Structure, Functions and Objectives of the National Center for Parasitology, Entomology and Malaria Control (CNM)
Malaria is a complex and priority public health problem for the Kingdom of Cambodia. Malaria operations commenced in Cambodia in 1951 with the avowed goal of country-wide eradication. By the early 1960s, after 6 years of spraying with DDT, the eradication campaign successfully brought malaria down malaria prevalence rates down from 60% to 0.9%. However, once the campaign stopped, the rates quickly jumped back up. The disruptions of the 1970s brought malaria control to a grinding halt and put the whole health services delivery system in total disarray. Once the revival of the public health system began, the Ministry of Health (MOH), Royal Government of Cambodia (RGC) founded and designated a specialized institution, the National Malaria Center (CNM) in 1984 to provide technical and material support to malaria treatment facilities in provincial and district hospitals. Throughout the 1980s the program struggled with extremely limited resources to treat the large number of cases among persons working in defense works along the Thai border. It was not until the early 1990s that logistical support for malaria diagnosis and treatment became integrated with the national essential drugs program and the National Malaria Control Programme (NMCP) could begin a transition from purely hospital‑based curative activities to more pro‑active community based education, evaluation and control activities. The CNM was then mandated to develop and execute nation-wide malaria control strategy. The CNM was reorganized in November/December 1995 with additional responsibilities for schistosomiasis and dengue control activities. Subsequently filariasis elimination programme was added to the list of disease control programmes covered by the Center. CNM has overtime evolved as the nodal department of the MOH responsible for the control of vector borne and parasitic diseases in Cambodia. This includes investigation, training and supervision of health staff and other interventions. In 2004, the Ministry of Health re-named the center as “National Center for Parasitology Entomology and Malaria Control” whilst retaining the original acronym. In January 2012, the Ministry of Health entrusted the responsibility for the Control of Neglected Tropical Diseases in Cambodia and implementation of an Integrated National Plan of Action focused on diseases controlled and eliminated by preventive chemotherapy 2012 – 2015 to CNM. Specific responsibilities entrusted to CNM include the control/elimination of Soil Transmitted Helminthiasis (STH), Schistosomiasis (SCH), Lymphatic Filariasis (LF), Foodborne Trematodiasis (FBT) and Strongyloidiasis and other parasitic diseases. Currently CNM co-ordinates three main programmes: Malaria, Dengue Hemorrhagic Fever (DHF) and Helminthiasis. In addition to its disease control responsibilities CNM also operates the national malaria reference laboratory and conducts a wide range of operational research projects in collaboration with non-governmental partners. CNM has therefore in recent years emerged as an apex training, research and program center carrying out innovative vector borne and parasitic disease control activities in Cambodia.
The changing role of the CNM is reflected by the change from a technical organization with separate departments of clinical care, entomology, parasitology, pharmacy and epidemiology to a service organization, organized by the type of external services provided.
2. Key Features
· A specialized institution set up by the Ministry of Health, to function as the national level nodal department responsible for the control/elimination of vector borne and parasitic diseases.
· The Center is equipped with Technical Experts in the fields of Public Health, Parasitology, Entomology, Epidemiology, Behaviour Change Communication and Program Management aspects of vector borne and parasitic diseases.
· CNM co-ordinates four main programmes; malaria, dengue haemorrhagic fever (DHF), filariasis and schistosomiasis and intestinal parasitic infections.
· The functions include basic and operational research, training and supervision of health staff and implementing, monitoring and evaluating disease control programs.
· CNM operates under the administrative authority of the MoH and in collaboration with other key partners such as Ministry of the Interior (in particular the departments of Health and Economy and Anti-Crime), Ministry of National Defense, Ministry of Women Affairs and Veteran, Ministry of Education Youth and Sports, Ministry of Health (in particular the Department of Food and Drugs, Central Medical Stores, PHDs and ODs), development partners, international and national NGOs, local governments and community structures.
· Major projects currently implemented include partnership with WHO, GFATM, USAID, NIH of USA, AFRIMS, NAMRU and a host of national and international NGOs.
According to the organogram (See Annex 1), the CNM is organized into three bureaus: Technical, Administration, and Financial. These are headed by Chiefs of Bureau. Further restructuring is currently under consideration in order to strengthen the management of the different national programmes operated by the Center.
