Quarterly Review 2 – 2021
Impact of COVID19:
Due to lockdown of Phnom Penh right before Khmer New Year (that is mid-April) we became seriously restricted in our activities first in Phnom Penh and then in the provinces. Our 38 employees at our NGO Head Office moved most of our work to online. It proved possible do a lot online especially temporarily. Our Head Office found itself to be in a red zone, Stung Meanchey. But the identified COVID19 cases were in other villages than our village. The area then went from being red zone to orange zone to yellow zone during the course of the Second Quarter.
Laboratory Services: Blood- and urine collections for our laboratory services had continued until before Khmer New Year but then we stopped it everywhere suspending our laboratory program effectively in order to reorganize it as explained further below. After reorganizing it relaunched again in Phnom Penh during June, with schedules for rural provinces to restart during July.
Medical Consultation sessions continued in about half of locations. Many plan to restart the consultation activities by mid July 2021. For example, 18 June 2021 there was postponement of Medical Consultations Angkor Chey Referral Hospital and Baray Santuk RH but both Health Centers (Champey and Kreul) in their OD’s were continuing to provide the services. This flexibility guarantees continued access of diabetes patients to the services inside the OD although the NCD clinic at Referral Hospital can be temporarily closed because overload from COVID19. The advantage of the cooperation between the Peer Educator Network and the public service is demonstrated by the chronic care system’s ability to adapt quickly and inform the patients thanks to the bridge-function of the Peer Educators who are able to provide updated information thanks to their privileged connectedness as part of the networks. If diabetes patients cannot get quality service, they become even more vulnerable to COVID19, will get more serious patients and even risk dying creating the much feared health service overload…! We had excellent collaboration from our local counterparts who do not need to be told about this.
Medicines: Throughout the second quarter 2021 our Revolving Drug Fund was able to supply medicines to all counterparts but it was sometimes difficult. Our priority was to maintain supply of medicines to our counterparts in the public services. The low number of staff allowed to go to our office meant we had to focus on the drug supply because thousands of patients depend on this. The Revolving Drug Fund staff remained operational with presence at the premises throughout Second Quarter. We applied for special permissions from the district to move in- and out of red zone for 9 staff. But then the procedure changed and we had to re-apply again, this time at Ministry of Health. We considered to rent temporarily stocks outside the affected area along a main road but then the lock down was lifted again. An airfreight arrived with Hydrochlorothiazide and some of the outstanding Metformin order as we were low on both these 2 items. A sea-freight container arrived also but that did not bring Metformin because that Metformin was not ready at the moment when this container had to leave Europe. That is why we ordered a 2nd sea-container to arrive early September. Another seafreight with long awaited Simvastatin arrived at Sihanoukville so the wrong port of discharge. We had been processing an incorrect Bill of Lading. This time we had received the medicines directly from supplier in India instead of via IMRES warehouse. We list also Gliclazide among the drugs in order to replace the cheaper Glibenclamide for patients older than 60 years, a recommendation that has found its way into the WHO updated guidelines. The price difference is quite large and Gliclazide cannot as be easily combined with other medications from our RDF, so we will see how its use evolves over the coming year or so.
Follow-Up: This Peer Educator activity has sharply reduced because before onset of COVID19 patients would meet in large groups at home of peer educator. This was halted. However since many patients are now getting vaccinated, the urban Peer Educators (also vaccinated) have resumed seeing them one by one on different days of the week, rather than all together at the same time. They apply ventilation, use alcohol and wear masks and face-shield, and keep physical distance.
COVID19-Vaccination. Luckily – in a way – the vaccination site for our area was located in front of our office at the Primary School. All our staff (including peer educators in Phnom Penh) have had 2 vaccinations. 96 out of 195 Peer educators had 2 vaccinations, about half (30 June 2021).
PPE: Our Training Unit created a video on Preventive Personal Equipment PPE how to put on and take off in khmer language. We supply PPE for all medical consultations and also for blood- and urine sample collections done at the Health Centers as part of the laboratory services for the members. It means that Peer Educators while helping are now also wearing those PPE.
