The health sector in Cambodia has received support from a wide range of donors since the earliest days of reconstruction. In the 1980s and early-1990s, donor assistance was mostly in the form of health service delivery. Over the last decade, the focus of assistance has gradually shifted from delivering services by donor agencies themselves to strengthening the government’s capacity to manage service delivery.

The Strengthening Health Systems Phase I (SHS I; 1992-1994), financed by ODA (presently DFID), UNDP and WHO, was the first attempt to bring a set of donor agencies together to jointly support the strengthening of MOH’s organizational capacity. Phase I was followed by two additional phases, SHS II (1995-1997) and the Health Sector Reform Project (HSR III; 1998-2001), with additional financial inputs by NORAD and the Netherlands (HSR III only). Phase II and the Phase III built consecutively on each previous phase, providing continuity and building the basis for a longer-term development and reform program.

In 1997, ADB and the World Bank initiated loan programs in the context of health system reform, for approximately $30 million and $20 million respectively over 5 years. The current Health Sector Support Project (HSSP) is intended to be a direct follow-on to these projects.

A number of individual projects tackled important sector weaknesses in 1990s, such as insufficient health infrastructure and inadequate technical and managerial skills of Ministry staff. However, major sector-wide problems were not adequately addressed. In particular, it was apparent that increasing salaries, improving the distribution of staff, regulating private sector health services, and improved and guaranteed long-term funding for the health sector in general required a sector-wide approach.

MOH and part of the donor community initiated the Sector-Wide Approach (SWAp) process in recognition of this need for a new and broader approach. The introduction of the SWAp process was led by WHO advisors and grew fairly smoothly out of HSR III⁴⁷. The Minister of Health expressed his personal support to the approach in February 1998, and this support was officially confirmed by MOH in early 1999.

According to CDC data, external funding for the health sector in 1999 amounted to US$71 million (CR 268 billion). The data shows a declining trend in the total amount after 1999. In 2001, external funding totaled US$66 million, including of US$21 million by multilateral agencies (of which US$14 million was loans and credits by the World Bank and the ADB) and US$31 million by bilateral agencies. External sources provide around two-thirds of public funding in health sector.

Table 7-1. Sources of external funding ($US thousands)

Source: Council for the Development of Cambodia 2002 [Public expenditure review of the Cambodia health sector, 2002: Annex 1].
Note: The table above is for indicative purposes only since there may be some information gaps.

In March 1999, MOH developed a document entitled "Step by step to a SWAp: action plan for 1999 and 2000" out of HSR III, with technical support from donor advisors. The document provided background information to support the introduction of the SWAp process and a preliminary timetable for moving toward a SWAp.

The key milestones in the process of SWAp/SWiM are highlighted in Table 7-3. The process to date can be divided into three stages: preliminary arrangements followed by a shift from SWAp to SWiM; joint sector review and subsequent sector strategy formulation; and the Joint Annual Health Sector Review in 2003.

In 1999, MOH conducted a stakeholder analysis to identify the positions of the major donors with regard to SWAp. Results of the analysis indicated that each donor had different views and positions on their support for SWAp. Relative positions of donors identified in the study could be classified into the following three categories.

The reasons for taking these positions may have differed among the donors, but some informants speculated that they might include the reluctance of some donors to support the common fund approach generally associated with ‘SWAp’. In response, the government made a series of attempts to identify an approach that would be more acceptable to all the key donors and consequently adopted a slightly modified scheme. In July 2000, the Minister of Health advocated that Sector-wide Management (SWiM) take the place of the previously proposed SWAp. He also proposed developing a Sector-wide Master Plan and a Medium Term Expenditure Framework (MTEF) under the SWiM. A SWiM Committee and a SWiM Technical Group to carry forward the SWiM process were established in this connection. The principle of SWiM is in line with that of SWAp, but the key difference between them is that SWiM does not include the common fund concept. The SWiM was thereby defined in such a way that MOH, donors and NGOs could all work together to build a common vision for the whole sector.

The first joint initiative following the inception of SWiM was the Joint Health Sector Review in 2000. Within the context of the sector review, a workshop was organized by MOH in December 2000 with the financial support of ADB, DFID, WHO and the World Bank and attended by all the major donors. The Review identified a number of critical issues in the health sector and addressed possible options for future discussion and measures for sector strategy formulation.

The development of a sector strategy was subsequently initiated based on the findings of the joint sector review. The process leading to the Health Sector Strategic Plan (HSP) 2003-2007 document involved intensive work by a Core Team consisting of four MOH staff, technical assistance by a set of TAs, and support from the donor community through a series of Health Sector Partners Meetings as well as coordination by the SWiM Advisor. Six technical working groups were formed, each made up of a mixture of government officials and donor technical advisors. The group members worked closely with the Core Team to formulate detailed strategies in the six priority areas proposed in HSP. Senior officials, including the Minister, committed themselves to the overall supervision of the whole process.

The joint working process produced the following outputs.

The overall process of the HSP development was governed and led by the senior officials of MOH including the Minister, Secretary of States and Director Generals. Several key informants suggested that the commitment of the senior officials facilitated the process of organizational decision making, and consequently contributed to the efficiency of the HSP development work.

A number of informants indicated 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 readiness to implement HSP as their own strategic plan. Currently, there is an initiative to increase ownership of the strategic plan at provincial and operational district offices, especially in six provinces supported by UNICEF. The study team observed during the field study in Prey Veng that the Ministry of Health Planning Manual⁴⁹, which was developed in conjunction with the HSP, has been increasingly used for decentralized and costed planning at provincial and operational district offices. The MOH plans to have referral hospitals and health centers develop costed annual plans from 2004 onward. It is certainly a good indication of the decentralized ownership of the strategic plan and it needs to be further enhanced.

