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DRAFT DISCUSSION PAPER

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Ministry of Health

Kingdom of Cambodia

A PARTNERSHIP CASE IN CAMBODIA:

Scaling up health interventions with high impact on mother and child mortality through sector wide

management

Prepared by

Dr Char Meng Chuor, Deputy- Director-general for Health For the

3rd ASEAN & Japan High Level Officials Meeting on Caring Societies: Development of Human Resources and Partnerships in Social Welfare and Health

Tokyo, Japan 28 Aug-1 Sept 2005



TABLE OF CONTENTS

TABLE OF CONTENTS ...................................................................................................................................................................... 1 1. INTRODUCTION ........................................................................................................................................................................ 3 2. COUNTRY BACKGROUND....................................................................................................................................................... 3

2.1. MACRO-ECONOMIC PERFORMANCE ....................................................................................................................................... 3 2.2. HEALTH SITUATION .............................................................................................................................................................. 4

3. THE HEALTH SECTOR’S CONTRIBUTION TOWARD THE ACHIEVEMENT OF THE CAMBODIA MILLENNIUM DEVELOPMENT GOALS 2015 .......................................................................................................................................................... 5

3.1. CHANGE IN HEALTH OUTCOME ESPECIALLY DURING THE PERIOD 1998-2003 ............................................................................ 5 3.2. REFORM IN HEALTH SERVICE DELIVERY SYSTEM ................................................................................................................... 6 3.3. MAJOR FACTORS CONTRIBUTED THE IMPROVEMENT IN HEALTH STATUS ................................................................................... 6 3.4. SOCIO-ECONOMIC IMPROVEMENT .......................................................................................................................................... 6 3.5. PROGRESS MADE IN THE HEALTH SECTOR .............................................................................................................................. 6

4. SPEEDING MCH RELATED MDG ACHIEMENT IN COUNTRY AND HEALTH SECTOR CONTEXT .................................... 7 4.1. COUNTRY LEVEL INITIATIVES IN PARTNERSHIP ........................................................................................................................ 7 1.1.1 STREAMLINE AND STRENGTHEN AID COORDINATION................................................................................................................................. 8 1.1.2 GOVERNMENT-PRIVATE SECTOR PARTNERSHIP ....................................................................................................................................... 8 1.1.3 PARTNERSHIPS WITH CIVIL SOCIETY AND NGOS ...................................................................................................................................... 8

4.2. PARTNERSHIP DEVELOPMENT IN THE HEALTH SECTOR ........................................................................................................... 8 1.1.4 COORDINATION COMMITTEE FOR HEALTH ................................................................................................................................................ 8 1.1.5 THE SECTOR-WIDE MANAGEMENT (SWIM).............................................................................................................................................. 9 1.1.6 JOINT PROGRAM TO SUPPORT THE HEALTH SECTOR STRATEGIC PLAN ...................................................................................................... 9 1.1.7 SCALING-UP INTERVENTIONS FOR MOTHER AND CHILD HEALTH THROUGH SWIM AND HSSP .................................................................... 10 1.1.8 SCALING UP MCH SERVICES THROUGH A MODEL OF PUBLIC-PRIVATE PARTNERSHIP: CONTRACTING OF HEALTH SERVICES ............................ 12 1.1.9 THEMATIC PARTNERSHIP CASES ........................................................................................................................................................ 12

5. ACHIEVEMENTS IN PARTNERSHIP ...................................................................................................................................... 14 5.1. OWNERSHIP AND CAPACITY ................................................................................................................................................ 14 5.2. TRANSACTION COSTS TO GOVERNMENT .............................................................................................................................. 14 5.3. CLIENT CONSULTATION MECHANISM (CITIZEN ARE STAKEHOLDERS TOO) ............................................................................... 14 5.4. DEMAND SIDE SUBSIDIES FOR THE POOR: THE EQUITY FUND .................................................................................................. 15 5.5. SUSTAINABILITY ................................................................................................................................................................. 15

6. LESSONS LEARNED IN SECTOR-WIDE MANAGEMENT .................................................................................................... 15 6.1. DEVELOPING AGREEMENT ON THE GENERAL PRINCIPLES OF PARTNERSHIP AT AN EARLY STAGE FACILITATES LATER PROGRESS.15 6.2. THEMATIC PARTNERSHIP WITHOUT SWIM PROCESS IS NOT BEST PRACTICE TO MOBILIZE MORE SUPPORT TO INTERVENTION WITH

HIGH IMPACT ON MOTHER AND CHILD MORTALITY. ............................................................................................................................. 15 6.3. STRONG COMMITMENT OF HIGH-LEVEL OFFICIALS CONTRIBUTES TO EFFICIENT DECISION MAKING PROCESSES.......................... 16 6.4. ESTABLISHING AN EFFECTIVE COLLABORATIVE FRAMEWORK BUILT ONE THE EXISTING STRUCTURE AND A SUFFICIENTLY

CONSULTATIVE PROCESS IS INDISPENSABLE FOR THE SUCCESS OF STRATEGY DEVELOPMENT. ............................................................. 16 6.5. PERSONAL TIES CAN HELP COMPLEMENT FORMAL COORDINATION STRUCTURES. .................................................................... 16 6.6. LEARNING PROCESS IN STEP-BY-STEP TOWARD HARMONIZATION/ALIGNMENT ......................................................................... 16

7. KEY CHALLENGES IN PARTNERSHIP FOR MCH ............................................................................................................... 16 7.1. DEVELOPMENT OF A COMPREHENSIVE MOTHER AND CHILD PLAN LINKED WITH HIV/AIDS WITHIN THE SWIM PROCESS ........... 16 7.2. IMPROVE ANNUAL OPERATIONAL PLAN (AOP) PROCESS ...................................................................................................... 17 7.3. ADDRESSING LOW PAYMENT ............................................................................................................................................... 17

8. CONCLUSION.......................................................................................................................................................................... 17 APPENDIX 1 ..................................................................................................................................................................................... 18 APPENDIX 2 ..................................................................................................................................................................................... 20 APPENDIX 3 ..................................................................................................................................................................................... 22 APPENDIX 4 ..................................................................................................................................................................................... 25 APPENDIX 5 ..................................................................................................................................................................................... 26 ENDNOTES AND REFERENCES .................................................................................................................................................... 29



A PARTNERSHIP CASE IN CAMBODIA:

Scaling up health interventions with high impact on mother and child mortality through sector wide management1

Prepared by Dr Char Meng Chuor, Deputy- Director-general for Health, Kingdom of Cambodia For the 3rd ASEAN & Japan High Level Officials Meeting on Caring Societies: Development of Human Resources and

Partnerships in Social Welfare and Health (Tokyo, Japan; 28 Aug-1 Sept 2005)

1. INTRODUCTION The purpose of this paper is to examine the development of partnerships in the health sector in Cambodia in the context of the worldwide movement toward building such partnerships among governments, civil society, donors, and NGOs. It attempts to do so through an analysis of the Sector Wide Management Approach (SWIM) as applied to the scaling up of programs for maternal and child health (MCH) in the health sector. The focus on MCH arises from the stated priorities of the Ministry of Health (MOH) as expressed at the most recent Joint Annual Performance Review conducted by the MOH and its partners in March 2005. The five priority areas under MCH include: (i) emergency obstetric care (ii) skilled attendance at delivery (iii) integrated management of childhood illnesses (iv) birth spacing and (v) full minimum package of activities (MPA) status for health centers. The focused objectives of this paper include the following:

(i) to review progress made toward realizing the partnership goals expressed in international and national fora, and

(ii) to examine health development partner allocations to determine if these match alignment goals

In an important sense the paper attempts to show partnership development in Cambodia by focusing on one key thematic area, maternal and child health, that has been chosen by the MOH and its partners as the highest priority within the health sector. The focus is on partnerships for maternal and child health (MCH) at both international and country levels, and is motivated by the concern that a fragmented partnership even when addressing such a high priority goal can place greater burdens on the health sector that can outweigh any potential gains. From the analysis conducted, it appears that stakeholder commitment to MCH survival is limited to words, since actual budgetary allocations show that other areas receive far more from partner funds than do MCH priorities. The paper concludes with a status update of achievements, lessons learned so far and key challenges anticipated in scaling up MCH interventions through partnerships at the country level. While the attention of all stakeholders to the importance of MCH as the overriding priority in the health sector has been drawn through the last Joint Annual Performance Review and National Health Congress conducted in March 2005, it is hoped that this paper will motivate key actors to move beyond mere formal commitments to actual resource allocations that will enable the MOH to achieve its stated goals.

2. COUNTRY BACKGROUND

2.1. Macro-economic performance Over the last decade, Cambodia has devoted significant time and made concerted efforts to raise the nation from the ashes of genocide under the Khmer Rouge, internal strife, and ravages of the protracted war in the region. For the first time in its recent history, the country has enjoyed an environment of peace, political stability, law and order, democracy, respect for human rights, and economic stability since 1999. A comprehensive reforms agenda is being implemented by the Royal Government, despite the many challenges it faces. The process of making the transition from a centrally planned economy to a market based system that began in the mid-1980s is continuing, along with rehabilitation and development efforts to put the nation back on a holistic path that will achieve the national goals of poverty reduction and sustainable development.

Economic performance over the past few years generally has been favorable, as Table 1 below indicates. Annual real GDP growth has averaged 6-7 percent reflecting both favorable external developments including large aid inflows, and prudent macroeconomic policies.2 In a stable political climate, private sector activities in both the formal and informal sectors have flourished. Following a 1996 trade agreement with the US, garment exports soared from $1 million to $1.1 billion in 2003. This period has also seen a steady growth in tourism contributing up to a third of real GDP. Aid inflows have averaged about 12 percent of GDP, helping finance a large portion of domestic investment including construction. While the ending of the Multifibre agreement in 2004 has exposed the vulnerability of the garment sector to external competition from countries in the region, data from the first quarter of 2005 show a limited adverse impact. Current expectations are that the adverse effects will be minimal and that the garment industry will witness continued growth, although perhaps not as high as in the recent past.

TABLE 1: SELECTED MACRO-ECONOMIC INDICATORS

Indicator 1998 1999 2000 2001 2002 2003

Preliminary

Population (in Millions) 12.2 12.5 12.8 13.1 13.5 13.8

Per Capita GDP (in US$) 252 275 279 282 296 306

Real GDP Growth (in %) 3.7% 10.8% 7.0% 5.7% 5.5% 5.2%

Real GDP % share (at current prices):



Indicator 1998 1999 2000 2001 2002 2003

Preliminary

Agriculture (in %) 45.2% 42.3% 37.6% 35.5% 33.4% 34.8%

Industry (in %) 17.2% 18.1% 22.1% 24.2% 26.3% 26.7%

Services (in %) 33.6% 33.9% 35.2% 34.8% 34.2% 33.2%

Inflation (in %, period average) 14.8% 4.0% -0.8% -0.2% 3.3% 1.2%

Riel/US$ parity (annual average) 3,774 3,813 3,859 3,924 3,921 3,980

Sources: Ministry of Economy and Finance; National Bank of Cambodia; and National Institute of Statistics/Ministry of Planning. Cambodia‘s economic and human poverty is pervasive. Cambodia is the poorest country in South East Asia and ranks 73 rd out of

92 less developed countries on the UN Human Poverty Index.3 About 36% of the population live below the poverty line

4, 90% of

whom live in rural areas5. Household surveys

6, participatory poverty assessments

7, and longitudinal research

8 provide qualitative

and quantitative evidence of the extent, depth, nature and causes of poverty in Cambodia. Within this context, for the Royal Government, growth with equity is the most powerful weapon in combating poverty and it remains committed to pursuing policies that encourage macroeconomic stability, shifting resources to more efficient sectors, and integrating within the global economy. Latest draft estimates of the poverty headcount ratio suggest that it has dropped from the 36% level to 28% in 2003-04, based on

the results from the latest Cambodia Socio-Economic Survey (2003-04).9

As in any human undertaking, the Royal Government‘s efforts and achievements have not been exempt from insufficiency of actions and weaknesses. Indeed, the current national production structure is still far too small and concentrated in a few areas and must be expanded and diversified to ensure sustained economic growth.

The Royal Government recognizes that Cambodia still has a long way to go, and has to overcome numerous obstacles to achieve sustainable progress and prosperity for the country and its people. The promotion of harmonized efforts by the Cambodian people to reduce poverty continues to be the most important objective of the Royal Government. The Royal Government recognizes that the problems of poverty cannot be solved overnight, or in one month, or one year.

