Assessing Private Sector TB Services in Cambodia
By Elizabeth Goodrich

Over 30 U.S. Agency for International Development (USAID) staff attended a Quality Assurance Project (QAP) briefing in mid-June to hear the results of QAP’s study of private sector services for tuberculosis (TB) in Cambodia. Under the study, 492 service providers and 60 TB patients were interviewed to document current knowledge and practices. In addition, the study used mystery shoppers to visit 273 pharmacies and drug sellers. With a view toward improving private sector TB services, the study assessed the nature and extent of such services currently provided. Joy Riggs-Perla, Chief of Party for URC’s Health Systems Strengthening in Cambodia project, presented the findings. The study itself was led by Gani Perla, a technical advisor to QAP, with his colleagues from Cambodia’s National TB Program. The results of the QAP study are being used to develop strategies for private-public collaboration in the national program.

Clydette Powell, Medical Officer of the USAID Bureau for Global Health, introduced Ms. Riggs-Perla by noting the need for a better understanding of the role of the private sector in the delivery of TB services. Dr. Powell said that Cambodians spend a disproportionate share of their incomes for healthcare and that they can buy TB drugs without a prescription, both causes of concern for global health.

Ms. Riggs-Perla opened her remarks with statistics from the 2002 National TB Prevalence Survey that reported high prevalence and death rates (540/100,000 and 90/100,000, respectively). The survey also indicated that 48% of TB symptomatics either self-medicate or seek treatment directly from pharmacies as their initial place of treatment. Interestingly, traditional practitioners and healers are rarely used for TB treatment. She noted that the QAP study covered the urban areas within three provinces (Battambang, Siem Reap, and Kratie) and the municipality of Phnom Penh. National TB Program (NTP) staff collected the data, trying to interview as many private doctors, pharmacies, and drug sellers as possible within the provincial towns.

Doctors operating private clinics are an important source of TB services, as nearly 80% provide TB consultation. Most (92%) are government doctors who maintain a private practice. Of these, 47% claim to be familiar with the DOTS strategy and to use it for their patients. While 96% indicated that both physical examinations and sputum examinations are needed to confirm TB, 67% also said that X-rays and sputum exams are needed. Fees appear to be relatively small. Three fourths said that they provide counseling, but most do not have any information, education, and counseling (IEC) materials to offer. Most (74%) expressed a willingness to offer IEC materials to patients if they were provided. About 46% reported having had TB training recently.

Asked where they refer patients to buy drugs, doctors could choose one or more options and indicated the following: sell drugs from their own supply (33%), refer to a pharmacy (31%), refer to a government hospital (24%), or “other” (23%). The amount doctors sell largely depends on the amount of cash the patient has: A month, a week, and “other” were most frequently indicated in this multiple-choice question.

Ms. Riggs-Perla also noted that self-medication is common: Neighbors often share their left over medicines, and pharmacies and drug sellers are widely used as sources of drugs for self-medication, as the study confirmed. The study also found that most pharmacies carry TB drugs, although 42% say that they refuse to sell TB drugs without a prescription.

Of particular concern for issues of drug resistance, is that drug sellers report that clients tend to buy only a week’s or a month’s worth of TB drugs even when free TB drugs are available through the National TB Programme, Ms. Riggs-Perla stated. Although the quality of drugs was not investigated in this study, drugs available from drug sellers in general are known to be of poor quality, as they sell expired and adulterated drugs, many of which are given to children. Pharmacies and drug sellers claim to counsel clients about TB (43% always and 17% some of the time), but again the counseling may not be appropriate given that many do not have much knowledge of the DOTS strategy of the national program. On the positive side, most seem to be enthusiastic about providing TB educational materials if they had access to them.

Mystery clients reported that 48% of pharmacies asked for prescriptions and confirmed that 43% refused to sell TB drugs without one. Some of their worst news was that they were offered 57 different types of drugs often for multiple symptoms, but the good news was that 37% were referred to a government facility for TB symptoms. Half of pharmacists did counsel them on drug dosage, duration, side effects, etc., and 12% counseled on the correct testing and treatment strategy.

Ms. Riggs-Perla summarized the key implications of the study as follows: TB case management among private providers in Cambodia is poor but most pharmacies and drug sellers offer TB drugs and a large variety of other drugs for treating TB symptoms. Drug dispensing does not adhere with national guidelines, TB information given to clients is limited, client referral is low, and social stigma is strong.

She recommended that strategies be developed by NTP to work with private providers, pharmacies, and drug sellers to reduce harmful practices and help bring them into compliance with the national TB control strategy. She noted that linkages with and support of NTP should be initiated, and support from local health offices to implement a public-private mix to respond strategically to TB will be crucial, given that many of them are in fact functioning as private sector providers. The leaders of the National TB Program are very much aware of these issues and have expressed the desire to move ahead rapidly to formulate national private-public mix strategies and pilot test alternative approaches.

For more information on the Cambodia Private Sector TB Study, contact Gani Perla at gperla@urc-chs.com.