A NATIONAL HEALTH SYSTEM EMERGING FROM THE PAST
Despite the near complete devastation of its infrastructure and human resources during the period from 1975‐1979, and the further challenges that beset the nation during the following two decades as it sought to divest itself of the Khmer Rouge insurgency and reopen doors to international engagement and development, the Cambodian health system is recovering rapidly, and while numerous challenges remain, Cambodians are fortunate to have a proactive reformist Health Ministry. While many hospitals still lack adequate equipment, trained personnel and basic capacities, both the management of the Ministry of Health, and the management and staff of health facilities themselves appear to share a commitment to improving services and expanding service delivery capacity. There are currently 8 national and 69 referral hospitals functioning in 77 Operational Districts that each service a population of between 100‐200K people. Within this framework are a further 972 health centres and 72 health posts. Numerous NGO’s also operate special purpose health facilities (i.e.: trauma centres, rehabilitation clinics or specialist paediatric hospitals) throughout the country.
Snake bite recognised as an important problem
Concern about the burden of envenoming by snake bite in Cambodia was prompted by a perception that cases increase during the “rainy season” (late May to August), particularly in Provinces along the Mekong and Tonle Sap floodplains. Despite this perception, a lack of accurate data within the Ministry of Health has made it difficult for health managers to make informed decisions on the extent of resourcing required to deal with snake bite accidents. Snake bite is not currently a notifiable injury, and as a consequence centralised reporting of incidence, disability and mortality does not occur. It is perceived by health authorities that a majority of snake bite injuries are not treated in a health facility, and while there is some direct evidence that supports this from at least one Province, there is no specific data that would enable calculation of the proportion of non‐presenting cases at provincial or national level. In 2007 WHO/WPRO engaged consultants from the SEAMEO TropMed Network to conduct a preliminary investigation of the snake bite problem in Cambodia, and as a result a report was presented to the Cambodia Ministry of Health identifying several priority issues:
- Need for epidemiological data;
- Requirement for comprehensive information on the types and distributions of venomous snake species;
- Development of national guidelines for the management and prevention of snake bites;
- Review of current and future antivenom procurement and distribution policies;
- Development of a relevant clinical management training programme;
- Increased effort to prevent snake bites;
- Overseas study visit by a technical working group to either Thailand or Viet Nam to examine commercial antivenom production and distribution methods.
In response to this initial report, the Ministry of Health requested further assistance through WHO/WPRO to action some of these identified priority issues. The WHO engaged GSI CEO David Williams to carry out an initial assessment and collect information to enable us to address specific terms of reference. The major priorities were to:
- Develop an understanding of the capacity of the Cambodian health system (and in particular, its hospitals and personnel) to treat and manage envenomed snake bite patients;
- Collate and examine any snake bite data available from Cambodian hospitals or other sources;
- Obtain an appreciation for the practical issues that may influence the outcome of any proposed intervention strategies;
- Determine which antivenom products are available, and investigate the current supply and distribution of antivenoms throughout Cambodia;
- To seek information on the distributions of various medically important snake species.
This work led to the production of a detailed report to WHO and the Cambodian government which recommended a proposed action plan for improving several aspects of the management of snake bite in Cambodia, focusing on:
- Improved reporting and surveillance;
- Community awareness and education;
- Specific paramedical and medical education and training.
- The procurement of snake antivenoms, with specific advice on the appropriate types and dosages of antivenoms suitable for use in Cambodia.
FIndings in the report highlighted problems, and documented current trends including preliminary analyses of snakebite epidemiology in some of the worst affected provinces, and antivenom distribution patterns. Deficiencies in the capacities of hospitals to treat snakebites effectively were reported, and solutions proposed. Areas of expertise were also identified and a number of stakeholders were able to put forward their views on the issues that were raised.
The Cambodian Ministry of Health has responded very positively to recommendations of the report written by David Williams and colleagues Dr Simon Jensen and Dr Mark O’Shea. Steps are being taken to improve the reporting of snake bites to the Ministry so that national data can be acquired and use to make informed planning decisions. Snake bite education and first aid training has been incorporated in new Cambodian first aid courses, and a variety of educational materials are being prepared.
The Cambodian Ministry of Health is also moving to replace their existing antivenom supplies from India with species specific antivenoms manufactured in Thailand. For more than a decade, Cambodia had been a dumping ground for inefficacious, non-specific Indian antivenoms that are often poor quality and carry an unacceptably high risk of producing potentially life-threatening adverse drug reactions. None of the products were made using venom from snake species that occur in Cambodia, and in one case, a particularly unscrupulous supplier had provided an Indian-made product intended for treating snake bite in Africa, but which had also been shown to fail miserably in that regard, as well as being entirely inappropriate for treating Cambodian snake bites. Since early 2010, the Ministry of Health has been purchasing much more appropriate antivenoms specific to snakes found in Cambodia, from a manufacturer in neighbouring Thailand.
Thanks to a progressive, proactive Ministry of Health, a responsive Regional WHO Office, and some hard work by dedicated experts, the prognosis for snake bite patients in Cambodia is looking up!