2.2. Health Situation War has impacted on the nature of poverty, creating a large number of returnees and internally displaced people, high rates of disability, and a large number of female-headed households. The poor in Cambodia lack food security, access to natural resources, access to physical infrastructure, social infrastructure and services. Chronic and catastrophic illness is a major cause of

indebtedness10

, asset sales, and impoverishment, and poverty makes the poor more vulnerable to infectious diseases due to poor

nutrition and unhealthy living conditions.

Several nation-wide household surveys have provided evidence of the large inequities in access to, and utilization of, health services, according to socio-economic status. Analysis of socio-economic disparities in health status and utilization based on data

from the 2000 CDHS indicate that the full basic immunization rate11

for the richest quintile (67.7%) was more than double that for

the poorest quintile (28.6%). Similarly, the poorest quintile (28%) was almost four times more likely not to have received either the

BCG, DPT, or measles vaccination than the richest quintile (8%).12

Data from the same source also show that pregnant women

belonging to the richest quintile (79.6%) were four times more likely to have had more than one antenatal checkup from a medically trained provider than those in the poorest quintile (21.9%). It appears therefore, that the public health system has failed

to target resources to those most in need; recent benefit incidence analysis (2002)13

shows that the poorest 20% of the population

benefit least from public spending. Rural-urban and regional inequities in health status are also significant.14

The civil war of the seventies and the ensuing political unrest during the past twenty years left Cambodia with a poor public sector infrastructure and services. The Khmer Rouge decimated the health system: of the 1,000 doctors trained prior to 1975, fewer than 50 survived the regime. In 1979, the restoration of a functioning health care system became one of the highest priorities of the new government of the People‘s Republic of Kampuchea. Although there has been some improvement in recent years, health indicators in Cambodia are among the most adverse in the region. For instance, only Lao PDR, Myanmar, and Timor Leste have higher infant mortality rates. Health infrastructure needs significant strengthening. The quality of health services both in public and private sectors is poor. Skills of health care providers need to be upgraded. Although considerable progress has been made in the last 5 years, further support and consolidation are required to improve access and utilization of health services, especially by the poor and disadvantaged. The capacity of MOH to plan, finance and manage health services remains weak, and needs to be strengthened.

Currently, health and demographic priorities to be addressed are: (1) high infant and child mortality including high post-neonatal mortality, mortality and morbidity from diarrheal diseases, acute respiratory infections, vaccine-preventable diseases, dengue and malaria; (2) high rates of under-nutrition among women and malnutrition among children; (3) high maternal mortality ratio, and deaths from obstetric trauma and septic abortions; (4) high case fatalities from infectious diseases, particularly HIV/AIDS, TB, and malaria; (5) high total fertility rate and consequent population growth (6) harmful practices among consumers and providers,



including unhealthy lifestyles and widespread inappropriate health seeking behavior; and (7) an increasing rate of traffic accidents and injuries in recent years.

3. THE HEALTH SECTOR’S CONTRIBUTION TOWARD THE ACHIEVEMENT OF THE CAMBODIA MILLENNIUM DEVELOPMENT GOALS 2015

3.1. Change in health outcome especially during the period 1998-2003 Over the past decade, the Royal Government of Cambodia and its health development partners together have attempted to rebuild and recreate the health sector from the ashes of the enormous destruction caused by the genocidal regime and the ensuing civil war. Even though this attempt was faced with multiple challenges, the achievements in the health sector have contributed substantially to improving the health and well-being of our people. The trend in infant mortality rate is patterned with the country political and socio-economic development as the figure below shows:

Trend of Infant Moratlity Rate in Cambodia 1976-2005

8579

91 93

66

129

Pol Pot

0

20

40

60

80

100

120

140

1976

-80

1981

-85

1998

6-90

1991

-95

1996

-00

2001

-05

5y-period

IMR

: per

100

0LB

Pol Pot regime

GenocidePolitical instability including

the 1997 coup

The Royal Government of Cambodia (RGC) is fully committed to the Millennium Development Goals (MDGs), and has put maternal and child mortality reduction as high priorities for its Health Sector Strategic Plan, 2003-2007 (HSP). Cambodia‘s health related targets under the MDGs are to reduce the under-five mortality rate (U5MR) to 65 and the infant mortality rate (IMR) to 50 per 1,000 live births by 2015. The key maternal health target is to reduce the maternal mortality ratio to 140 per 100,000 live births. However, in the Cambodia Millennium Development Goals Report 2003, the RGC has honestly admitted that Cambodia is facing an enormous challenge to meet these targets with recognition of the urgency for better-coordinated actions by all relevant sectors in Cambodia, including those supported by external partners.

Indeed, the improvements in health status may be termed remarkable, as evidenced by recent national survey findings. Recent findings from two nationwide surveys provide impressive new evidence of the achievements made in the health sector over the

past five years.15

Life expectancy at birth for males has risen from 52 years in 1998 to 60 years in 2003, and for females from 56

to 65 years over the same period. In addition, infant mortality has also declined rapidly from 93 infant deaths per 1,000 live births in 1998 to 66 deaths in 2003, a decline of 29%. Similarly, child mortality has also witnessed a steep decline from 31 child deaths per 1,000 children 1-4 years of age to 17 deaths (45% decline). Underpinning these improvements in life expectancy and infant and child mortality are rapid declines in the total fertility rate, which has dropped from an estimated 6.0 children in 1990 to 4.0 in 1998 to 3.3 in 2003. Maternal mortality has continued to decline as well: from a maternal mortality ratio of an estimated 900 maternal deaths per 100,000 live births in 1987, it has declined to 473 in 1998, 437 in 2000, and 413 in 2002. Given the rapid declines in fertility quoted above, it is likely that maternal deaths have declined further since 2002.



From the figures above, it appears that the improvements in life expectancy have been three to four times faster than equivalent improvements in most other developing countries. Similarly, reductions in infant mortality are more than twice the amount typically experienced in other developing countries (12% reduction over a 10 year period), even though the level of infant mortality continue to remain high at 66 infant deaths per 1,000 live births. Maternal mortality has continued to decline as well: from a maternal mortality ratio of an estimated 900 maternal deaths per 100,000 live births in 1987, it has declined to 473 in 1998, 437 in 2000, and 413 in 2002. Given the rapid declines in fertility quoted above, it is likely that maternal deaths have declined further since 2002.

The number of patients with health problems has been reduced. HIV/AIDS prevalence among adults age 15-49 years has declined from 3.3% in 1998 to 2.0% in 2000, 2.1% in 2001, and 1.9% in 2003. Polio disease has been eliminated and leprosy now is not a public health problem in Cambodia. The tuberculosis prevalence rate (Smear positive) of 470 per 100,000 persons in 1997 declined as well to 360 in 2002 (a 23% decline).

3.2. Reform in Health Service Delivery System Since 1997, public health care management has been reorganized on a population basis. In this reformed district system called ―The Health Coverage Plan (HCP)‖, the basic unit of health care is the ―Operational District‖. It provides a comprehensive primary health care (PHC) package based on the original comprehensive meaning of PHC. The operational district covers a population of 100-200,000 persons. It should not be confused with existing administrative districts of the country which are not population or community based. In each operational district are health centres serving a population of 10,000 people each. Health centres are staffed with 5-7 people and provide a basic integrated package of health care referred to as the Minimum Package of Activities (MPA). These services are basic preventive, promotive and curative care. Each health centre provides outreach services to local communities. Each health centre will have a joint community co-management committee where local community representatives have responsibility for overall management of the health centre

In each operational district is one referral hospital (total of 69 nation-wide). These hospitals receive cases refereed from the health centres and manage complicated cases, operations, inpatients, serious illnesses requiring admission etc. Such services are referred to as the Complimentary Package of Activities (CPA).

Both the referral hospital and the health centres thus meet a communities basic health needs and are managed as a single system of health care. At its most basic, such a system can provide a pregnant women with ante-natal care; provide good delivery care; manage any complications as they arise; if a complicated delivery, correctly manage and refer (transport) that woman to the referral hospital for safe delivery and if medically indicated a safe caesarean section. Thereafter returning a healthy mother and child to her home in her village and provide follow up care and contraceptive advice.

The concept is thus holistic and meets an individuals basic but comprehensive needs from the home to the hospital.

3.3. Major factors contributed the improvement in health status

3.4. Socio-economic improvement As is well known, socioeconomic improvements16 can yield tangible gains for health status and health utilization. Over the past few years, the economy has grown at a steady pace averaging about 6% per annum. Prudent fiscal management on the part of the RGC and increases in investment in key industries such as tourism and garment manufacturing have contributed to this growth. The adverse effects of the ending of the Multi-fiber agreement have yet to be felt in a significant way in the garment industry, and the scale of job loss has been considerably less than expected. GDP per capita has increased from $252 in 1998 to $306 in 2003. From 1998 to 2003 over the 5 year period, the RGC has constructed 14,230 km. of new rural roads, built 1,247 new bridges for a total length of 23,331 m., 40,500 wells, and 6,412 ponds. Proportion of the population with access to safe water sources has expanded from 28% in 1998 to 44% in 2004. Proportion of the rural population with access to safe water sources has expanded to 40% in line with the CMDG goal for 2005. 70% of urban residents now have access to safe water as well, up from 30% in 2000. Access to sanitation has also increased from 17% in 2000 to 55% in urban areas, and to 16% in rural areas. The proportion of households using iodized salt has also increased from 12% in 2000 to 28% in 2003-04. There have been significant improvements in education as well: the number of female students in secondary school has increased from 104,816 in 2000-01 to 192,730 in 2002-03. Literacy rates of adult female which were just 57% in 1998 now stand at 64% in 200417. All of the above factors have undoubtedly played a contributory role in sustaining the reductions in mortality that have been witnessed over the past five year period. With continuing investments in infrastructure, safe water and sanitation, and expansion in educational opportunities, the improvements in health status and utilization will likely continue over the long term.

3.5. Progress made in the health sector These achievements in the improvements of health status and well-being arise also from the improvements in the health sector, spanning human resources, health infrastructure development, health education, and coverage rates, in addition to quality of care and quantity of services. Several other health related indicators at output and outcome level provide evidence in support of the reported infant and child mortality declines. These include the very high coverage for measles and DPT3 vaccinations, as well as vitamin A coverage for children 12-59 months old reported in the preliminary results of the Cambodia Socio-Economic Survey 2003-04. Additionally, there has been a steady if slow increase in the utilization rates of public health services over the past 3-5



year period, coupled with a steady decline in case fatality rates for both malaria and dengue hemorrhagic fever. Concomitant with these encouraging signs in health outputs and outcomes has been the significant expansion of public health infrastructure across the country. Increasing number of health centers are now able to offer full Minimum Packages Activities (MPA) over a 24 hour period. During the period 1998-2004, the number of functioning health centers was increase by 115% and the number of district referral hospital with major surgical operation was increase by six folds allowing them to cater to expanded numbers of patients. Critical shortages of health professionals such as nurses and midwives have been filled by recruiting and training in these categories. Procurement of pharmaceuticals and medical supplies has become more systematic, and distribution to health facilities in a timely manner has resulted in fewer stockouts. Institution of innovative programs such as contracting and equity funds have expanded access for the poor, and the more remotely located populations, as well as resulting in an improvement of the quality of care. Finally, strong support from some of the health development partners and improved managerial practices at provincial and operational district levels have enabled outreach visits to both nearby and remote villages to occur in a more regular fashion, resulting in greater proportions of the population receiving both preventive and curative services.

Significant progress have been made since 1998 in both provision of basic health services, diseases controls interventions and promotion of women and child health. The total number of health centers (HC) with adequate capacity to provide minimum package of activities (MPA) has increased from 386 in 1998 to 823 in 2003. The number of referral hospitals (RH) with major surgical services increased from 3 in 1998 to 15 in 2003. The success of disease control interventions was seen with the increase in cure/detection rate of tuberculosis, decrease in prevalence of adult tested HIV positive, and decrease in incidence and case fatality rate of malaria, dengue hemorrhagic fever, measles and cholera, and the eradication of poliomyelitis since 2000. The percentage of pregnant women with at least two antenatal care visits increased from 19% in 1998 to 33% in 2003. The use of modern contraceptive methods delivered by the public health facilities increased from 9.7 in 1998 to just over 19.9% of the married women aged 15 to 49 in 2003. In 2003, 70% of children aged 12-59 months received at least one vitamin A supplement.

