Write up on CENAT and NTP

National Tuberculosis Control Program (NTP): Strategic plan for 2011-2015

Goal: The main goal of the NTP is to contribute to improving the health of the Cambodian people in order to contribute to socio-economic development and poverty reduction in Cambodia by reducing the morbidity and the mortality due to tuberculosis.

The overall objectives for 2011-2015 are to ensure equity and universal access to quality TB services; maintain a high cure rate of more than 85%; and reduce the prevalence of TB and death due to tuberculosis by 50 % by 2015 relative to the 1990 figures, in order to contribute to attaining the Millennium Development Goals (MDG).

Objectives:

• Objective 1. To consolidate and maintain high quality TB services nationwide in order to achieve universal access to quality diagnosis and treatment.
• Objective 2. To improve and ensure equitable access to TB services focusing on the poor and community participation.
• Objective 3. To respond to TB/HIV co-infection, drug-resistant TB, childhood TB and to other high risk groups and challenges.
• Objective 4. To ensure adequate resources and strengthening coordination for TB control and contribute to health system strengthening.
• Objective 5. To strengthen Monitoring and Evaluation System and to promote research activities for TB control

Background information on TB and the national TB control program

TB in Cambodia: Cambodia has made impressive achievements in relation to TB control, well documented through repeat national surveys which showed a 36% reduction in smear positive TB cases between 2002 and 2011 – 269/100,000 in 2002 compared to 171/100,000 in 2011. The country has already met the Millennium Development Goals (MDG) target to halve TB deaths by 2015 relative to 1990 baseline and is on track to half the TB prevalence prior to 2015.  However, given the historically high disease burden in Cambodia, it continues to have one of the highest incidence and prevalence rates in the world. The 2007 drug resistance survey (DRS) showed 3.5% MDR-TB in new cases and 10.3% in re-treatment cases, indicating an increase from the first survey (2001) result of 0/638 (0%) of MDR in new cases and 3/96 retreatment cases (3.1%). The 2009 national HIV sero-prevalence among TB patients survey showed further decline at 6.4%, though a significant decline from a peak of 11.8% in 2003, it still constitutes a significant TB/HIV co-epidemic.

Organization of TB service: The National Centre for Tuberculosis and Leprosy Control (CENAT), under the Ministry of Health, is coordinating TB activities in the country. The country is administratively divided into 24 provinces and further on into 184 districts. In terms of health care provision, the 24 provinces are divided into 77 Operational Districts (OD). At the provincial level there is Provincial Health Department (PHD), which is responsible among other things for TB control in the province. At the PHD there is a medical TB supervisor and a laboratory supervisor. The TB supervisor is responsible for the planning, coordination and supervision; he also receives quarterly TB reports from the ODs. Each Operation District has its referral hospital and one Health centre for every 10,000 population. Each OD has an OD TB supervisor who is also responsible for supervising the Health Centers and reporting OD level activities to the PHD level. In addition to this, a large network of community volunteers have been engaged by partners through the Community DOTS (C-DOTS) programme to promote TB related information, identify and refer TB suspects, and serve as DOT watchers for patients in their communities.

TB control strategy in Cambodia: In response to the need for controlling TB in the country, the National Tuberculosis Control Program (NTP) has been set up since 1980. From 1980 to 1993, treatment approaches of long duration were applied. DOTS was introduced through public hospitals in 1994, and successfully expanded to achieve 100% DOTS coverage at health center level in 2004. The NTP has achieved a significant improvement in the TB situation in the country having achieved full DOTS coverage in 2004, sustaining treatment success rates of over 90% for the past 13 years. Though the case detection rate of smear positive TB cases has declined in recent years, the overall number of TB cases continued to increase till 2010, partly because of increased focus and capacity for diagnosing smear negative TB.  In 2011, the number of TB cases (all forms) notified to the NTP decreased for the first time to 39,670 cases, while treatment success of new smear positive TB cases was maintained at 94%.

NTP partners: TB control has been priority of the Ministry of Health over the past years and this commitment has paved the way for donors and technical agencies to contribute to the effort. Major donors for the programme in recent years include Canada International Development Agency, loan from the World Bank, Japan International Cooperation Agency; Global Fund to Fight AIDS, TB and Malaria;  and USAID. A large group of technical partners support the NTP: CATA, CHC, CRS, FHI, HEAD, JATA/RIT, MSF-F, PATH, PFHAD, Institute Pasteur Cambodia, RACHA, RHAC, SCA, TBCAP/TB CARE I partners (JATA, WHO, FHI, KNCV, US-CDC, WHO), VOR-ORT etc.