Slightly smaller than the U.S. state of Oklahoma and poised to become a lower middle-income country, the Southeast Asian nation of Cambodia is home to nearly 16 million people. About one-third of Cambodia’s population is under the age of 15 years, but declining fertility rates and increasing life expectancy mean the population structure is slowly aging.
According to WHO, health status has substantially improved since 1993 with a substantial drop in mortality rates coupled with a rise in life expectancy at birth to 62.5 years in 2010 — a 1.6-fold increase from 1980. Although the Government has made significant gains toward rebuilding the health system since the 1990s, including significantly increasing funding for healthcare, the actual amount allocated remains at only 1.4% of GDP.
While Cambodia’s adult HIV prevalence rate is just 0.64 percent, risk of other infectious diseases such as bacterial diarrhea, hepatitis A, and typhoid fever — along with vector-borne diseases like dengue fever, Japanese encephalitis, and malaria — is extremely high. Non-communicable diseases (NCDs) are also on the rise and are now estimated to account for an equal number of deaths as infectious diseases.
WHO reports that inequities in health outcomes — particularly differences in urban vs. rural healthcare and those based on socioeconomic status — remain an obstacle to achieving health outcomes that are on par with other countries of the region.
With support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta, AIHA launched a blood safety project in Cambodia in December 2012. In late 2015, we launched an injection safety project through our HIV/AIDS Twinning Center Program, which is supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), and funded by CDC/Cambodia.
Project to Strengthen Blood Services in Central Asia, Ukraine, and Cambodia
(2012 – Present)
AIHA, in partnership with the Australian Red Cross International Humanitarian Blood Program, is working together to support the implementation of the Cambodian National Strategic Plan for Blood Transfusion Services 2013-2017 across four strategic areas:
- National policy and legislation
- Hospital and patient blood management
- Community and donor motivation
- Nationally coordinated blood services
Additionally, this project supports three cross-cutting areas — health system integration, training and education, and monitoring and evaluation.
Building on an assessment of the blood services in Cambodia performed in 2011-2012 by the Australian Red Cross International Humanitarian Blood Program, AIHA is supporting ongoing technical assistance for the implementation of the country’s National Strategic Plan for Blood Transfusion Services 2013-2017 (NSP).
Over the years, this project has come to represent a collaborative model for successful implementation of health systems strengthening efforts. Click here to learn more.
Key accomplishments of this project to date include:
National Policy and Legislation
AIHA team members finalized the revised national blood policy following consolidation of feedback received at the December 2014 Policy Round Table. They provided this policy to the National Blood Transfusion Center (NBTC) for final review and the document has been translated and submitted to the Ministry of Health for approval.
A financial consultant met with the NBTC to review their current records and method of accounting. Blood costing and cost recovery were discussed with NBTC, the Ministry of Health, and Calmette hospital, with an agreed way forward for a pilot model. As of March 2015, the costing model for determining costs and cost recovery was developed, piloted, and finalized, and all NBTC staff were trained. The NBTC is responsible for local implementation and management.
Hospital and Patient Blood Management
AIHA team members updated the demand planning tool for hospital blood management for 2014 and delivered it to NBTC for dispersion to the five hospitals participating in the demand planning pilot project. In 2014, all regional centers (SRCs) received training on the need for demand planning and begin working with local hospitals to meet supply and demand needs.
Collaboration with Calmette Hospital progressed with the development of several protocols and committees for hospital management of blood which provides a great basis for future hospitals.
Two-day clinical and nursing workshops were conducted in Siem Reap in April 2014 with participants from Siem Reap and surrounding provinces, and in Phnom Penh in August 2014. The focus for both workshops was teaching content from the Cambodian National Clinical Guidelines for Blood Transfusion. Patient identification was recognized as a problem area for most hospitals. The importance of patient identification was covered in the Nursing Workshop. The Guidelines encourage full name, age/date of birth and a hospital identification number as the minimum.
AIHA team members updated the clinical guidelines per feedback from the clinical workshops and, as of March 2015, the second edition is now in the final stage of printing, waiting only for the preface to be signed off by the Ministry of Health prior to dissemination and provision to hospitals throughout Cambodia. The guidelines are posted on the www.cambodiablood.com website.
A template for the Terms of Reference for the Provincial Technical Working Group (TWG) for Blood (hospital transfusion committee) has been drafted and distributed to relevant Provincial Health Departments (PHD) for comment. Kampong Cham PHD has piloted the first provincial TWG using the Terms of Reference.
Community and Donor Motivation
In January 2014, the AIHA team held a workshop to train new public relations officers and donor recruiters from NBTC and several provinces. The workshop included a focus on creating and utilizing existing materials. It was attended by 29 participants, who developed a six-month strategy for targeting, recruiting, and retaining donors for their region.
As of September 2014, the AIHA team had reviewed national VNRBD activities and incorporated them into a single-year plan to ensure a cohesive approach to VNRBD recruitment and retention. The team supported development and implementation of a national strategy and calendar for social media advertising, and assisted with the Nagasaki and NBTC university campaigns to encourage university students to become involved in voluntary donation. Ongoing weekly support for mobile collection organization was provided to help NBTC donor recruitment staff better plan and meet mobile targets. Support for VNRBD recruitment in the three key provincial sites — Battambang, Kampong Cham, and Siem Reap — has also been ongoing, along with the provision of IEC materials for national and provincial use to promote VNRBD, family donor conversion and the social media strategy. As of March 2015, all donor recruitment planning resources and marketing strategies have been handed over to local staff to maintain and continue. Under the project, Australian Red Cross Blood Service will continue to provide technical support and advice from Australia in this area until the new donor recruiter positions have been filled.