However, the effort to improve health status is being made in a context of severe resource constraints and serious post-conflict institutional challenges. Despite the strong commitment from the Royal Government of Cambodia (RGC) in support of the health sector, an adequate level of the Ministry of Health (MOH) expenditure seems a long way off to cover the basic package of public health services - with little dependant on external assistance - which was estimated, by the World Bank to cost around US$12 per

capita per year for a low-income country such as Cambodia18

. The recent figure suggested in a Report of the Commission on

Macroeconomics and Health is that the minimum per capita sum19

needed annually to introduce the essential

health interventions for low income countries should be approximately 34 USD by 2007 and 38 USD by 2015. Of great concern, is that the health development partners are yet to pay adequate attention to maternal and child health interventions and move from policy to practice. From the Table below it would appear that the RGC has already reached the recommendation of the report of the Commission on Macroeconomics and Health that the percent of the national budget allocated to health should be a minimum of 1% of GDP by the year 2007.

Government Recurrent Budget allocated to the Ministry of Health 1995-2005

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

% of GDP 0.4% 0.6% 0.5% 0.5% 0.6% 0.9% 1.0% 1.1% 1.2% 1.3% 1.3%

% of total government budget 5.0% 7.4% 7.4% 6.7% 4.4% 10.3% 10.3% 11.0% 11.6% 12.5% 11.7%

US$ per Capita $1.5 $2.4 $1.7 $1.3 $1.7 $2.5 $2.8 $3.4 $3.8 $4.3 $4.4

% of total government budget 5.0% 7.4% 7.4% 6.7% 4.4% 10.3% 10.3% 11.0% 11.6% 12.5% 11.7%

4. SPEEDING MCH RELATED MDG ACHIEMENT IN COUNTRY AND HEALTH SECTOR CONTEXT Significant progress has been made at both country/sector/thematic to streamline and strengthen coordination of effort among all stakeholders in particular to achieve health related MDGs for Cambodia. At the same time, the international community has made significant advances in addressing issues concerning harmonization of donor practices and improving aid effectiveness.

4.1. Country level initiatives in partnership Since the launch of Cambodia‘s New Development Cooperation Paradigm, the Royal Government has put in place institutional mechanisms and management systems to support aid coordination and management through the Council for the Development of

Cambodia.20

Currently, Cambodia partnership development is taking part of international arena (See APPENDIX 1). However, in

spite of major improvements, the current situation as reflected in the findings of the just completed OECD/DAC survey for Cambodia continues to present challenges to which solutions must be found to improve aid effectives. The current situation is a good illustration of inadequate Government ownership of many projects; ―piece-meal‖ efforts, and insufficient coordination and support by donor agencies for Royal Government‘s sectoral/ thematic programs; the uncoordinated approaches for capacity development; proliferation of different procurement, disbursements, auditing, and progress monitoring and reporting procedures among agencies; and the use of donor-supported project management units staffed either by expatriates or by nationals who are paid significantly higher salaries than those with comparable qualifications employed in the public sector.



Some of the major initiatives of the Royal Government to strengthen its capacity to manage development assistance and to build

partnerships with national and international development partners are described below.21

1.1.1 Streamline and Strengthen Aid Coordination Soon after the launch of the New Development Cooperation Partnership Paradigm for Cambodia, the Prime Minister appointed CDC/CRDB to be the RGC‘s Partnership Focal Point within the Government. As the Partnerships‘ Focal Point, CDC/CRDB is responsible for coordinating and mobilizing resources for public investments, and to provide support to ministries/agencies to enable them to effectively manage the process of establishing partnership arrangements with Cambodia‘s national and external partners. However, the Lead Responsibility for building sectoral partnerships remains firmly in the hands of each sectoral ministry/agency.

On 10 September 2004, Samdech Hun Sen, the Prime Minister endorsed the proposal to create 17 Joint Technical Working Groups at the sectoral/thematic level. To ensure coordination among the 17 joint technical working groups, he also endorsed the proposal to create a ―Government-Donor Coordination Committee (GDCC)‖ to provide policy guidance, to set priorities, and to propose measures to solve problems raised by joint technical working groups.

The Royal Government also initiated work on the preparation of RGC Action Plan to implement the Rome Declaration‘s commitment, a recommended next step in the Rome Declaration. The plan was jointly endorsed as part of the partnership agreement between the RGC and donors agencies in 2004.

The RGC is taking more concrete action in terms of forging better partnerships by detailing an explicit strategic framework for

development cooperation management.22

The framework details the RGC‘s approach to development cooperation management

together with a national program to implement the strategy.

1.1.2 Government-Private Sector Partnership The Royal Government recognizes that improving the business climate and creating an enabling environment for private sector development are key pre-requisites for fostering growth, creating jobs, reducing poverty and achieving sustainable economic development. To remove the critical bottlenecks impeding the development of the private sector as well as to provide inputs in the processes of administrative and regulatory reforms, a Government-Private Sector Forum was established in December 1999. It has been meeting once every six months and is supported by seven Business-Government Sectoral Working Groups, which meet monthly to identify and recommend actions to resolve sector-specific problems. To further strengthen the key institutional mechanisms to support the implementation of the Rectangular Strategy, at the last Government-Private Sector Forum held on 20 August 2004, Samdech Hun Sen, the Prime Minister announced the formation of a Steering Committee for Private Sector Development.

1.1.3 Partnerships with Civil Society and NGOs The process of building partnerships with the civil society and the NGOs is now well underway. The adoption of the Commune Administration and Election Laws in 2001 and the successful election of 1,621 Commune/Sangkat (C/S) Councils in February 2002 represent a bold step to move forward Royal Government's efforts to promote more responsive public service delivery and to enhance the participation of the citizens in local socio-economic development to alleviate poverty. The election of the Commune Councils has deepened the foundations of democracy and will accelerate the governance reform process through decentralization. The Royal Government is aware of the immense challenges it faces in formulating and refining the policy and regulatory frameworks, mobilizing sufficient domestic and external financial resources, developing broad awareness of the concepts and principles underlying democratic local governance and building the capacity of both the Commune Councils and government institutions to effectively carry out their responsibilities and mandates. The Royal Government, however, is confident that the momentum it has already achieved will enable it to meet the challenges. Nevertheless, achieving sustainable gains will require time and will depend in large part on the level of partnerships that are build between the various jurisdictional levels within the government; between government and the donor community; and between government, international and national partners, the local Councils, and especially the civil society.

4.2. Partnership Development in the Health Sector

1.1.4 Coordination Committee for Health Since 1991, the MOH has put in place a Coordinating Committee for external aid in the health sector (COCOM) chaired by a secretary of state for health. 23 The COCOM‘s function is the rehabilitation and future policy development and planning of Cambodia's health services, including determining national health sector needs for financial and manpower resources. Its second function is the co-ordination of current and future activities of all international and non-government organizations and others working in the health sector. Permanent memberships include the MOH key senior staff, bilateral & multi-lateral organizations, and MEDICAM (a Committee of NGOs working in the medical field). COCOM‘s meetings are held monthly. The Director of Cabinet chairs the COCOM Secretariat, an Executive Committee of COCOM. The WHO, through its Strengthening Health System (SHS) project, provides technical assistance to the Secretariat.23 COCOM has established thirteen technical sub-committees to address specific health issues such as Maternal and Child Health, and has extended its operations into most provinces though the Provincial Coordinating Committees for Health (PROCOCOMs).



In addition, NGOs organized the Medical Coordinating Committee for Health (MEDICAM), a forum opened to all NGOs working in the health sector, with representatives to the COCOM and the sub-committee of COCOM.

In 2004, the CoCom was converted into the Technical Working Group for Health (TWGH) to be aligned with partnership framework at both national and internal arena following the Rome Declaration (See APPENDIX 5). Based on the its TOR developed based the TOR of the existing CoCom, the TWGH strengthen its secretariat and developed a concrete annual plan of action to contribute to the implementation of RGC‘s Action Plan for Harmonization and Alignment, in which MOH is one of the pilot Ministry, alongside with the Ministry of Education, for moving forward to the SWiM/SWAp.

Sub-committee for maternal and child health is a relatively strong Sub-committee compared other. This sub-committee was able to assist the MOH in development of MCH related strategic and/or technical guideline but it capacity to maintain its relatively high priority in term of external aids has been gradually undermine since many partners was increasingly interested in disease control programs especially HIV/AIDS. The proportion of financial/technical resource dedicated annually to HIV/AIDS was estimated at around 23% of the total external flow to health compared to the 7% dedicated to national programs for MCH.

1.1.5 The Sector-wide Management (SWiM) A number of major sector-wide problems are being addressed by donors individual projects designed to tackle specific weaknesses such as insufficient infrastructure and inadequate technical and management skills of Ministry staff. Although the ministry has good relationship with most development partners and other government institutions, there are six linked issues arise: (1) does the method of allocating donor funding encourage a sustainable health care system? (2) Are the allocations consistent with the government‘s own health policy goals? (3) To what extent were the external funds managed using the MOH structure? (4) When will the government be able to adequately fund and manage the health sector with little dependence on external aid? (5) Should MOH extent MOH expand its public-private partnership e.g. contracting to NGOs? (6) How can public entities under MOH administration support the decentralization policy of the Royal Government? What is the Government‘s role in health, and what tasks should it be doing and what shouldn‘t it be doing?

To address the above-mentioned issues, the Sector-wide Management (SWiM) is being pursued, which has most of the characteristics of a Sector Wide Approach (SWAp), but excludes establishing a mandatory common fund basket and completely adopting common project implementation arrangements (See APPENDIX 4). In keeping with the Action Plan for Harmonization and Alignment of the Royal Government of Cambodia (RGC), the SWiM mechanism should be a step towards a SWAp. This would significantly increase opportunities for coordination of efforts and provide flexibility for the allocation of scarce resources while reducing transactions costs in the long run. To this end, a coherent system of planning and implementation processes has been developed in recent years, beginning with the Health Sector Strategic Plan 2003-2007 (HSP), Annual Operational Plans, Joint Annual Performance Reviews, and 3-Year Rolling Plans linked to the Medium Term Expenditure Framework and the Public Investment Program. All of these are joint procedures designed to allow the health sector to draw on the strengths of its constituent parts. They will however require considerable support in the medium term if they are to achieve their desired results. Government health expenditure has been increasing. In 1999 the approximate total government expenditure on health was US$ 2.85 per capita, increasing to US$ 3.30 per capita in 2003. Overall health sector financing in Cambodia absorbs approximately 10% of GDP, which is the highest among developing countries in Asia. An estimated 70% of health sector financing is from "out-of-pocket" payments, representing approximately USD 24 per capita, with donors paying approximately two thirds of the remainder. An accurate overall costing for health sector strengthening is not available for Cambodia, however the total cost for a health sector to be capable of delivering on basic health goals reflected in the Health Sector Strategic Plan, including HIV/AIDS, TB and Malaria goals, has been estimated by the Commission on Macroeconomics and Health to be approximately US 24 Dollars per capita. For Cambodia this would come to approximately 312 Million Dollars annually, including all National Programs, clinical services, pharmaceuticals, administration etc. With total public expenditures on health at about 10 dollars per capita in Cambodia, there will remain an enormous funding gap impeding delivery on overall goals.

1.1.6 Joint Program to support the Health Sector Strategic Plan DFID with the World Bank, Asian Development Bank and the Government of Cambodia are preparing to implement a joint programme, the Health Sector Support Programme (HSSP). HSSP aims to support development of the health sector in Cambodia, mainly by strengthening the sector's capacity to manage resources efficiently, to improve the performance and quality of the services and, ultimately, impact on the health status. In parallel with the development of HSSP, the Ministry of Health (MOH) has been developing a sector strategy, together with an M&E plan, an MTEF and operational plans. The MOH and donor partners also plan to move towards Sector Wide Management (SWiM), a sector wide approach without the expectation of pooled funding by all partners. Both the MOH and development partners are keen to see the HSSP supporting and strengthening the health sector strategy. As pre-programme work DFID has provided support to the MOH for development of the strategy, MTEF and monitoring and evaluation plans (See also APPENDIX 2).

In addition, a large proportion (77%) of budget dedicated to all provincial health department (PHD) for both management and provision of basic health services especially MCH services at Referral Hospital, Health Centers, Health Posts and out-reach activities is committed through the national budget and the health sector support project.



Annual Operational Plan 2005 for PHDs

Source of Fund US$ million %

Government (Including salary and medicines/supplies from Central Medical Store) 36.70 57%

Health Sector Support Project (ADB, DFID, UNFPA & World Bank) 13.12 20%

Other partners (Including medicines/supplies from Central Medical Store) 13.78 21%

User-fees 0.97 2%

TOTAL PHD budget for AOP2005 64.58 100%

1.1.7 Scaling-up Interventions for Mother and Child Health through SWiM and HSSP There is full political commitment to reducing mother and child mortality (MDG4) as evidenced by the overall goal for the health sector which has been framed as ― to enhance health sector development in order to improve the health of the people of Cambodia, especially mothers and children, thereby contributing to poverty alleviation and socio-economic development.‖ The strategies jointly agreed to by MOH and its health development partners include the implementation of safe motherhood, birth spacing and IMCI interventions to improve mother and child health status. It should be noted that MCH services have been institutionalized within the public health system through the National MCH Center (NMCHC). The NMCHC oversees the implementation of a number of programs with a direct impact on maternal and child health such as the ARI/CDD program, the national immunization program established in 1986, and the reproductive health/safe motherhood program established in 1994.