The Administration Bureau is primarily responsible for administration including personnel and logistics management. The bureau oversees the functioning of 6 units, namely Administration, Transportation, Procurement, Library, Security and Cleaning. The procurement unit is responsible for the quantification, ordering and purchasing of drugs, commodities, equipment and goods required by the Programmes operated by CNM.
The finance bureau manages all financial matters including donor supported grants and projects. The Bureau’s work is carried out by two units, namely Accounting and Planning and Materials.
The Technical Bureau oversees treatment, training and supervision for the four disease-specific programs. The malaria program is the largest among the disease specific programs managed by the Technical Bureau, accounting for 75 percent of the Technical Bureau’s staff. The work of the Bureau is carried out by twelve technical units- Entomology, Epidemiology, Research, Vector Control, Monitoring and Evaluation, Laboratory, Health Education, IT, Helminthiasis, Filariasis, PPM and Village Malaria Workers.
Personnel and Staff
CNM has 155 staffs (as of 1 October, 2012) with the following break-up:
o 89 are presently on the Government rolls working
o 13 are contractual staff
o 24 are temporary staff
o 7 are staff who have suspended their jobs without payment
o 22 staffs who working on Global Fund grants
CNM Director (01 person)
CNM Vice Directors (07 persons)
Technical Bureau (73 persons)
- Entomology unit,
- Epidemiology unit,
- Research unit,
- Vector Control unit,
- Monitoring and Evaluation unit,
- Laboratory unit,
- Health Education unit,
- IT unit,
- PPM unit
- Village Malaria Workers unit
- Helminthiasis unit,
- Filariasis unit,
Administration Bureau (46 persons)
- Administration unit
- Transportation unit
- Procurement unit
- Security unit
- Cleaning unit
Finance Bureau (6 persons)
- Accounting unit
- Planning and Materials unit
Detailed organograms of the CNM and job responsibilities of heads of the bureaus / units are provided in Annex 1.
The National Malaria Center (CNM) is one of the health institutions of various institutions under the Ministry of Health, which is responsible for the control of vector-borne diseases. It co-ordinates three main programmes: malaria, dengue haemorrhagic fever (DHF), Neglected Tropical Diseases (NTDs), except trachoma. Its role as the apex centre of reference and operational research is envisaged to be developed in the years to come.
The main functions of the CNM are:
a) To provide technical assistance to the MoH for determining government policies, objectives and effective national strategies
b) To define effective policy interventions and frame technical guidelines and operational policies in order to guide the provinces, operational health districts and health facilities for implementation of various programme strategies.
c) To assess the resource gaps from time to time in order to assist the MoH for mobilizing the required resources and providing an equitable support based on the magnitude of the problem.
d) To assist the MoH for budgeting and planning of the logistics pertaining to the different programmes overseen by the Center.
e) To strengthen the institutional capacity at all levels through training, supervision and on-the-job mentoring
f) To support the health system network for providing access to the population and to supervise program activities,
g) To monitor program implementation through regular monitoring visits and submission of reports and returns
h) To establish quality assurance for diagnostic and case management services including cross checking of blood slides for quality control,
i) To periodically evaluate the various program interventions, projects and programmes
j) To conduct entomological studies, drug resistance studies and carry out appropriate operational research studies
k) To collaborate with national and international partners and donors.
EVOLVING CNM FUNCTIONS DECENTRALIZATION/DE-CONCENTRATION
Within the context of the Royal Government de-concentration/de-centralization policies, several functions are being progressively decentralized to provincial, district and community levels. For instance, CNM does not have direct authority for planning, budgeting and financing of its national programmes at provincial, district and communities level. The Department of Planning and Health Information (DPHI) leads the sector planning process for local health authorities and guides these entities during the entire planning process including formulation of Annual Operational Plans (AOPs). The primary health care functions including treatment and prevention for all three programs (viz. malaria, dengue and helminthiasis involving a wide range of activities such as bednet distribution, abate distribution, antihelminthic drug distribution, diagnosis and treatment by VMWs, etc.), are in the process of being decentralised to the district and community councils. Such decentralisation involves direct transfer of human, financial, logistic and other appropriate resources (except procurement of health products and pharmaceuticals which will be undertaken through the MOH national budget) to the district and commune councils with decision making and implementation resting with these entities. CNM inputs will be limited to setting the direction for priority interventions to be delivered at each level of the health system, but it will have no mandate in actual resource allocation to the implementing agencies. Bottom-up planning including formulation of AOPs at every level of implementation will be encouraged and nurtured over the next several years during which CNM will provide guidance for prioritisation and actual implementation.
