in the tissues of the thigh and left knee joint. Despite aggressive surgical debridement and antibiotic therapy, the patient died on day three. Serotyping of blood, wound, and synovial cultures revealed K1-type K. pneumoniae.

CONCLUSIONS

Although K. pneumoniae is common, monomicrobial necrotizing fasciitis and septic arthritis caused by this pathogen has not been reported previously outside Asia, where it is rare. The appearance of this infection in the Western hemisphere may reflect geographic spread of the aggressive K1 phenotype. Physicians treating patients with symptoms and signs of necrotizing fasciitis or septic arthritis, particularly in the setting of underlying chronic illness or recent travel to Asia, should consider K. pneumoniae as a potential cause and treat accordingly.