Given the high priority placed by the MOH on MCH interventions, and the partnership approach adopted as described above, one would expect to observe enhanced allocations to the NMCHC which is primarily responsible for these interventions, and to the National Center for Parasitology, Entomology, and Malaria Control (formerly the National Malaria Center or CNM) which administers the malaria prevention and control program (since malaria constitutes a significant share of the total burden of disease for children under 5 years), as well as control and prevention of dengue hemorrhagic fever, schistosomiasis, and helminths, all of which disproportionately affect children under 5 years. Both these rows have been shaded to show their relative importance for maternal and child mortality compared to HIV/AIDS and TB/leprosy. In fact as the Table overleaf shows, health development partners allocate substantially more of their external assistance to NCHADS and for TB/leprosy (66%), than they do for the NMCHC and the NCPEMC (34%). The RGC, however, in an almost mirror image of external assistance, and true to the MCH priorities it has established, allocates 59% of its total to NMCHC and the NCPEMC, and 41% to NCHADS and TB/leprosy. As a result of this unsynchronized allocation pattern, the percent of the total RGC plus donor budget allocated to MCH priorities is only 38% versus the 62% that flows to NCHADS and TB/leprosy. Clearly, alignment of health development partners resource allocation to the priorities of the MOH demands a greater proportion earmarked for the NMCHC than is currently the case.

Several sub-committees/working groups for ―thematic issues‖ related to the above-mentioned programs have been formed and are functioning since the early 1990s, but it has been difficult to ensure complementarities among these competing priorities for external assistance. Of greater concern is that the sub-committee for MCH established in 1992 and regularly functioning since then has not been able to get donors to fund more activities for MCH in terms of actual resource allocation. Explicit commitments to MCH as the overriding priority of the MOH is reflected in the Health Sector Strategic Plan 2003-07 (HSP) and more recently, at the Joint Annual Performance Review in March 2005. Based on the above information, the conclusion could be drawn that thematic partnerships involving a vertical approach may undermine the priorities established at both local and international levels regarding MCH, such as the MDGs.

Government and Donors Budgetary Allocation on National Centers in charge of Key Public Health Programs

National Institutions RGC + Donors RGC Donors

US$ million % US$ million % US$ million %

NMCHC (Maternal and Child Health programs) 6.5 16% 2.0 45% 4.5 12%

NCPEMC (Control and prevention of malaria, dengue hemorrhagic fever, schistosomiasis, and helminths)

8.5 21% 0.6 13% 7.9 22%

National Center for Tuberculosis and Leprosy 6.3 16% 0.7 16% 5.6 16%

National Center HIV/AIDS, Dermatology and STDs 19.3 47% 1.1 25% 18.2 50%

TOTAL 40.6 100% 4.4 100% 36.2 100%



Some steps to addressing the imbalance in investment have been taken as part of the process of sector wide management (SWiM). For instance, core actions agreed to by all stakeholders at the Joint Annual Performance Review conducted in March,

2005, as well as the MOH Guidelines for Preparation of Annual Operational Plans, 200624

issued in June, 2005 place the highest

priority for the period 2005-2006 on the following:

- Emergency Obstetric Care

- Attendance at Delivery by Trained Health Providers

- Integrated Management of Childhood Illnesses

- Full MPA status for Health Centers, and

- Birth Spacing services. MOH criteria for appraisal of the annual operational plans for 2006 prepared by central departments and institutions, national programs, and provincial health departments will focus on the following:

(i) Health Service Delivery

- Emergency obstetric care services at referral hospitals and health centers, community interventions such as support to village health support groups and the health center management committees and the commune councils

- Attendance at delivery by trained health providers

- Strategy for Integrated Management of Childhood Illnesses at referral hospitals and health centers through expansion in training of health staff for at least 50% of HCs and RHs, as well as providing health education on home based case management of the sick child, including recognition of danger signs

- Conduct outreach to remote communities (more than 10km from health center) at least 6 times a year

- Birth spacing services (expand availability of modern methods at RHs and HCs, expand community based distribution of birth spacing services, expand social marketing of contraceptives, and promote condom use for dual protection (for birth spacing and HIV/AIDS and STIs prevention).

(ii) Quality Improvement

- Strengthen Quality Improvement Office at MOH

- Establish national policy on quality assurance

- Pilot test QI in Pursat, Kampong Thom, and Kampot

- Develop evaluation tools for health centers and hospitals (iii) Human Resource Development

- Develop policy on attracting and training midwives for health centers

- Build further training plan on Emergency Obstetric Care for midwives at referral hospitals

- Accelerate deployment of midwives in remote areas

- Provide amenities to remote staff per MOH standard, including housing

- Staff management

- Establish accreditation system for health professionals

- Develop incentive policy for staff

- Review policy on staff recruitment (iv) Behavioral Change And Communication:

- Expand Number of Baby Friendly Hospitals;

- Finalize and implement national guidelines on providers‘ and clients‘ rights package;

- Implement behavioral change policy (v) Health Financing:

- Finalize and implement guidelines for equity funds, and seek government counterpart funding;

- Expand coverage of equity funds linked to quality improvement;

- Link performance-based salary incentives to better service delivery;

- Track health expenditure flows;

- Develop health insurance pilots (vi) Institutional Development

- Develop linked child survival and reproductive health strategies (MOH and Health Partners)

- Develop MCH leadership at all levels in MOH system

- Strengthen supervision and M & E for MCH; Reactivate Provincial Coordination Committee.



1.1.8 Scaling up MCH services through a model of public-private partnership: contracting of health services The large number of private providers in Cambodia has meant that the regulatory framework is difficult to implement effectively and the government, in practice, control only larger western style clinics in urban area. However, it was demonstrated that contacting NGOs for management of district health services is cost-effective in pro-poor context. The experiment significantly improved the access basic health service, especially MCH services for the poor and as well as apparent reduction in household expenditure on medical care of the 50% poorest segment of low income group. Some local NGOs were contracted for equity fund management.

As part of strengthening of basic health services through working in partnership with the private sector (NGOs), the Cambodian MOH experimented with contracting the management of health services to non-governmental entities in order to improve efficiency, cost-effectiveness and the quality of care (See APPENDIX 3). The Health Coverage Plan (HCP) mentioned earlier is the foundation for scope of services specified in the contract documents. The findings were generally positive: the contracting has increased the provision of basic health services from two to three fold, and in the contracting-out district, health expenditures of

poor households has reduced by 60-70% within the 3 years (1998-2001) of the pilot project25

. Moreover, the average annual

recurrent cost of contracting has stayed within the range of what the government could finance within the foreseeable future and the conclusion therefore is that contracting is a highly sustainable approach. The Ministry of Health is expanding the contracting of 11 ODs for the period 2004-2007 using resources from the Asian Development Bank, the World Bank, and DFID The annual per capita cost (a.p.c.c.) of the current contracting is estimated at around US$4.5, which is very much lower than the national average a.p.c.c. of public health service nation-wide for the same year.

1.1.9 Thematic Partnership Cases

4.2.1.1 Child Survival Partnership Both at global and national levels there is increasing awareness that without a major shift, the Millennium Development Goal 4 that calls for a reduction of childhood mortality by two-thirds in 2015 from the 1990 baseline will not be achieved. In fact, among measurable health goals, the world is farther from achieving the one for child mortality than any other. The Royal Government of Cambodia (RGC) is fully committed to the MDGs and has put child mortality reduction as a very high priority in its Health Sector Strategic Plan, 2003-2007 (HSP). Cambodia‘s targets for MDG 4 are to reduce under-five mortality rate (U5MR) to 65 and infant mortality rate (IMR) to 50 per 1,000 live births by 2015. In the Cambodia Millennium Development Goals Report 2003, it has honestly admitted that Cambodia is facing an enormous challenge to meet these targets with recognition for the urgency to increase better-coordinated actions by all relevant sectors in Cambodia, including those supported by external partners.

At global level this has led a group of international development partners to propose the formation of a new global partnership

called the Child Survival Partnership.26

The main purpose of this partnership is to collectively revitalize efforts and help countries

achieve the global child mortality Millennium Development Goal 4. This partnership brings together various actors, initiatives and programs in the field of child survival, and through high level advocacy has galvanized global and national action for accelerated reduction of child mortality worldwide. To date, this partnership encompasses several organizations, WHO, UNICEF, the World Bank, USAID, CIDA and the Bill and Melinda Gates Foundation. The Cambodian MOH mission met with some of these partners at the ―Child Survival: from Knowledge into Action‖ workshop held in Venice, in January 2004. During the workshop, the MOH presented the challenges that they are facing to achieve the child mortality reduction goal, proposing that the international community share responsibility with the government in addressing these challenges. It was agreed that a further discussion on the current situation, the constraints and the potential role of development partners to address the persistently high mortality of infants and under 5 children was necessary, and that a high level team visit Cambodia for this purpose. This visit occurred from 31 May to 2 June 2004.

Consequent to the High Level Visit to Cambodia, the MOH organized and led a National Child Survival Conference in October of that year. This was followed up by a December 2004 Child Survival Partnership Workshop. This workshop brought together key MOH officials at central and provincial levels, staff of more than 60 NGOs both local and international active in child survival, and more than 20 bilateral multilateral organization representatives. A key outcome of this workshop was the clear recognition on the part of all stakeholders that the MOH should provide the leadership in this area, with NGOs filling in the service delivery gaps, and the donors providing the necessary resources and technical assistance where required.

4.2.1.2 Global Alliance on Vaccines and Immunizations

GAVI first began its support to the Cambodian health sector in 2002 by supplying funding to the National Immunization Program (NIP). As is typical of GAVI, funding was in the form of performance-based grants to support introduction of the Hepatitis B vaccine, AD syringes and safe injection practices, and expansion and strengthening of routine immunization services.

An evaluation of GAVI‘s support funding supports the view that in many respects, the support has had positive effects, enabling the NIP to expand immunization coverage across the country.27 In particular, the support enabled NIP to launch innovative special initiatives such as Coverage Improvement Planning based on the WHO Reach Every District (RED) strategy, Post Activity Assessments that involve follow-up spot checks to ensure the validity of coverage data, and a pilot reward scheme that provides low financial incentives to health workers for every mother administered at least two tetanus toxoid vaccinations, and every fully



immunized child. As a result, coverage has steadily expanded reaching 83 percent for DPT3 vaccines and 75 percent for the measles vaccine, per the findings of the recently conducted Cambodia Socio Economic Survey 2003-04.28

It is important to note that the mode of the financing allows the NIP to decide for itself where the moneys could be put to best use. This flexibility on GAVI‘s part enabled the NIP to apply the first tranche for training of trainers for injection safety and development of IEC/BCC materials. Subsequently, funding was utilized for strengthening the cold chain, and follow-up health center training. Finally, recognizing that one of the critical constraints preventing improved coverage was the late disbursements of the national budget and the consequent failure to conduct village outreach sessions during the dry season when all areas of the country are accessible, the NIP allocated funding for supporting outreach sessions through payment of standard rates for transport costs and per diems for health center staff. This was a key factor in the improvement of immunization coverage across the country over the past three years.

Despite these noteworthy achievements, there are three potentially negative factors, arising from the very nature of GAVI financing, and its partnership with the NIP. First, GAVI‘s funding can only cover the short term. This has implications for the sustainability of NIP‘s use of funding for supporting outreach activities that typically contribute over 80 percent of all vaccinations administered. Both the MOH and NIP are acutely aware of these implications but recognize that long term sustainability can only be assured through increase in national budgetary allocations but more importantly, through more efficient and effective budget execution through timely disbursements from the central treasury. Second, driven by the performance-based nature of the funding and the threat of losing it because of a failure to achieve targets, the NIP has retained strong control over the allocation of those funds to provinces and operational districts where they determine need is greatest. This centrally driven top-down process runs directly counter to the MOH‘s own planning cycle that emphasizes bottom-up planning and increased decentralization, allowing lower level institutions to determine for themselves where resources are best utilized. Finally, again because of the performance-based nature of GAVI funding and the pressure to achieve performance targets, the NIP has focused these resources on areas with the highest numbers of non-immunized infants and children. These areas typically constitute those with some of the highest population densities in the country. This has implications for equity, since the areas with far lower population densities are some of the more remote areas of the country, and contain its most marginalized and vulnerable populations, including ethnic and religious minorities. At the current time, improving the pro-poor aspects of this funding appear limited. Perhaps over the medium term as the improvements in immunization coverage over the more accessible parts of the country are institutionalized, the NIP will alter its resource allocation patterns to benefit the neglected areas.

