Introduction: Cambodia has achieved significant progress in maternal health, yet remains in the group of countries with the highest maternal mortality ratio in South-East Asia. Extra efforts are needed to improve maternal health through assessing the coverage of maternal health services as a continuum of care (CoC) and identifying the gaps. Our study aims to explore the coverage level of the Optimal CoC by (1) measuring the continuity of optimal antenatal care (ANC), skilled birth attendance (SBA) and optimal post-natal care (PNC), (2) identifying the determinants of dropping out from one service to another and (3) of not achieving the complete CoC. Method: The study employed data from the Cambodia Demographic Health Survey 2014. We restricted our analysis to married women who had a live birth in the five years preceding the survey (n = 5678). Bi-variate and multivariate logistic regression were performed using STATA version 14. Results: Almost 50% of women had achieved the complete optimal CoC, while the remaining have used only one or two of the services. The result shows that the level of women’s education was positively associated with the use of optimal ANC, the continuation to using optimal PNC and achieving the complete CoC. More power of women in household decision making was also positively associated with receiving the complete CoC. The birth order was negatively associated with achieving the complete CoC, while exposure to the mass media and having health insurance increased the odds of achieving the complete CoC. Household wealth consequently emerged as an influential predictor of dropping out and not achieving the complete CoC. Receiving all different elements of ANC care improved the continuity of care from optimal ANC to SBA and from SBA to optimal ANC. Conclusion: The findings urge policy makers to approach maternal health care as a continuum of care with different determinants at each step. Household wealth was found to be the most influential factor, yet the study discovered also other barriers to optimal maternal health care which need to be addressed: future intervention should thus not only aim to increase wealth or health insurance coverage but also stimulate the education of women and empower women to claim power in household decision-making.

Background: Hypertension (HTN) is a leading cause of cardiovascular diseases and deaths globally. To respond to the high HTN prevalence (23.5% among adults aged 40–69 years in 2016) in Cambodia, the government (and donors) established innovative interventions to improve access to screening, care, and treatment at different public health system and community levels. We assessed the effectiveness of these interventions and resulting health outcomes through a cascade of HTN care and explored key determinants. Methods: We performed a population-based survey among 5070 individuals aged ≥ 40 years to generate a cascade of HTN care in Cambodia. The cascade, built with conditional approach, shows the patients’ flow in the health system and where they are lost (dropped out) along the steps: (i) prevalence, (ii) screening, (iii) diagnosis, (iv) treatment in the last twelve months, (v) treatment in the last three months, and (vi) HTN being under control. The profile of people dropping out from each bar of the cascade was determined by multivariate logistic regression. Results: The prevalence of HTN (i) among study participants was 35.2%, of which 81.91% had their blood pressure (BP) measured in the last three years (ii). Over 63.72% of those screened were diagnosed by healthcare professionals as hypertensive patients (iii). Among these, 56.19% received treatment in the last twelve months (iv) and 54.26% received follow-up treatment in the last three months (v). Only 35.8% of treated people had their BP under control (vi). Males, those aged ≥ 40 years, and from poorer households had lower odds to receive screening, diagnosis, and treatment. Lower odds to have their BP under-control were found in males, those from poor and rich quintiles, having HTN < five years, and receiving treatment at a private facility. Conclusions: Overall, people with HTN are lost along the cascade, suggesting limited access to appropriate screening, diagnosis, and treatment and resulting poor health outcomes, especially among those who are male, aged 40–49 years, from poorer households, and visiting a private facility. Efforts to improve the quality of facility-based and community-based interventions are needed to prevent inequitable drops along the cascade of care.

Background: Non-communicable diseases (NCDs) such as type-2 diabetes (T2D) and hypertension (HTN) pose a massive burden on health systems, especially in low- and middle-income countries. In Cambodia, to tackle this issue, the government and partners have introduced several limited interventions to ensure service availability. However, scaling-up these health system interventions is needed to ensure universal supply and access to NCDs care for Cambodians. This study aims to explore the macro-level barriers of the health system that have impeded the scaling-up of integrated T2D and HTN care in Cambodia.Methods: Using qualitative research design comprised an articulation between (i) semi-structured interviews (33 key informant interviews and 14 focus group discussions), (ii) a review of the National Strategic Plan and policy documents related to NCD/T2D/HTN care using qualitative document analysis, and (iii) direct field observation to gain an overview into health system factors. We used a health system dynamic framework to map macro-level barriers to the health system elements in thematic content analysis.Results: Scaling-up the T2D and HTN care was impeded by the major macro-level barriers of the health system including weak leadership and governance, resource constraints (dominantly financial resources), and poor arrangement of the current health service delivery. These were the result of the complex interaction of the health system elements including the absence of a roadmap as a strategic plan for the NCD approach in health service delivery, limited government investment in NCDs, lack of collaboration between key actors, limited competency of healthcare workers due to insufficient training and lack of supporting resources, mis-match the demand and supply of medicine, and absence of local data to generate evidence-based for the decision-making.Conclusion: The health system plays a vital role in responding to the disease burden through the implementation and scale-up of health system interventions. To respond to barriers across the entire health system and the inter-relatedness of each element, and to gear toward the outcome and goals of the health system for a (cost-)effective scale-up of integrated T2D and HTN care, key strategic priorities are: (1) Cultivating leadership and governance, (2) Revitalizing the health service delivery, (3) Addressing resource constraints, and (4) Renovating the social protection schemes.

