Imagine a village of 1000 people who don’t have the access to private clinic or a proper pharmacy. The nearest primary government health center is located at 5-10 km. Take 20 such adjacent villages which fall under the catchment area of the same health center with a combined population of 20,000. Assume one district would have 15 such aggregated areas with a total population of 300,000. Add the unpaved roads (>90%), non-existence of public transport, low density of population, daily per capita income of less than $1, lack of dedicated & skilled healthcare workforce plus low medical infrastructure resources with the government - and this gives us a mass public health problem yet to be solved in most parts of the world; or at least in country like Cambodia where 80% of population is rural. For the treatment of tuberculosis (TB), this scenario is no less than a public health disaster.
Cambodia, a country of 14+ million people in South East Asia, went through a tragic phase in 1970s which continued till late 1980s. The war and genocide dismantled the health system of the country. Hospitals were destroyed and skilled healthcare workforce was wiped off. Per capita government expenditure on health in 2009 in Cambodia was $28 (vs. $3426 in US, 0.8%). Treatment of tuberculosis in the public sector of such a country is definitely not an easy task considering it typically takes six months of daily treatment (DOTS).
In Dec 2010, Operation ASHA opened its first DOTS center in Phnom Penh, capital city of Cambodia. After encouraging results in India, Cambodia was the first foreign country to test the model of providing DOTS to tuberculosis patients in urban slums and rural communities. The organization arrived in Cambodia with the aim to replicate its model from India. But it struggled to replicate the success.
The population density of South Delhi in India, where Operation ASHA has large operations, is nearly 11,000 per sq. km where as Phnom Penh has 3,300 people per sq. km, the highest in Cambodia. The clear problem was low density of population and it made the organization go back to the blackboard and think deeply, especially since the next area of expansion was Takeo, a province in South Cambodia with a population density of just 237 people per sq. km.
An Operation ASHA worker prepares
drugs to be taken by a patient.
The model employed in high density urban slums of India involves setting up stationary centers within poor dwellings which are visited by the patients to receive their TB medications as per the plan of WHO-approved DOTS. The centers are strategically placed at locations which are accessible and surrounded by large population. This set up failed to pick up enough patients in Cambodia as the centers were not easily accessible to a sufficiently large population. So, after the first six months, the organization changed the model and employed counselors on motorbike.
Mobile DOTS Model
The mobile model encompasses a counselor traveling from village to village on a motorbike, carrying anti-TB drugs & other supplies. The counselor dispenses the medicines to patients at their homes, as per DOTS guidelines and spends substantial time everyday looking for those potentially suffering from TB. Due to fewer resources for medical technology in Cambodia, smear microscopy tests for TB diagnosis can only be performed in the lab at referral hospital (one in each district). So for detection, the counselor collects sputum samples from each of the suspected carriers and carries it to a pre-assigned location, where another staff ‘Sputum Collector’, again on a motorbike, is waiting to take sputum samples to the government lab for diagnosis.
The result is an effective, closely-knit and dedicated network of mobile healthcare workers bringing the cure to the doorsteps of people who otherwise don’t have ‘practical’ access to medical care.
Today, Operation ASHA has enrolled nearly 1300 patients covering 1+ million population in four districts. More than 95% of these patients were enrolled after the mobile operations began one year back. In the last four months, 35-40% of new tuberculosis patients being treated through the public health sector of each district have been enrolled through Operation ASHA. This is not only the testament of the success of the model but also an opportunity to study it further and change the way public health is delivered in the resource-constrained developing countries.
