Every morning, right about 8am, Vuthy* starts to feel out of sorts. On the way from his home in Meanchey district to the Khmer-Soviet Friendship Hospital, where he receives treatment, he breaks into a sweat.
“I have to come here every morning,” he said. “My body feels so uneasy. It seems like I’m getting a fever, and I’m hot every morning before I take it.”
Vuthy is one of about 140 former heroin addicts who make the trek to Khmer-Soviet every day to receive their allotted dose of methadone. For some, it’s a routine they have followed for nearly four years, and for all of them, in theory, it will continue for years to come.
However, with new patients declining, monthly drop-outs on the rise and its main donor phasing out funding by the end of the year, the Khmer-Soviet clinic – the only one in the country since 2010 – now finds itself at a crossroads, tasked with finding an “exit plan” that allows it to continue offering services while also trying to expand its reach on an already-tight budget.
Dr Chhit Sophal, a psychiatrist with the National Mental Health Program, oversees the program from a second-storey office in the clinic’s squat white building on the Khmer-Soviet campus. The main source of funding, he said, has been the Australian government, but as of December 31, that funding will disappear.
“This is very challenging for us, because we do not get any funding from the government yet,” Sophal said.
The Australian embassy in Phnom Penh confirmed that the funding would stop at year’s end, and said in an email last week that its aid funds were now being “refocused on reducing poverty in the Indo-Pacific region”, and called the methadone program one of “a range of positive results” to come out of its HIV/AIDS Asia Regional Program.
“For the remainder of 2013-14, the Australian and Royal Cambodian governments will work together to ensure that these results are sustainable,” the spokesman said.
Nonetheless, the shake-up comes at an inopportune time. Stakeholders in the methadone program met late last month to assess where the program stands, and to try to work out a way forward. A draft report presented to attendees paints a less-than-rosy picture.
Drop-outs have been steadily rising since the program’s inception, from an average of about two per month in November 2010 to an average of just under 10 per month in November last year. Since its inception, the program’s year-to-year retention rate has hovered around a respectable 70 per cent, but cumulatively, the losses account for almost half of the 252 patients to register since 2010.
What’s more, over the past three years, the number of new patients seeking treatment has steadily declined, from a peak of 27 in the program’s second month to just one last December.
“I think maybe among the street-based populations we are reaching saturation,” said a weary-looking Sophal on the day of the stakeholder meeting.
Methods are needed for recruiting patients in other at-risk groups, and past assessments have found as much, Dr Masami Fujita, team leader for HIV and TB at the WHO, said.
Over the past few years, the WHO has recommended satellite clinics and take-home doses to expand the program’s reach, but those initiatives would have depended on economies of scale in which higher numbers of patients cause the cost per patient program-wide to decrease.
“If the number of clients hit something like 250, then the cost would decrease – that’s what was discussed a few years ago,” Fujita said. “But the number of patients didn’t increase over the last two years.”
In this environment, Fujita said, the low enrolment rates became something of a catch-22. Enrolment remained low because measures like take-home doses and satellite branches were out of reach, and take-home doses and satellite branches remained out of reach because numbers remained low.
Currently, Fujita continued, there is a “bottleneck” in recruitment, as outreach programs are only able to reach about 350 injecting drug users, though the WHO estimates there are some 1,000 in Phnom Penh.
“Harm reduction” treatment, like that offered at Khmer-Soviet, seeks to mitigate the risks of heroin, but only by replacing it with indefinite, controlled and monitored methadone. As such, patients must make the trek to Khmer-Soviet every day to receive their doses, theoretically for many years, and possibly even for life.
While the treatment routine may be preferable to heroin addiction, it nonetheless represents a significant investment of time and effort for patients, Sophal said, and measures like satellite clinics and take-home doses are designed to reduce that effort.
“Some of [the patients] may be busy with work, so they cannot come here every day.”
At times, the hassles of the treatment can be just enough to nudge off patients who are barely clinging to the wagon, and though the effects vary between patients, missing a dose of methadone can be akin to coming off of heroin itself.
“I missed taking methadone one time when my baby was sick, and it made me feel like I had a high temperature and fever,” said Rithy*, standing in the shade outside the clinic on a recent morning.
Rithy, who stayed home to take care of his child, ultimately wound up sick himself, vomiting as he grappled with withdrawal. He managed not to cave in and seek relief in heroin, he said, by putting his child first.
“I do not care anything about myself anymore,” he said. “I do everything for my kids.”
In fact, Rithy – a slim 29-year-old with a messy mop of hair and a ready grin – is a poster child for patients who find it difficult to make it to the clinic each day. Since he started treatment more than a year ago, he has made the one-hour trip to the clinic from his home in Sen Sok district by bicycle almost every day to save money.
In the beginning, he said, during his long commute, he would focus on the thought of his children to prevent himself from veering off halfway to score more drugs.
“If I could bring the methadone home with me, it would be helpful for me to [find] work at a garment factory or something, because I wouldn’t need to spend time coming here,” said Rithy, who currently works from home. “I cannot get [an outside] job because of this problem. I cannot ask permission every day in order to come to the clinic.”
Sophal said that he, too, believes that satellite clinics and take-home doses would help to expand the program’s scope, but both require money, and in the case of take-home doses, a change in regulations for controlled substances like methadone.
“So we have to revise our guidelines, and to do that we need a consultant,” Sophal said, noting that there simply isn’t money for one.
“In order to increase the accessibility, I agree with [the WHO recommendations], but we have to think about resource mobilisation,” Sophal added.
“They want us to scale up our service, but they said, by the way, Australia wants to phase out its support,” he continued with a chuckle. “What do they want?”
David Harding, a technical adviser for drugs at Friends International, an NGO that refers users to the clinic, said that the idea of users paying for their treatment had been bandied about in the past, but that most users, like Rithy, could not afford it.
The idea was ultimately quashed, Harding said, but there is now talk that a similar system could be implemented in which civil society groups would pay on patients’ behalf with grants from outside donors, a system that raises questions over the extent to which the Ministry of Health would be accountable to NGOs.
“[Finding a donor is] as likely as being able to find funds for any of the activities that we’re involved in: there’s a chance that we can and there’s a chance that we can’t,” Harding said. “But there’s a chance that donors might not find it an appealing mechanism to become involved in because of this transparency issue.”
Harding said he is optimistic that the government would take the proposition of keeping the clinic afloat seriously, given the amount of attention it draws – UN Secretary-General Ban Ki-moon visited in 2012, he said – but in Cambodia, as in many countries, “issues related to health are not always on the top of governments’ list”.
Minister of Health Mam Bun Heang could not be reached for comment.
Though Sophal said that he had not yet formally requested that the ministry provide funding, he said that he, like Harding, was optimistic.
“I think they must. They have no choice.”
*Names have been changed to protect patients’ identities.