4.2.1.3 Global Fund to Fight AIDS, Tuberculosis and Malaria The GFATM was set up in January 2002 to make additional resources available as quickly as possible to scale up the fight against HIV/AIDS, TB and malaria. So far, Cambodia has successfully secured funding for proposals submitted for the first, second, and fourth rounds. The MOH is the Principal Recipient with KPMG Cambodia as the Local Fund Agent. The principal achievement of the Fund has been the partnerships it has established between the MOH and civil society and NGOs operating in the country. This is the first example of the MOH entering into close relationships with NGOs and channeling resources to them. While the GFATM has appreciably increased the funding available for these three disease prevention and control efforts in the country, potentially

serious weaknesses remain.29

One issue, it seems that that the GFATM is not flexible enough to allow for financing some health project that address specifically demand side interventions related the control of the three diseases. For instance in 2003, the Ministry was not succeed in getting GTATM approval for a project that attempt to reduce the financial barrier of access for the poor to health services related with malaria, tuberculosis and HIV/AIDS for mothers and children. Moreover, although the GFATM mode of financing is driven and initiated recipient to donors, not all activities it support are planned in harmonization with the Ministry of Health Annual Operational Plan process as the request for funding is strictly time-bound.

Another issue, although set up to reduce bureaucratic delays for program funding and implementation, bottle-necks continue to exist partly arising from in-country structures and systems and partly from the heavy reporting requirements imposed by the Fund. It has not helped that these reporting requirements have frequently been changed causing even further delays, and a diversion of focus on the part of the sub-recipients (NGOs) from implementation to monitoring and reporting. Although capacity building is a cross cutting issue, little priority has been given to it in the effort to achieve the prescribed targets. A failure to ensure availability of baseline data at the start for many of the sub-recipients has made the measurement of change virtually impossible, and has emphasized process indicators over outcomes. The evaluation of the first and second rounds referred to earlier also found extensive evidence of over-achievement of targets with significant under spending indicating deficiencies in establishing targets, and estimating expenditures required. An earlier evaluation conducted in Cambodia remarked on many of the same factors,

indicating that the partnership possibly lacks the flexibility that could enable some of these issues to be resolved30

as did an

overall assessment on NGO participation in the Fund.31



5. ACHIEVEMENTS IN PARTNERSHIP

5.1. Ownership and Capacity The overall process of the SWiM was governed and led by the senior officials of MOH. It was noted that the commitment of senior officials facilitated the process of organizational decision making, and consequently contributed to the efficiency of the HSP development work. It also appears that the joint working process involving donors and all the departments of MOH was the key element for success, and that the joint working process was instrumental in making MOH officials better understand HSP, as well as to equip them with the readiness to implement HSP as their own strategic plan. Currently, ownership and capacity building is

expanded to provincial and operational district offices through the Annual Operational Plan (AOP) process32

, which requires

decentralized and costed planning at provincial and district levels. The 1st health sector AOP for 2005 consolidated from 58 MOH institutions was approved by the Health Sector Steering Committee in October, 2004.

The capacity of MOH officials, especially in understanding the sector strategy and leading the joint working process with donors, depends in part on individual expertise and familiarity with the topics of discussion. During the three successive Joint Annual Performance Reviews in 2003, 2004 and 2005, each of the six technical working group sessions went forward with different degrees of involvement and leadership of MOH officials. While donor participants mainly facilitated and/or suggested policy options, government officials demonstrated their capacity in leading discussions in some groups. A significant achievement in this regard is the latest JAPR that took place in 2005. This was fully organized and led by MOH officials through the merging of the JAPR with the National Health Congress, the latter being an official event that has taken place annually since 1980. While it may be too early to draw conclusions about the extent to which the capacity of MOH officials developed through this process, the series of the joint working activities have been perceived definitely contributing toward it.

5.2. Transaction Costs to Government The administrative burden on the government of coordinating with each donor individually is an important issue of aid coordination. To date, limited evidence has been reported about the effectiveness of SWiM in this respect. However, there is a potential to achieve a reduction in the administrative burden of MOH if the current aid coordination mechanisms (including joint planning and reviews) continue. For instance, the Health Sector Support Project co-financed by ADB, DFID, UNFPA, World Bank and RGC reduced the transaction cost to the government through a number of joint process: project design, approve annual budget through the MOH Annual Operational Planning process, project monitoring report (Semester), supervision mission, mid-term and final review. Data needed for the project monitoring sheet was obtained from the MOH routine report system. This kind of arrangement could potentially reduce administrative costs to MOH, by reducing reporting requirements to MOH imposed by different projects, and reducing the administrative resources required to organize separate review workshops.

5.3. Client Consultation Mechanism (Citizen are stakeholders too) The promotion of clients‘ rights and providers‘ rights is one of the goals of the Behavior Change and Communication key area of work in the current health sector strategic plan. The rights aim at fostering changes in attitude and behaviour towards effective health service delivery and greater health empowerment of the Cambodian people. After going through several documents review, meetings and working sessions, the working group for client‘s rights has finalized a set of packages for clients‘ rights and providers‘ rights. The packages are composed of three elements: Key concepts, Application and Responsibilities. The key concepts define the meaning of each right. The applications outline the key actions to be carried out in order to put the respective rights into practice. Responsibilities underline the accountability of clients and providers for exercising their rights in a reasonable manner.

These draft packages were put into discussion in a consultative workshop on 14-15 January 2005 with 65 participants representing the health providers, the community, health partners and other civil societies including lawyers and labor union.

Client‘s rights have been also discussed at three consecutive years at the Joint Annual Health Sector Review workshop since2003. The draft was finally reviewed based on recommendation made during the Joint Annual Health Sector Performance Review 2005, and formally endorsed by the Ministry of Health in the same year.

To date, the packages of clients‘ and providers‘ rights include the following 7 rights:

1.- Right to equality, and to be free from all forms of discrimination

2.- Right to information and education

3.- Right to health care and treatment

4.- Right to confidentiality

5.- Right to privacy

6.- Right to choice and informed consent

- Right to express opinion and to participation At facilities level, client‘s consultation mechanisms were established in according to the MOH‘s Policies and Guideline for Community Participation in Support of Health Center. The mechanisms include the Village Health Support Group selected through village election, the commune councils as part of the health center management committee as well suggestion box put at all health facilities.



5.4. Demand side subsidies for the poor: the equity fund At present, the substantial support from the Royal Government and donors to the health sector is mainly through supply side subsidies that effectively lower the cost of health care. However, these subsidies generally do not reach the poor because of barriers to access such as high prices. Equity funds can help to reduce this imbalance through a demand side subsidy complementing the existing supply side subsidies. Equity Funds are an alternative financing strategy initiated in selected areas in

Cambodia to promote the use of priority public health services among the poorest by lowering financial barriers to access33

. The

MOH is scaling up this third-party financing instruments using both its own fund and external aids. Formal system for Equity Fund is being established based on the Strategic Framework for Equity Funds and the National Equity Fund Implementation and Monitoring Frameworks. However, it is just an interim solution as the establishment of social insurance scheme can take a long way off.

5.5. Sustainability The development of the HSP, MTEF, 5-year implementation plan and initiative on review process could be counted as a progress in terms of the institutional capacity building of MOH and a step towards the development of a sustainable government system for coordinating aid in the health sector. Most government officials and donor representatives regarded HSP as the basis to enhance sector-wide management capacity of MOH and the umbrella framework for health sector activities through the NPRS.

However, some key challenges lie ahead to enhance sustainability of aid coordination systems initiated under HSP, including the strengthening of the system to collect donor assistance information, the capacity to implement HSP, and the coordination with vertical programs in health. Addressing these challenges will help strengthen institutional capacity of MOH to manage the sector program and enhance the sustainability of aid coordination systems at MOH. The HSSP) funded jointly by World Bank, ADB and DFID started recently to strengthen the system within MOH, alongside implementation of HSP and building sustainable health system.

Concerning the achievement in public-private partnerships, it was demonstrated that the average annual recurrent cost of contracting was only $3.00 per capita for contracting-in and $4.50 per capita for contracting-out, within the range of what the government could independently finance within the foreseeable future and therefore a highly sustainable approach. Moreover, several MOH senior staff and domestic consultants have acquired significant skill level in contractual management skills. However, an unpredictable and poor disbursement achievement of the government budget is a key challenge for sustainability and rational planning.

6. LESSONS LEARNED IN SECTOR-WIDE MANAGEMENT

6.1. Developing agreement on the general principles of partnership at an early stage facilitates later progress. At the inception stage of SWiM, MOH recognized that several donors had difficulty fully supporting pooled funding, specifically single combined budgeting. In response, MOH made it clear that it had no intention of excluding any donor from partnership and took up the SWiM approach instead of the earlier proposed SWAp. Most of the donor representatives interviewed in the present study expressed their support to the principles of SWiM and the SWiM process has seen active participation and cooperation by all the major donors.

6.2. Thematic partnership without SWiM process is not best practice to mobilize more support to intervention with high impact on Mother and Child Mortality.

Although the sub-committee for MCH has been established since 1990s, it seems that it has been unable to draw attention of all partners to adequately move from policy to action for MCH. Stakeholder commitment limited the ―by mouth‖ as resource allocation to disease control programs but less to main child/mother killers.

Fragmented partnership even when addressing such a high priority goal can place greater burdens on the health sector that can outweigh any potential gains. From the analysis conducted, it appears that stakeholder commitment to MCH survival is limited to words, since actual budgetary allocations show that other areas receive far more from partner funds than do MCH priorities.

However, the situation is being change with a consensus made between the RC and its health development partners about continuing high levels of support to the priority goals of maternal and child health within the Sector Wide Management process including the Health Sector Strategic Plan 2003-07, the Joint Annual Sector Performance Review, the Annual Operational Plans, and the on-going process for development of National Strategic Development Plan 2006-10.

While the attention of all stakeholders to the importance of MCH as the overriding priority in the health sector has been drawn through the last Joint Annual Performance Review and National Health Congress conducted in March 2005, it is hoped that key actors to move beyond mere formal commitments to actual resource allocations that will enable the MOH to achieve its stated goals.

6.3. Strong commitment of high-level officials contributes to efficient decision making processes. The HSP development process involved inter-linked key steps that required critical decision making at the organizational level. Obstacle two a single step may severely affect the whole process. A prolonged process is normally required before making organizational decisions in Cambodia. The strong commitment to the HSP development work by the senior officials, including the



Minister, Secretary of States and Director Generals, contributed to efficient decision making processes and smooth implementation of the work.

6.4. Establishing an effective collaborative framework built one the existing structure and a sufficiently consultative process is indispensable for the success of strategy development.

The existing Coordination Committee on Health (CoCom) that have been functioned for around 10 years before the SWiM process was the main forum for consultation. However, the establishment of a technical focal point represented by the Core Group composed of MOH technical staff and SWiM development advisor was indispensable to facilitate consultation/decision process.

6.5. Personal ties can help complement formal coordination structures. While acknowledging the significant value of formal coordination frameworks, the importance of personal ties between individuals representing donors in carrying forward aid coordination was noted. Their experience with the SWiM process suggests that formal meetings and circulation of notes by e-mail generally serves the purpose of information sharing among donors, but that personal connections between individuals also carry critical information not shared through formal channels and of great interest to donors.

6.6. Learning process in step-by-step toward harmonization/alignment The most common feature in resource mobilization concerns three main areas: (1) Planning, monitoring and Evaluation; Financial Management; and Procurement. However, it seems the 1st area was the most feasible one to be started. The MOH has completed its first Sector Annual Operational for 2005. Currently, some partners start to look for harmonization in the areas of procurement of pharmaceuticals product starting from the ARV medicines.

7. KEY CHALLENGES IN PARTNERSHIP FOR MCH

7.1. Development of a Comprehensive Mother and Child Plan linked with HIV/AIDS within the SWiM process MCH needs to be brought back on to the global agenda rather than fragmented e.g. child survival? There is a proliferation of new disease/problem/intervention-specific bodies in health with their own steering committees/boards and secretariats. All of these result in a lot of "high level" time-consuming meetings and it is expensive to finance the secretariats and to find good people to staff them. For me the priority is to get more resources into countries and, where needed, good quality TA. The current increasing attention to child survival is great but needs to be aimed at, and measured by, more resources and action in poor developing countries.