Expansion: The first group of candidate Peer Educators from Kampong Tralach in Kampong Chhnang finished training on April 7th . Among the 6 candidates 5 passed the exam, while 1 will have a new opportunity in 3 months to have more time get in good shape. Memorandum of Agreement with the OD was signed. PE’s were vaccinated. They have identified around 20 patients but we postponed setting up the full service because Center of Hope postponed the refresher-training of doctors but we are now planning to try that out “online” during Q3.
Reorganization of the laboratory service: We have used the period of suspension to make 5 important changes to the blood- and urine collection system: 1) no more urine- and blood collection at our office, but this will be done exclusively at government Health Centers by the nurses (as this was already happening in the rural provinces). 2) We distribute Protective Preventive Equipment (PPE) for the teams and training on how to put it on and take it off safely. 3) a more pro-active planning and reaching-out to who should get a laboratory profile instead of just passively waiting to provide the service to whoever shows up. This means creating a system of making appointments with patients who have not used the laboratory service for more than a year according to our database. This is being prepared by the Program Department. 4) urine- and blood collection sessions must be conducted a few days before the medical consultation session. 5) the planning of the blood- and urine collection must be done jointly with the health center staff, not just by ourselves.
e-Learning: During full month of June 2021, there were 4 of our staff who did the Moodle course to learn the skills on “how to teach online using Moodle software”. It has great potential for all of us. We can use what we learned and continue with follow up course on Basic Administration skills to install software on our server.
EMR: We have a created an EMR (electronic medical record). It exists also as hard copy version of a physical file for use at Referral Hospital and Health Center to have it there of each case that is residing in the health center coverage area. For example all patients with diabetes are extra vulnerable to COVID19 so the Health Center should know who these patients in their area are to be able to contact them via the community-network to make sure they are reached to get vaccinated and updated and followed-up and referred in case they go out of control. 1 case has the basic information on A4 two sides: Identification and address, lab results, prescriptions and medicines bought.
External environment in which we operate:
Meeting with MoH-PMD Directors took place before the lockdown in April to discuss about our program. The message from Directors echoes the sounds coming from the General Secretariat of the National Council on Social Protection that there is a role for the private sector to play in the future. There could be limits on how much money can be charged. World Bank is again searching for a suitable model that is not NGO. We asked MoH to express clear support for peer educator networks for diabetes and hypertension.
CMS shortage of NCD medicines: During a meeting with MoH-NIPH-PMD-WHO and others MoH-PMD announced there are not enough drugs for the NCD program so public facilities must use the user fees in order to buy the NCD medicines. A provinces answered they are solving the problem by asking the patients to come back to the clinic every week. That generates more user-fees but of course this is difficult for patients. This further contributes to patients not seeking care, which could result in more victims if COVID19 really starts to spread. I shared an overview of prices for the same type of NCD drug charged by IMRES, IDA, MoPoTsyo and some open market prices. We recommend MoH to buy lower cost drugs for the coming 5 years and also to monitor the prices that are being charged to NCD patients in the provinces. In a 2nd meeting on Medicines organized by WHO, again the shortage of drugs was announced and MoH asked for guidance from WHO. The meeting shared the current checklists used by MoH and found that they do not monitor if NCD drugs are available at Referral hospitals or Health Centers. As long as there is no monitoring there is also no problem….
IBC: We were invited to join the IBC Cambodia as not for profit private organisation. The IBC is an association of private enterprises, which is not “political” or “regional” like for example the Eurocham.
Internal Organization
Board member changes: Early April the changes were submitted to the Ministry of Interior whose staff confirmed it has been received.
Audit Financial Statement: The auditor completed the financial audit of 2020 and we are adapting to follow the new standards of the ACAR (formerly National Accounting Council). We have successfully implemented the change from bookkeeping in USD to bookkeeping in Cambodian Riels including in our software. The consultancy that we had hired to help us with this has ended. Several other financial and accounting reforms were implemented as advised by the consultant. It has resulted in a more timely bookkeeping.
Expensive ventilation: Our electricity costs are much higher since we apply ventilation and air-conditioning combined.