5. vision, mission, goal, aim and objectives of CNM
5.1 Vision Statement
CNM envisages a self-sustained and well informed, healthy Cambodia with equitable access to quality health care services nearest to their residences; where people live in a clean environment, adopt healthy lifestyles including practices that discourage mosquitoes and other vectors from causing nuisance and disease; where there may be vectors and parasites but no vector-borne and parasitic diseases such as malaria, dengue filariasis, helminthiasis and schistosomiasis exist, and even if cases do occur sporadically, they are promptly diagnosed and effectively treated.
5.2 Mission Statement
It is our commitment to continuously empower through operational research, training and capacity development, all those involved in vector and parasitic control at different levels in the country both in the public and private sectors, in relentlessly undertaking all possible and appropriate actions in order to ultimately eliminate vector borne and parasitic diseases in the country.
5.3 Goal of CNM
To serve as an efficient and effective apex center of excellence for ultimately eliminating from the country the common vector borne and parasitic diseases.
5.4 Overall Aim of CNM
To contribute to the improvement of the health status of the population of Cambodia by developing robust systems and supporting the local capacity and thus contributing to sustainable reductions in the morbidity and mortality from malaria, dengue fever, schistosomiasis, and other helminths, and elimination of filariasis.
5.5 Objectives of CNM
1. To operate flexible enhanced programs that can deliver effective vector borne and parasitic disease control within identified time spans.
2. To ensure that the right diagnostics and treatment for vector borne and parasitic diseases are available to all people – especially the poor and disadvantaged living in urban and rural areas.
3. To continuously keep a vigilant watch on the vector borne and parasitic disease situation in the country and make appropriate policy, program and operational recommendations from time to time.
4. To carry out operational research studies the outcomes of which will directly feed back into program enhancement.
5. To contribute to the continuous capacity-building of all the institutions and personnel involved in vector borne and parasitic disease control at all levels in the country.
6. To assist the MOH and relevant entities for mobilizing in time all the required resources including financial from all possible sources, national and international in order to control the vector borne and parasitic diseases in the country.
6. Strategic Directions for CNM
In the short-term, CNM’s activities are directed in a way to meet with the Millennium Development Goal of halting and reversing the incidence of malaria and other vector borne and parasitic diseases by the year 2015 and contributing towards reduction of poverty.
The strategic directions that CNM wishes to pursue over the next 15 years (see Figure 1) in order to control/eliminate parasitic and vector-borne diseases include the following: Comprehensive Case Management, Mass Drug Administration, Integrated Vector Control, Behaviour Change Communication and Capacity Building (including Training, Human Resource Management, Procurement Management, Monitoring &Evaluation, Operational Research, etc.). CNM will endeavour to build sustainable partnerships and mobilise the required resources over the next 15 years in order to ensure that the vision and goals of CNM are realized. These strategic directions are briefly described below.
6.1 Comprehensive Case Management
A three-pronged approach to case management comprising of (1) free provision through public health facilities including those in the police and defense sectors; (2) free provision through community volunteers (for e.g. malaria EDAT through Village Malaria Workers or VMWs) and schools (for e.g. helminthiasis) (3) subsidized provision through the private sector (for e.g. antimalarials though PSI) will be employed throughout the country and further strengthened through continued clinical research to determine candidate regimens suitable for the country and carrying much less probability of developing drug resistance, suitable and regular updating of national diagnosis and treatment guidelines (for malaria, DHF, etc.), training of both public and private health sector providers (including referral hospitals) on the national guidelines, making more robust estimates of requirements of diagnostics and drugs and commodities, procurement from manufacturers/ suppliers who adhere to GMP standards, improved drug and commodity management practices (including curtailing the pernicious practice of pilferage of public sector drugs) at all levels down to the health center level, monitoring community drug use practices, establishing and maintaining drug and parasitological diagnosis quality assurance system and carrying out an all-out campaign against counterfeit drugs and rigorous implementation of the ban on artemisinin monotherapy, improving referral services especially for severe and complicated cases (for e.g. malaria, DHF and schistosomiasis, although no severe cases of the latter have actually been reported during the last decade) and those requiring surgery (for e.g. lymphatic filariasis) whether first seen in public or private sector. The CNM will endeavor to ensure compliance of the private sector with government regulations through collaboration and advocacy efforts in order to reduce in particular the morbidity and case fatality from DHF and malaria.