Also, these global bodies should not be dominated by powerful, self-interested lobby groups that want more money for research on MCH based in western universities. While recognizing the need for some continuing research, perhaps we don't need a huge new effort put into describing and dissecting the problem. We know what the problem is, what the technical solutions are. We have incorporated the technical solutions into our policies and strategic plan and we have the infrastructure we need. Therefore, some very focused research on the HOW, maybe necessary. We also know, largely, WHAT needs to be done, and it is difficult and costs money. The question for child survival is: Are we going to make the investment or not? If not, lets stop talking about the MDGs.

There is a huge need for more action on MCH but that action must be on the ground and within countries. If we need a new global alliance/partnership/initiative to make it happen (as seems to be so often the case these days), it is necessary that the requirements and the consequent burden imposed on governments be as light as possible. In fact, it may make more sense for the world to use already existing international agencies such as WHO, UNICEF, and UNFPA more fully, and demand more from them rather than continually creating new bodies under the guise of ―partnerships‖.

7.2. Improve Annual Operational Plan (AOP) Process One key way to strengthen partnership efforts is through the annual operational plan preparation process of the MOH. Currently it is deficient in that a number of partner budgetary allocations and proposed expenditures are not reflected in the plan. Although requests are routinely made for the required information, most of it is not forthcoming. Greater appreciation on the part of the partners for the critical importance of the AOP in achieving sector priorities would help overcome this constraint. As already noted, currently MCH priorities do not seem to be receiving the high priority established jointly in the JAPR 2005.

7.3. Addressing low payment A final critical issue is the currently low salaries being paid to MOH staff. While several efforts are underway within the RGC to improve civil servant salaries and benefits, progress is slow. Meanwhile, the low salaries have the effect of undermining motivation and morale, and encouraging moonlighting and the pursuit of alternate occupations, particularly private practice. Individual partners have attempted to solve this problem by topping up salaries. However, each of them follows its own rules and there is a plethora of differential rates in effect. Bringing about a rational allowances scheme would enormously strengthen the impact of the additional amounts and improve morale and motivation.

8. CONCLUSION Fragmented partnership even when addressing MCH as high priority goal can place greater burdens on the health sector that can outweigh any potential gains. From the analysis conducted, it appears that stakeholder commitment to MCH survival is limited to words, since actual budgetary allocations show that other areas receive far more from partner funds than do MCH priorities.



The SWiM in Cambodian Health Sector is a process, under the MOH‘s leadership, for stakeholders including NGOs and others health related private sector, donors-lending agencies as well as MOH staff and others to work together within a common strategic framework and mutually management agreement without establishing a mandatory pooled fund and/or completely adopting common project implementation arrangements. Currently, this process enable a consensus made between the Royal Government of Cambodia and its health development partners about continuing high levels of support to the priority goals of maternal and child health. It is hoped that key actors are moving beyond mere formal commitments to actual resource allocations that will enable the MOH to contribute toward the achievement of MDGs through reduction of mother and child mortality.



APPENDIX 1

Cambodia Partnership Developments in the International Arena

In the international community there is now a general consensus that in order to improve aid effectiveness a greater emphasis

need to be given to enhancing the ownership of the development process by the recipient countries.34

The OECD/DAC, the World

Bank and the United Nations Development Group have also been collaborating on several joint initiatives to bring greater

coherence to ODA supported programs.35

In November 2002, the Task Force on Harmonization of Donor Practices established

by the OECD/DAC completed and published ―Good Practices Papers‖ as guidelines on good donor practices in the following areas: (1) The Framework for Donor Co-ordination; (2) Country Analytic Work and Preparation of Projects & Programs; (3) Measuring Performance in Public Financial Management; (4) Reporting and Monitoring; (5) Financial Reporting & Auditing; (6) Delegated Co-operation. These papers were endorsed at a High Level Forum on Harmonization held in Rome in February 2003. At this meeting the heads of multilateral and bilateral development institutions and representatives of the IMF, other multilateral institutions, and partner countries issued a Declaration that included a comprehensive set of commitments by the development partners to improve harmonization and alignment of ODA supported activities to improve aid effectiveness in order to achieve the

Millennium Development Goals. It is now commonly referred to as the Rome Declaration.36

The Rome Declaration is a

commitment by development partners to implement the following activities to enhance harmonization and alignment of ODA supported activities:

- Ensuring that development assistance is delivered in accordance with partner country priorities, including poverty reduction strategies and similar approaches, and that harmonization efforts are adapted to the country context.

- Reviewing and identifying ways to amend, as appropriate, our individual institutions‘ and countries‘ policies, procedures, and practices to facilitate harmonisation. In addition, we will work to reduce donor missions, reviews, and reporting, streamline conditionalities, and simplify and harmonise documentation.

- Implementing progressively — building on experiences so far and the messages from the regional workshops — the good practice standards or principles in development assistance delivery and management, taking into account specific country circumstances. We will disseminate the good practices (synthesized in Annex A) to our managers and staff at headquarters and in country offices and to other in-country development partners.

- Intensifying donor efforts to work through delegated cooperation at the country level and increasing the flexibility of country-based staff to manage country programs and projects more effectively and efficiently.

- Developing, at all levels within our organisations, incentives that foster management and staff recognition of the benefits of harmonisation in the interest of increased aid effectiveness.

- Providing support for country analytical work in ways that will strengthen governments‘ ability to assume a greater leadership role and take ownership of development results. In particular, we will work with partner governments to forge stronger partnerships and will collaborate to improve the policy relevance, quality, delivery, and efficiency of country analytic work.

- Expanding or mainstreaming country-led efforts (whether begun in particular sectors, thematic areas, or individual projects) to streamline donor procedures and practices, including enhancing demand-driven technical cooperation. The list of countries presently involved includes Ethiopia, Jamaica, Vietnam, Bangladesh, Bolivia, Cambodia, Honduras, Kenya, Kyrgyz Republic, Morocco, Niger, Nicaragua, Pacific Islands, Philippines, Senegal, and Zambia.

- Providing budget, sector, or balance of payments support where it is consistent with the mandate of the donor, and when appropriate policy and fiduciary arrangements are in place. Good practice principles or standards — including alignment with national budget cycles and national poverty reduction strategy reviews — should be used in delivering such assistance.

- Promoting harmonized approaches in global and regional programs.37

On behalf of the Royal Government of Cambodia, the Council for the Development of Cambodia (CDC) has actively participated in the work on the preparation of the Good Practices Papers by the OECD/DAC Task Force on Donor Practices established by the OECD/DAC Working Party on aid effectiveness and donor practices. OECD/DAC has now formed a Task Team to monitor progress on harmonization and alignment issues. OECD/DAC has also set up a facility to provide support to in-country efforts on

harmonization and alignment issues.38

Following the Rome meeting, Cambodia was selected as one of 14 pilot countries to implement the Rome Declaration at the country level. Early in 2004, the Task Team carried out a survey of progress made on harmonization and alignment in the 14 pilot

countries.39



In Cambodia, the process of completing the three part survey questionnaire involved extensive consultations within Government institutions, among donors, and between Government and donors. Some of the survey findings provide clear evidence of both the achievements and the constraints that surround harmonization and alignment in the country.

- An overwhelming proportion agreed (63%) that donors are supportive of the government‘s harmonization agenda. Evidence for this belief probably stems from the joint declaration on harmonization and alignment issued by the RGC and 12 of its development partners on 2 December 2004 which calls for a number of far reaching changes on both the Royal Government and the donors‘ part.

- With regard to whether the government is coordinating aid – is there a formalized process for dialogue? Is government proactive? Is government in the driving seat? And do donor rules support harmonization? – all answers yes.

The major findings of the survey for Cambodia were as follows: (1) Both donors and GOC (RGC) see the national development strategies as being clearly stated, however they are not fully operationalized. It is reported that greater prioritization and a streamlining of quantitative indicators at sector level is required; (2) Experimentation of budget support as a delivery mechanism has been limited to date. In most cases where budget support was delivered, disbursements were contingent on performance indicators such as the timing of policy reforms, rather than in alignment with GCO budget cycle; (3) Do donor projects use country systems? The results of the donor responses in terms of percent of donors using country systems in the following areas is as follows: audit - 1 percent; M&E - 11 percent; reporting - 6 percent; disbursements - 12 percent; and procurement - 14 percents; (4) While approximately 400 donor missions were sent to Cambodia in 2003, less than 10 percent were taken jointly." 8 organizations (USAID, FAO, WHO, ADB, Japan, UNICEF, World Bank, and UNESCO) accounted for 86 percent of the total number of missions; (5) Only four organizations, ADB, DFID, WB, and UN reported agreement on delegated cooperation arrangements. Delegated cooperation has been defined as an arrangement by which one donor acts on behalf of another donor; (6) Key challenges that remain in Cambodia include the implementation of recommendations on coordination and harmonization with full government ownership and donor buy-in."



APPENDIX 2

Moving Sector Wide in Health: The Health Sector Support Project 2003-07

The Project

The HSSP is a joint donor project executed by the Ministry of Health to support the MOH in the implementation of its five-year Health Sector Strategic Plan 2003 – 2007 (HSP). The goal of the HSP is ‘to enhance health sector development in order to improve the health of the people of Cambodia, especially mothers and children, thereby contributing to poverty alleviation and socio-economic development’. The main funding partners are Royal Government of Cambodia (RGC), ADB, DFID, UNFPA and the World Bank (WB) with WHO providing additional technical support and the sector donor lead. The project‘s purpose is to improve people’s health by strengthening sector performance and providing better quality and more accessible health services.40 The overall value of the project is US$100 million.

How The Project Began

The MOH developed its HSP during a joint process with donors and other stakeholders in 2002. A sector review in 2000 and evaluations of different service delivery and financing approaches throughout 2000 and 2001 informed the strategy and contributed to the project design.

During this time the MOH also explored with its partners their readiness to enter into a SWAp. Support at that time was delivered through separate bank projects and a WHO-led technical support project as well as a variety of other projects. The ministry and partners‘ preferred option was a sector-wide management approach (known as SWiM). In a SWiM, donors and technical partners commit to support the implementation of the HSP and align the technical content of their support and their financial support to that HSP, but there is no common basket of funding.

Key mile stones for project design

Preparation Partners

ADB DFID WB UNFPA

Project identification Mission Separated but conducted in the same period around 2001-2002 (The Sector Strategic was developed in the same period)

During the period 2002-2003 (later after ADB, DFID and World Bank) Project Design including appraisal The Health Sector Support Project (Excluding DFID support to Safe

motherhood, HIV/AIDS and IDPBS)

Negotiation Joint Negotiation at the WB Office in Phnom Penh (with DFID a observer): 20-22Oct2002

Formal agreement Signed in Feb2003: IDA Credit #3728KH; ADB Loan # 1940CAM(SF), 1st DGA#TF H016, 2ndDGA# TF h015KH; DFID Trust Fund TF051053;

Signed on 11Jun2003:Project doc.

Effective date Effective date tied with establishment of Mngt. Structure + Development of a single Financial Management Manual

No legal covenant

How The Project Is Managed

The MOH and HSSP partners want to manage the project in a way that builds government and sector capacity. However, MOH capacity is currently not yet sufficient to fully integrate the management of HSSP into the ministry. Financial management and procurement (using ADB and WB guidelines) are housed in the ‗HSSP Secretariat‘ within the Department of Planning and Health Information. It is staffed by both government and consultant staff. The Project Director and Project Co-ordinator are senior MOH staff41.

Technical assistance to the project is procured by the MOH using ADB or WB funding. TA is housed in the relevant counterpart departments. DFID also funds TA for the development of an incentive scheme and of management capacity within the MOH which, when implemented, will help to integrate other project functions more effectively within the ministry. DFID also provides a separate call-down TA facility focusing specifically on supporting planning, management and financing issues.

What Progress We Have Made

Annual operational planning (AOP): the MOH has introduced annual operational planning. Some HSSP resources (primarily WB and UNFPA) are allocated through the annual operational planning process which. For the first time the MOH is developing sector wide plans reflecting all funding sources. This is approved by a high level MOH committee (the Health Sector Steering Committee).

Joint Annual Performance Review: The JAPR, a sector-wide review of performance and sets priorities for the next AOP. All stakeholders participate.

More integrated management arrangements: as the AOP is more established, planning and monitoring of project outputs is being integrated into the wider MOH framework for planning and monitoring.