Donor recruitment staff from Siem Reap, Battambang, and Kampong Cham traveled to NBTC in November 2014 to attend an annual meeting to set 2015 targets and discuss approaches to improve VNRBD through social media and mobile planning. The outcome formed the basis of the 2015 donor recruitment strategy. Donor recruitment staff from Siem Reap, Battambang, and Kampong Cham traveled to NBTC in February 2015 to attend a technical meeting to further develop the 2015 donor recruitment strategy and monitor the 2015 targets set in November. A local advertising and marketing firm called 17 Triggers offered pro bono support to locally build the marketing strategy of NBTC. This collaboration will develop a sustainable and ongoing relationship and enforce key marketing and public relations skills required of a donor recruiter.
Nationally Coordinated Blood Service
In response to the December 2014, SIMS assessment conducted by CDC at the NBTC, a plan to address areas highlighted by CDC has been drafted and approved by project partners. Technical assistance to support the implementation of the recommendations has been incorporated into the 2015 planning. As part of the accreditation focus, the project will work closely with the NBTC Quality Manager to develop an accreditation road map and implement good manufacturing practices at NBTC. The NBTC Quality Manager will also be the NBTC lead to review all staff positions descriptions, implement document control and manage training sessions. In relation to training, the Quality Manager has developed a training schedule that identifies key trainers in each department and developed training templates to be shared with all staff conducting training.
An updated Donor Selection Guidelines relevant to Cambodia was created and is now in use at NBTC. New procedures addressing collection methods, infection control, donor health assessments, counselling, donor reception and post donor care were written and training in all occurred in February 2014. A joint working agreement with NCHADS will see a relationship between the two strengthened to improve the referral process for donors with positive TTI results. An assessment of mobiles by the donor care team also took place with some recommendations given to improve processes.
The AIHA team held donor collection, care, and counseling training at Siem Reap Blood Centre in February 2015 for participants from Siem Reap, Battambang, military blood banks, and NGO hospital blood banks. The training covered the procedures and requirements for whole blood collection, pre-donation counseling and donor selection guidelines. The meeting was also a platform for feedback on the SOPs and guidelines, and to adapt the documents to become more applicable in the provinces. All SOPs were reviewed considering the feedback received and the discussions surrounding the donor selection guidelines led to new conditions common in the provinces to be added, such as guidelines for amputees.
Component manufacturing training at Kampong Cham Blood Centre in February 2015 has allowed the center to continue the transition from whole blood issue only to component issue. Training in platelet manufacture has occurred at NBTC and Kampong Cham. Kampong Cham is leading the transition from replacement donors to voluntary donors as they implement monitoring to switch off replacement donors when not needed and keep the hospital informed. Battambang Blood Centre also has begun the transition from distributing only whole blood to now distributing components of whole blood.
Immunohematology training supported by PACOM was conducted in October 2014 to introduce newly updated SOPs in line with the national laboratory program. Training covered both theory and practical sessions in ABO grouping, cross-matching and antibody screening. The training course was also delivered in Siem Reap, Battambang, and Kampong Cham.
Significant support was provided for selection of automated testing platforms for infectious disease screening and immunohematology at NBTC, and subsequent preparation of the procurement requests and justifications. Chemiluminescence for IDS and gel card technology for immunohematology have been selected by NBTC for their future automation platforms.
The AIHA team provided support to NBTC to help them prepare for the next Global Fund grant concept note. There was a wider Ministry of Health-run stakeholder consultation process in late 2014 to develop the proposal, which identified a number of key focus areas for the blood program, including operationalization of a number of district hospitals to provide transfusion services. These have been provided to NBTC by the Ministry of Health, and onto the technical team. They will be reviewed and incorporated into the NBTC 2015 operational plan with appropriate technical assistance provided.
NBTC Director Dr. Hok Kim Cheng participated as a speaker in the October 2014 AABB Annual Meeting program, “Global Blood Safety Programs,” describing the blood services in Cambodia, current challenges and steps being taken to strengthen blood safety. Emily Tonks, Technical Program Manager for the Blood Safety Project of the Australian Red Cross, gave an oral presentation titled “Building Capacity in National Blood Programs: Cambodia,” at the meeting.
Cambodia Injection Safety Initiative
(2015 – Present)
This initiative supports the Cambodian Ministry of Health’s efforts to prevent parenteral transmission of HIV, particularly through unsafe and unnecessary injection practices. In addition to the Ministry of Health, AIHA is also working with two local NGOs — 17 Triggers and Ponleur Kumar — to implement this PEPFAR-supported project.
The 2014 HIV outbreak in Cambodia’s Battambang’s Roka commune resulted in more than 240 people contracting HIV and highlighted the fact that unsafe injections have the potential to greatly contribute to HIV incidence in the country. Due to this outbreak, the Ministry of Health has since prioritized risk reduction strategies to mitigate this mode of HIV transmission.
In response, AIHA launched a new HIV/AIDS Twinning Center partnership in 2015 to support the Cambodian Ministry of Health’s efforts to reduce the demand for unnecessary injections and increase the demand for non-injectable alternatives among the general public.
With funding from PEPFAR, HRSA, and CDC/Cambodia, this project is working to raise public awareness about unsafe injection practices through targeted behavior change communication and outreach interventions.
AIHA has engaged two local implementing partners to implement the project — 17 Triggers and Ponleur Kumar — and has developed a research protocol, translated it into Khmer, which was submitted to the Ministry of Health for approval in January 2017. Following approval, AIHA and our partners will conduct an assessment to determine which messages and interventions are the most viable to achieve the project’s objectives.