Introduction Integrated care interventions for type 2 diabetes (T2D) and hypertension (HT) are effective, yet challenges exist with regard to their implementation and scale-up. The ‘SCale-Up diaBetes and hYpertension care’ (SCUBY) Project aims to facilitate the scale-up of integrated care for T2D and HT through the co-creation and implementation of contextualised scale-up roadmaps in Belgium, Cambodia and Slovenia. We hereby describe the plan for the process and scale-up evaluation of the SCUBY Project. The specific goals of the process and scale-up evaluation are to (1) analyse how, and to what extent, the roadmap has been implemented, (2) assess how the differing contexts can influence the implementation process of the scale-up strategies and (3) assess the progress of the scale-up. Methods and analysis A comprehensive framework was developed to include process and scale-up evaluation embedded in implementation science theory. Key implementation outcomes include acceptability, feasibility, relevance, adaptation, adoption and cost of roadmap activities. A diverse range of predominantly qualitative tools—including a policy dialogue reporting form, a stakeholder follow-up interview and survey, project diaries and policy mapping—were developed to assess how stakeholders perceive the scale-up implementation process and adaptations to the roadmap. The role of context is considered relevant, and barriers and facilitators to scale-up will be continuously assessed. Ethics and dissemination Ethical approval has been obtained from the Institutional Review Board (ref. 1323/19) at the Institute of Tropical Medicine (Antwerp, Belgium). The SCUBY Project presents a comprehensive framework to guide the process and scale-up evaluation of complex interventions in different health systems. We describe how implementation outcomes, mechanisms of impact and scale-up outcomes can be a basis to monitor adaptations through a co-creation process and to guide other scale-up interventions making use of knowledge translation and co-creation activities.

Integrated care of chronic patients improves quality of their management, but there is scarce evidence of its implementation in different healthcare settings. With this article, we wanted to determine the level of integrated care implementation in the management of T2D (diabetes) and HT (hypertension) in three different settings: Belgium, Slovenia, and Cambodia. This was an observational study with integrated approach. It was conducted in primary health care organisations in three countries. In each primary health care organisation, we aimed to include primary care workers that worked with Type 2 Diabetes (T2D) and hypertension (HT) patients. Data was collected with the Integrated Care Package (ICP) grid (consisting of six elements: identification, treatment, health education, self-management, caregiver collaboration, and care organisation). ICP is almost completely implemented without major differences within Slovenia. There is a considerable variability across practice types in Belgium. Implementation is constrained by health system resources in Cambodia. Some elements, especially identification, are better implemented then others, across health systems. Countries can enhance integrated care for chronic diseases by implementing central policies, standardized protocols, and local adaptation, addressing resource constraints, promoting systematic screening and health education, and providing training for healthcare workers, tailored to community needs, to improve patient outcomes and healthcare delivery.

Introduction: The ‘Scale-Up diaBetes and hYpertension care’ (SCUBY) project provides evidence on scaling-up integrated care (IC) in Cambodia, Slovenia, and Belgium. This paper examines macro-level barriers and facilitators to scaling up IC in these settings. Methods: We used a multi-case study design, with each country being a case. Document review, focus groups, and stakeholder interviews were conducted. The WHO health system building blocks guided the thematic analysis. We then visualised and examined the interlinkages between barriers in each country. Results: Common challenges to scaling up IC across the three health systems relate to: governance and leadership; health workforce; inadequate health financing system; and fragmented health information systems. In Cambodia, access to non-communicable disease (NCD) services and medicine are important issues. IC scale-up is facilitated by its strong governance and public health service model in Slovenia but health workforce shortages risk progress. In Belgium, the fragmented governance system and predominant fee-for-service provider payment are important barriers. A common response to health workforce and workload challenges was task shifting: to primary care nurses in Belgium, peer supporters in Slovenia, and community health workers in Cambodia. Conclusions: Examining differences and similarities between barriers in each health system stimulated reciprocal learning. Interactions between health system barriers in specific contexts require further attention to move complex health systems forward.