How Harmonisation And Alignment Is Going Amongst HSSP Donors

The HSSP donors aim to reduce the management burden on government as much as possible. Practice has evolved since the beginning of the project in 2003. Now review missions consisting of all funding partners are conducted twice a year. The first review of the year follows on from the ‗Joint Annual Performance Review‘42. One Aide Memoire is produced and shared with government. One monitoring report is provided to all donors. One external audit is conducted covering all donor funds. There is division of labour across the sector (e.g. World Bank on drugs and



supplies and ADB on training) but where HSSP donors are working jointly we aim to send consistent feedback to government on key policy issues. The process for HSS mid-term review is being developed to integrate with Mid-term Review for the sector

The Further Possibilities To Improve The Project’s Effectiveness:

- Improved co-ordination of TA across all HSSP agencies. Improve the focus among TA on capacity building.

- More co-ordination among partners to provide evidence for the policy dialogue with government. The TWG Health is developing as the place for this. WHO, UNFPA, DFID and MEDICAM sit with government on the TWG Secretariat.

- Develop provincial capacity to use the annual operational plan effectively

- Longer term planning could be improved but information from all donors to enable this has been limited.

- Use of single procedure being developed by the Ministry of Economy and Fiance



APPENDIX 3

Contracting of Publicly Provided Health services

Contracting under Pilot phase 1998-2002

Under the ADB-funded Basic Health Services Project, Contracting was first tested in 5 Operational Health Districts (OD) with another 4 ODs used as controls. Two types of Contracting were used:

"Contracting-Out" – Contractors actually employed the health staff who took leaves of absence from the government. "Contracting-In" – Contractors managed civil service staff in the OD on the Government's behalf.

Contracted districts showed a rapid increase in all health indicators, particularly MCH indicators, compared to the control areas:

Contracting also reduced out-of-pocket expenditures on health care by the poor by more than 70%, making this a highly effective poverty reduction intervention,

The recurrent governmental/donor expenditures for Contracting were only about $4.50 per capita, less than the combined average donor/government health expenditure in non-contracted areas.

An external evaluation found that government contracting of the provision of health services to non-governmental entities is: Feasible, Cost effective, High-performing and Equitable (effectively targets and benefits the poor)

The success of the contracting pilot in Cambodia has won international acclaim and been documented in worldwide publications:

Since then, several other countries have followed Cambodia's example, including Afghanistan and Bangladesh. Other countries, including Nigeria, are planning it.

Contracting of Health Services under HSSP: extension phase

Based on the results of the pilot, 11 ODs were contracted under the current Health Sector Support project. Although the "contracting-out" model had produced higher results than "contracting-in", the MoH decided to adapt a modified form of contracting-in in order to maintain the civil service structure. A description of the HSSP Contracting approach follows.

The Government hires an NGO to develop and manage an OD health system and ensure that specific health services are provided to the population, with equal access for the poor.

Specific Objectives:

To ensure that 100% of planned health facilities are fully functional, with an adequate type and amount of MoH staff, drugs and equipment and functioning community participation mechanisms;

To bring previously unregulated private practice by civil servants into the formal government sector using Contractual mechanisms between the OD and health facilities;

To develop a mechanism whereby the combination of civil service salaries and performance-linked incentive awards provide an adequate compensation package for MoH civil servant;

To develop transparent, affordable, equitable user fee systems which generate sufficient revenue to fund the above staff incentive awards;

To reduce maternal morbidity and mortality through increased provision of antenatal care, delivery by trained attendants, and delivery in a health facility;

To reduce out-of-pocket expenditures on health care by the poor through increased utilization of affordable public sector services; and,

To reduce preventable morbidity and mortality among children through the delivery of key preventive services (e.g.: immunization, VAC, birth-spacing).

Methodology:

Contractors work with civil service staff to deliver the services, under contract to the MoH. ALL service delivery is done by MoH staff. Most on-site managerial functions are also done by MoH staff with capacity-building, training and supervision from the Contractor.

Contractors must ensure the provision of the MPA at all HCs and designated level of CPA at each RHs

Contractors must achieve specific coverage targets (immunization, antenatal care, etc). Targets are set according to baseline survey data and results are measured by a repeat survey in the last year of the contract. If the targets are not met the Contractor will have a financial penalty.

―Management By Results‖ : Contractors decide on their own strategies and approaches and are paid according to results.



Contractors have great flexibility in methods. However, they must:

Follow MOH Technical Protocols

Follow the Health Coverage Plan

Establish a transparent user fee system in consultation with the community and health workers

Make performance contracts with health facilities, providing incentive awards based on actual performance and abstention from private practice

Staffing arrangements

Contractors have a small number of Key Personnel of their own to manage the program, and bring in short-term trainers and consultants in the early phases to develop MoH staff capacity.

Actual service delivery is provided by civil service health staff who are seconded to the Contractors by the PHD. Contractors and PHDs sign a Secondment Agreement listing the staff who PHD seconds to the Contractor.

Seconded civil servants still receive their usual civil service salary from the MOH. They also receive incentive awards from the Contractor if they abstain from private practice, respect the rules, and their health facility achieves specific targets set by the Contractor.

Seconded staff keep their original position within the civil service, but while working for the Contractor, the Contractor may assign them to other locations and duties.

Contractors have full management authority over seconded staff within the Contracted ODs, but must will follow civil service law regarding disciplinary measures.

In cases where the PHD and Contractor agree the number of civil servants available is not enough, the Contractor may hire some ―casual‖ staff out of the Contract budget. These staff receive payment similar to civil service staff, and are replaced by civil servants as soon as available.

Operating budget, drugs, medical equipment

Contracted ODs receive a government operating budget at the same level as non-contracted districts, disbursed quarterly directly to the Contractor (provincial bank account in riel) using the PAP mechanism.

PHDs are notified of the amount of budget provided to the Contracted ODs and involved in post-audits.

Contractors must follow the Government procurement and expenditure regulations in using the government budget

The MOH provides drugs and medical supplies to the Contracted ODs following usual government procedures.

Role of the Provincial Health Department (PHD)

1. PHD DIRECTORS SERVE on the MOH MONITORING GROUP which approves Terms of Reference, evaluates Proposals, monitors contracts, and decides on release of progress payments.

2. PHDs SUPPORT Contractors by:

Seconding civil service staff to the Contractor as specified in the Contract and Secondment Agreement between the PHD and Contractor.

Providing essential drugs, medical supplies, vaccines, cold chain equipment and other medical equipment to Contracted ODs

Conducting procurements as requested by the Contractor for amounts above 5,000,000 riel, as required by government procurement regulations.

Conducting any other procurements that the Contractor is allowed to do at OD level but asks the PHD to do instead.

Facilitating coordination and liaison between the Contractor and other Government and Non-Governmental agencies working in the OD or Province, including letters of introduction, arrangement of meetings, and sharing of written information and reports.

Providing the Contractor with all relevant technical protocols and directives from the national TB, malaria, PEV, PMI and HIV/AIDs programs and from the Health Information System, and technical assistance related to national programs and HIS as requested by the Contractor.



PHDs MONITOR Contractor performance quarterly through a Monitoring team of 3-4 persons assisted by the MOH domestic Contracting Specialist, using checklists and procedures provided by MOH.

Financial Sustainability:

The average cost per capita for Contracting in 2005 is under $4.50 per person per year inclusive of donor and government costs:

Province (Nb. of OD): Contractor Population Estimated per capita budget

Government* Donor (HSSP) Total Expenditure

Kampong Cham (2ODs): SCFA 317,495 $2.00 $1.88 $3.88

Takeo (2ODs): SRC 323,564 $2.00 $2.14 $4.14

Prey Veng (2ODs): HNI 298,771 $2.00 $1.84 $3.84

Koh Kong** (2ODs): CARE 127,189 $1.80 $3.65 $5.45

Rattanakiri** (1OD): HNI 112,924 $1.80 $4.00 $5.80

Mondulkiri** (1OD): HNI 41,201 $1.80 $6.13 $7.93

Preah Vihea** (1OD) 145,300 NA (Contract recently awarded)

TOTAL 1,369,444 $1.95 $2.47 $4.42

*: Salary, medicine supplies (in kind), recurrent budget. **: Remote area: forest, mountain, island

This compares very favorably with international standards and with expenditures elsewhere in Cambodia:

Source Government External Assistance

Total

WHO Recommendation for Least Developed Countries (Report of the Commission on Macro-economic and Health) for 2007

$6 $14 $20

Actual Nationwide MoH expenditure Cambodia 2002 $ 3.40 $ 7.60 $11.00

Contracted ODs in Cambodia (Estimated 2005 based on the 1st semester)

$ 1.95 $2.47 $ 4.42



APPENDIX 4

The Health Sector has been moving forward, since the period early 1990s, to a best practice in partnership called Sector-wide Management (SWiM) in which private sector and partners as well as Ministry of Health employees and others can work together within the framework of an agreed strategic plan towards its desired outcomes. The SWiM has six keys characteristics: (1) Government led process of coordination; (2) Agreement on a clear sector policy, strategy; (3) Medium Term expenditure Framework and Annual Operation Operational Plan; (4) Joint Monitoring and Evaluation; (5) Clients and stakeholders consultation mechanism; and (6) Funding mechanisms and harmonized system without compulsory pooled fund.

Key achievements were made with three successive stages presented as followed:

Progress made in SWiM

Step for Sector Programa Achievements in Health Sector

Government-led process of donors coordination

CoCom started in 1991 and converted into Technical Working Group-Health in 2004

Concept paper on SWAp (road map) issued in 1998

Agree on a cleat sector policy and strategy

Joint Health Sector Review in 2000

Health Sector Strategic Plan 2003-07 (SWiM instead of SWAp)

MTEF MTEF available since 2002 although poorly updated

Monitoring and Evaluation Evaluation and Monitoring Framework

Joint Annual Performance Review significantly broadened in scope and improved each year

Joint Mid-Term Review process being developed with support from all stakeholders

Clients and stakeholders consultation

Explicitly supported with the 14th article of the RGC‘s Political Platform

At facility level: Village Health Support Group, Suggestion Box, a representative of Commune Council as part of each Health Center Management Committee

Formal endorsement of the Clients‘ Packages prepared by a Working Group

Client and Stakeholders consultations are always part of the Joint Annual Performance Review process

Being conducted as part of the design of the Mid Term Review process

Funding mechanisms and harmonized system

Harmonizing sector planning process (Medium Term Expenditure Framework, Public Investment Program, Three Year Rolling Plan, etc.)

1st Annual Operational Plan for 2005 (AOP 2005)

Some joint processes in Health Sector Support Project funded by ADB, DFID, WB, UNFPA (Using AOP)

Being at early stage of harmonization in procurement and financial systems

a: Contents of this column are adapted from OECD. Draft Outline of the Good Practice Paper on Providing Harmonised Support to Sector Approaches, Task Team on Harmonization and Alignment, Fifth Meeting, 6-7 July 2004.

During the inception stage the Cambodian MOH understood the Sector-wide Approach (SWAp), in the international context, as a "new way of working for donors and recipient governments in which they together, in partnership, take a sector-wide approach to planning and financing health services. The Government and donors collectively accept a set of goals, objectives and strategies, a single combined budget to implement the plan and where appropriate systems for common management of resources"43.

The SWiM inception in Cambodia was started with a preliminary road map i.e. the ―Step by Step to a SWAp44" developed in March 1999. A stakeholders analysis conducted in 1999 indicated that each donor had different views and positions on their support for SWAp. Alternative options identified could be classified into three categories: (1) cannot participate in SWAp; (2) Support concept but unlikely to participate under the current timeframe established by MOH; and Support and will participate. As a result the MOH adopted a Sector Wide Management (SWiM) approach in 2000. The SWiM45 is an approach, under the MOH's leadership, for all stakeholders sector wide including, NGOs and others health related private sector, donors-lending agencies as well as MOH staff and others to work together within a common strategic framework for the period 2003-2007 and mutually management agreement without establishing a mandatory pooled fund and/or completely adopting common project implementation arrangements".

The SWiM approach has most of the SWAP features i.e., sector wide planning, but excludes establishing a mandatory common funding basket and completely adopting common project implementation arrangements.46



APPENDIX 5

TERMS OF REFERENCE FOR

THE TECHNICAL WORKING GROUP HEALTH (TWGH)

Background

These Terms of Reference (TOR) are developed in light of the transformation of the long-standing Coordinating Committee for Health (CoCom) into one of the Technical Working Groups (TWG) for Royal Government of Cambodia and development partner coordination across all sectors.

An examination of the existing TOR of the CoCom, as updated in 2001, in the light of this was undertaken by the CoCom at its meeting on 9 September 2004. They were found to be still relevant and covering most of the points included in the generic TWG TORs of September 2004.

Mandate and Scope

The principal function of the Technical Working Group Health is to ensure effective coordination of the response of the Royal Government of Cambodia, led by the Ministry of Health, in responding to the health challenges of the country. The TWGH provides a mechanism for the MoH and its development partners jointly to: identify priorities; harmonize activities; discuss and address technical issues; improve utilization and mobilization of resources; and facilitate monitoring of progress.

