Quarterly Review 4 – 2019

(October, November and December 2019)


After we had had a discussion at the office of the NSSF, the National Social Security Fund, their staff went
to visit Pochentong Hospital in order to see the peer educators in action during a medical consultation
session and to interview patients. Hopefully we can work out an arrangement with NSSF so it reimburses
the Hospitals (or us?) for the drugs that are being dispensed to patients who are entitled to NSSF benefits.

Normally, during 4th Quarter we hand out the Revolving Drug Fund Pharmacy rewards to our counterparts
in the Operational districts, based on the volumes sold, satisfaction of the patients (annual standard
surveys held to get feedback from users) and the adherence to prescribed treatment over the past 12
months, calculated from the data in our database. The progress in all OD’s is striking. This RDF has been
running since 2005, but only since 2012 in the public services, and it is getting better and better… all
indicators show upward trends in all districts and it is financially sustainable. The great majority of noninsulin using patients are cross subsidizing the insulin distribution logistics, keeping a 1000 insulin using
patients continuously supplied with insulin and insulin syringes. The insulin distribution by itself would
not be financially sustainable, but because it is embedded into a more comprehensive drug distribution
system it free-rides on that.

The Ministry of Health disseminated its new Standard Operating Procedures for Diabetes and
Hypertension in Primary Care. This is relevant because the peer educator is officially mentioned in this
guideline and their role in primary care is recognized.

MoPoTsyo presented its activities during the annual review of the National Multisectoral Action Plan for
NCD, held in Siem Reap

We have started discussions with Ministry of Health about continuation of program for 4 years after 2020,
because 2020 is the last year of our current Memorandum of Agreement. We also talk with our
counterparts at Operational District level, Provincial Health Departments. We will also begin to discuss
with the Provincial Governor of each province because during 2019-Q4 the Law on Decentralization and
Deconcentralization has been approved and it will be effective from 2020 January 1st onward.

MoPoTsyo has provided the list of 195 health facilities (all not Provincial hospital) where there is a peer
educator to MoH-PMD, with the list of OD’s and provinces so it should be possible to prevent overlap and
coordinate and link the data.

Training:

All 6 Peer Educators passed exam after training (3 Posenchey OD, 2 Phnom Sruoch, 1 Baray Santuk);

On 19/12 and 20/12 we organized for 49 doctors (who did 30,000 medical consultations for our members
in 2019) a training-workshop at Tonle Bassac 2. It was opened by Ministry of Health’ Director General for
Health, H.E. Dr Hok Kimcheng. Day 1 was entirely dedicated to Diabetes and complications such as Chronic
Kidney Disease, with Endrocrinologist Dr Sum Satha in charge. Day 2 was led by Head of Medicine Dpt of
Calmette Dr Bory Sotharith, with advice from Dr Frances Daily. It was about infections likely to affect
diabetic patients, and management of septic shock, with a focus on Melioidosis, when to suspect it in
remote area, where to get a reliable micro-lab culture test, how to take a good sample and how to treat
Page 2 of 2 October, November and December 2019
(intensive phase and maintenance phase). Melioidosis is thought to cause more deaths in Cambodia than
TB, AIDS and Malaria combined and most often the victims are hyperglycemic rice farmers who are in
contact with contaminated soil and with infected farm animals. By organizing this training workshop the
rural doctors got the algorithms they need to deal with it. Next year we will follow up with them. We
received very positive feedback this year from the participants. The meeting was closed by Dr My
Seanghorn, Vice Director of Preventive Medicine Department.

On 23/12, +/-165 active peer educators came for a 1-day gathering to discuss with them on a number of
issues such as how we can strengthen their work-relationship with the Health Center. The Standard
Operating Procedure for Diabetes and Hypertension in Primary Care (2019) officially mentions Peer
Educators but practice is still not clear. We aim to put the PE between the HC and Village Health Promoter
so he/she can function as a bridge promoting education and collect data. We plan to start to pay small km
reimbursement for the PE to visit every village now and then.

Action Research and Scientific Publications:

On 11 November University of Washington researcher Lesley Steinman submitted to JMIR a new article
for their special issue on mHealth, with the Title: “Can mHealth messages improve management of
diabetes and hypertension in a hard-to-reach population? Lessons learned from a process evaluation of
mHealth to support a peer educator model in Cambodia using the RE-AIM framework.”JMIR stands for
Journal of Medical Internet Research, see https://www.jmir.org/ Now we wait for news on acceptance.

On 20 November the scientific journal PLOS ONE published Akiyo Nonogaki’s article “Factors associated
with medication adherence among people with diabetes mellitus in poor urban areas of Cambodia: A crosssectional study”, see https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0225000

On 25 November another publication related to a research done by Faculty of Medicine with support from
NUS Singapore on the general situation with regards to Diabetes care in Cambodia was published.
Patients’ and healthcare providers’ perspectives of diabetes management in Cambodia: a qualitative study
in BMJ Open. We had been facilitating for the researchers (N.U.S. Singapore) to interview our members
see https://bmjopen.bmj.com/content/9/11/e032578?rss=1

On 25 November National Institute for Public Health began a hypertension research related to wearable
devices with our Urban Peer Educators to interview +/- 30 to 50 patients.

On 3 December Prof Wim van Damme from ITM (Belgium) came to discuss CINAC. That stands for Chronic
Interstitial Nephritis in Agricultural Communities, a condition that has been around for some decades
already, see https://www.ncbi.nlm.nih.gov/pubmed/28186530 for description on Sri Lanka. Victims were
exposed to toxic agrochemicals through work, by ingestion of contaminated food and water, or by
inhalation. The disease is characterized by low or absent proteinuria, small kidneys with irregular contours
in CKD stages 3–4 presenting tubulo-interstitial lesions and glomerulosclerosis at renal biopsy. Of course
the agrochemical industry is keen to maintain controversy about whether it is caused by the use of
pesticides. ITM and NIPH are planning to investigate if it occurs here and if a connection can be shown
with the use of dangerous pesticides. They are also interested in our diabetic patients with kidney injuries.
But it will be difficult to disentangle the causes as hyperglycemia contributes to CKD also.

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