TWGH actions will support Cambodia to attain the Millennium Development Goals through implementation of the RGC‘s Rectangular Strategy, the current national development plans and the National Strategic Development Plan (NSDP) 2006–2010. While the TWGH helps to identify realistic policy goals it is the RGC/MOH that will take policy decisions.

The TWGH will facilitate the implementation, monitoring and evaluation and, where necessary, modification of the Health Strategic Plan linking with other sectors and their TWGs as needed. The TWGH will help all stakeholders to fully participate in dialogue on issues within its scope.

Functions and Objectives

The major functions of the TWGH are to:

Provide a forum for sharing information between key stakeholders

Advise the MoH on strategic and policy issues

Provide a monitoring overview of sector performance

Facilitate intra-sector and inter-sector harmonization and alignment

The objectives of the TWGH are:

To review progress, discuss issues and give oversight to the design, implementation and management of the Health Strategic Plan;

To promote the improvement of Sector-Wide Management (SWIM) and progress toward a Sector-Wide Approach (SWAP) in the health sector;

To promote efficient use of limited resources in the health sector through prioritization, coordination and joint activities and through use of appropriate the Medium-Term Plans such as the Medium-Term Expenditure Frame-work and/or the Three-Years Rolling Plan.

To review progress and advise on the development and implementation of sub-sector plans;

To discuss and advise on plans for the Joint Annual Performance Review and the mid-term review and final evaluation of the Health Strategic Plan and to ensure that review findings are taken into account in the preparation of the Annual Operational Plans;

To discuss health sector linkages to larger government initiatives for poverty reduction and to ensure adequate health sector input to the Consultative Group (CG) process;

To discuss implications of, and provide input to, larger government-wide reforms such as those in public administration, public financial management, decentralization and governance in co-ordination with the Government Donor Co-ordination Committee;

To ensure regular sharing of information from health sector partners on progress in implementation of projects and to review plans for new projects to ensure their relevance and to avoid duplication;



To enhance monitoring and evaluation of progress through use of agreed indicators (including CMDG indicators), and regular reporting on targets and benchmarks;

To review results and give advice on important pilot initiatives in service delivery, financing, management and quality improvement and ensure that lessons learned are used in policy development.

To strengthen linkages and mechanisms for coordination with the Sub-CoComs, ProCoComs and Working Groups to facilitate the achievement of the harmonization and alignment objectives at the implementation level.

Organization and operation

Membership

The participation of the TWGH will continue as in the past for the CoCom with the MoH issuing invitations to attend meetings to relevant MoH departments, national programmes and institutions, other line ministries, bilateral and multilateral development partners, MoH gender focal point(s), and selected NGOs and/or their umbrella organization(s).

Chairing and Coordination

The TWGH will be chaired and led by the Minister of Health. In the absence of the Minister of Health, the Chair of the Secretariat of the TWGH, Secretary of State Prof. Eng Huot will take the Chair in the meetings. In case of his absence, he will request the Minister to nominate an alternate. The Chair will have overall responsibility for pursuing the objectives of the TWGH in line with the principles mentioned in the Keynote Address to the Government-Donor Monitoring Meeting by the Prime Minister on 10 September 2004. Tasks of the Chair will include: organizing and chairing meetings; ensuring minutes are taken and disseminated to all members and attendees; and coordinating preparation of annual work plans. The Chair will ensure effective communication links between the TWGH and relevant RGC Ministries.

Development partners will nominate a lead coordinator and alternate lead coordinator. The lead coordinator and alternate will support the Chair in pursuing the objectives of the TWGH.

Meetings and Work Plans

Meetings will be held monthly with an agenda and minutes will be produced and disseminated.

The TWGH will prepare and agree an annual work plan for the joint activities of the TWGH (as distinct from the Health Strategic Plan and the AOPs), clearly specifying tasks, timelines and responsibilities. The TWGH will be responsible for securing the financial resources to implement the agreed work plan.

Secretariat

The Secretariat will provide administrative support to the TWGH and take major responsibility for supporting the implementation of the TWGH Workplan.

The TOR of this Secretariat would be initially to:

prepare the TWGH meeting agenda and documentation

prepare and distribute minutes of the TWGH meetings

ensure follow-up of decisions taken at TWGH meetings

coordinate preparation of the annual TWGH Workplan

support implementation of the annual TWGH Workplan

assume any of the functions of the TWGH as might be delegated to it by the TWGH.

The Secretariat will be chaired by Secretary of State Prof. Eng Huot, with Vice Chairs being the Director General for Health and the Director General of Administration and Finance.

The Ministry of Health and Health Partners will nominate members of the Secretariat, as outlined in the TORs of the Secretariat.

Crosscutting Issues and Thematic Sub-Groups

The TWGH will develop strategies to ensure crosscutting issues including gender, human rights, public administration reform, decentralization and environment are addressed within the workplan of the TWGH. In the case of gender, the TWGH will support monitoring and reporting on indicators of performance, drawn from the Cambodia Gender Assessment. The existing health sector focal point for gender and one donor member of the TWGH will be nominated as gender focal points to advise on gender issues, and/or assistance from the Gender TWG may be sought.



ENDNOTES AND REFERENCES

1 The findings and opinions expressed in this document are those of Dr. Char Meng Chuor, and should in no way be taken to reflect the policies or opinions of the Cambodian Ministry of Health. In addition, some references and sources are still to be verified and/or reflected upon.

2 Asian Development Bank. Asian Development Outlook 2005: Economic Trends and Prospects in Developing Asia: Southeast Asia. Manila, The Philippines. 2004.

3 United Nations Development Programme. Human Development Report 2003. Section 3: Human and Income Poverty, Developing Countries.

4 In 2001, the poverty line in Cambodia was the cash equivalent of Riels 54,050 per capita per month, this was equivalent to US$0.45 per day, considerably less than the World Bank‘s ―dollar a day‖ adjusted measurement for extreme poverty: PPA 2001.

5 Ministry of Planning with World Bank. 1999. Cambodia Poverty Assessment.

6 Cambodia Socio-Economic Survey 1997, Cambodia Socio-Economic Survey 1999.

7 Participatory Poverty Assessment: Cambodia. 2001.

8 Seng Bunnly and Prapassorn Suthumvijit. ―Health and Landlessness‖. December 2000.

Cambodia Land Study Project, Oxfam.

9 Personal communication, 28 July, 2005

10 Seng Bunnly and Prapassorn Suthumvijit. ―Health and Landlessness‖. Cambodia Land Study Project, Oxfam. December, 2000.

11 Defined as those infants between 12-23 months who have received BCG, DPT, and measles vaccinations.

12 Gwatkin, Davidson R., et al. Socioeconomic Differences in Health, Nutrition, and Population in Cambodia. 2nd edition, Washington, DC, The World Bank. 2004.

13 Undertaken within the context of the Public Expenditure Review of the Health Sector in Cambodia. 2002.

14 See Cambodia Demographic and Health Survey. 2000.

15 See National Institute of Statistics, Ministry of Planning. Cambodia Inter-Censal Population Survey 2004, General Report. Phnom Penh, Cambodia. November, 2004; and National Institute of Statistics, Ministry of Planning. Demographic Estimates and Revised Population Projections. Phnom Penh, Cambodia. June, 2005.

16 Note: most figures quoted in this paragraph refer to: Royal Government of Cambodia. Implementing the Rectangular Strategy and Development Assistance Needs. Phnom Penh: Cambodia, Nov 2004. Prepared for the 2004 Consultative Group Meeting for Cambodia.

17 Ministry of Planning; Cambodia Inter-censal Population Survey 2004, GENRAL REPORT, Nov 2004.

18 The World Bank. World Development Report, Investing in Health. New York: USA. Oxford University Press, June 1993.

19 Gro Harlem Brundtland; Macroeconomics and Health: Investing in Health for Economic development. Geneva, World Health Organization 2001.

20 See Siddiqui, Farid and Niloy Banerjee. Towards Improved Aid Effectiveness in Cambodia. Phnom Penh, Cambodia: United Nations Development Programme. April 2005; and Banerjee, Niloy. Turning Principles of Aid Harmonisation and Alignment into Practice: The Challenges for Asian Countries. Phnom Penh, Cambodia: United Nations Development Programme. April 2005.

21 Council for the Development of Cambodia, Cambodian Rehabilitation and Development Board. Building Partenerships for Development, An Update. Phnom Penh, Cambodia. Prepared for the 7th Consultative Group Meeting for Cambodia, 6-7 December, 2004, Phnom Penh, Cambodia.

22 Royal Government of Cambodia. Strategic Framework for Development Cooperation Management. Phnom Penh, Cambodia. Draft. July, 2005.

23 Ministry of Health. Terms of Reference, Coordinating Committee (COCOM). Phnom Penh, Cambodia: COCOM Secretariat, Unpublished, Jan. 1994.



24 Ministry of Health, Kingdom of Cambodia. Guidelines for Preparation of Annual Operational Plan 2006. Phnom Penh, Cambodia. Department of Planning and Health Information, April 2005.

25 England, Roger. Experiences of Contracting with the Private Sector: A Selective Review. London, DFID Health Systems Resource Centre. March, 2004.

26 Child Survival Partnership Secretariat. What is the Child Survival Partnership and what does it do? New York, USA. Undated.

27 Hsi, Natasha and Mizan Siddiqi. Evaluation of GAVI Immunization Services Support Funding Case Study: Cambodia. Bethesda, MD, USA: Abt Associates. August 2004.

28 These figures constitute preliminary findings from the CSES 2003-04 conducted by the National Institute of Statistics, Ministry of Planning. Further data analysis currently is underway, with coverage for the other vaccines and for full immunization expected shortly.

29 Ministry of Health, Communicable Disease Control Department, Office of the Principal Recipient for the Global Fund. Report: Mid-Term Review, Rounds One and Two. Phnom Penh: MOH. December 2004-January 2005.

30 Kober, Katharina and Wim Van Damme. The Early Steps of the Global Fund in Cambodia. Belgium: Directorate General Development Cooperation. December, 2003.

31 International HIV/AIDS Alliance. NGO participation in the Global Fund: A Review Paper. London, UK. October, 2002.

32 Ministry of Health. The Ministry of Health Planning Manual. Phnom Penh, Cambodia. Department of Planning and Health Information, March 2003.

33 Ministry of Health. Strategic Framework for Equity Funds Promoting Access to Priority Health Services Among the Poor. Phnom Penh, Cambodia. Version 1, September, 2003.

34 ActionAid International. Real Aid: An Agenda for Making Aid Work. Johannesburg, South Africa. June, 2005.

35 Organisation for Economic Cooperation and Development, Development Assistance Committee. Harmonising Donor Practices for Effective Aid Delivery. Paris, France. DAC Guidelines and Reference Series. 2003.

36 Rome Declaration on Harmonization, Rome, Italy, February 25, 2003.

37 World Bank. Harmonization Follow-up: Global Architecture and World Bank Activities. Washington, DC, USA. Operations Policy and Country Services. September 22, 2003.

38 Council for the Development of Cambodia, Cambodian Rehabilitation and Development Board. Cambodia’s Report on Progress Toward Enhanced Aid Effectiveness. Phnom Penh, Cambodia. Prepared for the Second High Level Forum OECD/DAC, 28 February-2 March 2005, Paris. February, 2005.

39 Organisation for Economic Cooperation and Development, Development Assistance Committee. Survey on Harmonisation and Alignment: Measuring Aid Harmonisation and Alignment in 14 Partner Countries. Paris, France. Preliminary Edition. February, 2005.

40 The key components are:

- Expanding coverage of the health service delivery (construction, drugs and equipment for new and renovated facilities, contracting of NGOs to manage district level services and equity funds)

- Support for public health priorities (e.g. communicable diseases, nutrition, maternal health)

- Support to help the MOH plan, manage and co-ordinate the sector

41 The Project Director has since been appointed Secretary of State.

43 Government-Donor Partnership Working Group, Sub-Working Group 3. Practices and Lessons Learned in the Management of Development Cooperation, Case Studies in Cambodia. Phnom Penh: Cambodia. January 2004

44 Ministry of Health, Cambodia. Health Sector Reform III Project (1999). Step by Step to SWAp, Action Plan for 1999 and 2000.

45 Ministry of Health, Cambodia. Health Sector Strategy Plan 2003-2007, Volume I. Phnom Penh, Cambodia: Ministry of Health, August 2002.

46 Vincent Turbat, Ioan-Sergiu Luculescu, and Peter Bachrach. Health Sector Support Project, Project Preparation Mission. Washington, DC, The World Bank. Aide Memoire, March 28 to April 12, 2001.

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