The capacity of MOH officials, especially in understanding the sector strategy and leading joint working process with donors, may depend on individual expertise and familiarity with topics of discussion. During the 2003 Joint Review, 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 led some of the working groups, government officials demonstrated their capacity in leading discussions in some other groups. While it may be too early to draw conclusions about the capacity of MOH officials, the series of the joint working activities (represented by the Joint Sector Review) have been perceived by many as a capacity building process for MOH officials.

The Health Sector Partners Meeting has primarily served as a forum for discussing issues around the HSP among donors. However, it also provided opportunities for donors to share information and consult with other partners on their future plans and status of program implementation. For example, the EU recently brought its plan to provide assistance for MOH to the Health Sector Partners Meeting and consulted all the donors for potential areas that could require support. The framework of Health Sector Partners Meeting has thus played a role in helping the donor community adjust activities among themselves, in order to avoid overlaps of assistance.

These efforts at improving aid coordination may well contribute to the improvement of the health sector’s performance in a long run. In fact, this is one of the reasons many donor representatives are so interested in improving aid coordination. However, HSP is still in its early implementation stage, so it is still too early to discuss its achievements in the health sector.

The development of the HSP, MTEF, 5-year implementation plan and initiation of its 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 interviewed 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 national programs in health, which are discussed in detail in the next section. 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. As part of MOH’s effort, the Health Sector Support Project (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.

At the introductory stage of SWAp, MOH recognized that several donors had difficulty fully supporting the principles of SWAp, 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.

The HSP development process involved several key steps that required critical decision making at the organizational level. A prolonged process is normally required before making such organizational decisions in Cambodia’s context. However, an informant indicated that 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.

A number of interviewees agreed that the working framework (which involved inputs from the Health Sector Partners Meeting, the Core Team and the SWiM Development Advisor) was indispensable for the successful development of HSP. In particular, they stressed that the process, which took around one year and involved consultations with various stakeholders, was key to later achievements. This experience implies that establishing an effective collaborative working framework and a sufficiently consultative process are a key to successfully developing sector-wide strategy.

While acknowledging the significant value of formal coordination frameworks such as the Health Sector Partners Meeting, a number of people interviewed by the study team mentioned the importance of personal ties between individuals representing donors in carrying forward aid coordination. 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.

The foremost among all the challenges facing MOH, is establishment of a sustainable and reliable system within MOH to collect and disseminate donor related information on current status and future plans of donor assistance. Reliable information on donor funding is particularly required for feeding MOH’s investment figures to PIP and MTEF, as well as for development of costed plans at the central and provincial levels. The International Relations Office of MOH in collaboration with the Council for Development of Cambodia (CDC) has been working on building the AID Management Information System (AIDMIS), but it has not yet produced satisfactory outputs. Several obstacles to such a system have been identified, such as the complexity of categorizing donor assistance by funding and implementation schemes. While acknowledging the need to improve communication within the Ministry, an MOH official pointed out the importance of further cooperation of donors, especially in information sharing around donor activities and funding. A government official of MOH stressed that the information on donors’ inputs to each province is critical to carry forward the decentralized planning process under the current health sector reform. These challenges need to be addressed, potentially by technical assistance from donors to develop the data management capacity of the International Relations Office, in particular to carry forward future aid coordination. The education sector has been largely successful in strengthening the AIDMIS and its process may possibly be applied to the health sector.

The existence of two coordinating frameworks, namely CoCom and the Health Sector Partners Meeting has undoubtedly contributed to advancement of the SWiM process to date. However, the Health Sector Partners Meeting has lost its direction and entered a transition period, particularly since the completion of the HSP development in August 2002. The roles of the Health Sector Partners Meeting alongside CoCom may therefore well have to be revised in order to identify the best arrangement that enables MOH and partners to maximize the effectiveness of donors’ assistance as well as to minimize the transaction cost that is required for MOH in coordination with donors. It may be helpful for MOH and partners to review coordination frameworks and how they work in other sectors, e.g. the education sector, in order to obtain ideas for better coordination.

Although the MOH has made a major progress in developing the HSP with support of its partners, the HSP’s implementation remains as a major challenge. In particular, the need for capacity development at the sub-national level seems to be large, although it is not necessarily clear what kind of skills are in short supply. There are some indications, however. For example, our field study in Prey Veng has revealed obvious capacity gaps in such areas as accounting and financial management at local offices, which may constrain effective implementation of the strategy. MOH officials working at the operational level also stressed that technical staff, in particular of midwives working in the government system, is far from sufficient to achieve better health service delivery under the HSP. Therefore, there is an urgent need for MOH to identify capacity gaps in administrative and technical skills in the government’s health system that are required for the implementation of HSP.

Some external partners are already providing technical assistance for capacity development in the health sector. ⁵⁰ The ongoing projects alone, however, will not be sufficient to meet the vast need for capacity development. Additional resource mobilization will be needed to achieve the sector targets set out in the HSP. It is important to make sure that new projects are aligned under the HSP and the resulting capacity development needs.

The coordination of donor assistance with national programs (or vertical programs) should be discussed from two different aspects: (i) information sharing on donor assistance to national programs; and (ii) coordination of financial incentives provided at the health center level.

(i) Officials at the central departments of MOH reported that they have faced difficulties in obtaining information on donor assistance provided for national programs, especially inputs to each province. This has made it difficult for them to develop budget/expenditure plans and to estimate overall resources available. Thus, there is a clear need to consolidate the information system within MOH, such as the AIDMIS, that includes assistance information provided for the national programs.

(ii) It was reported that different per diem schedules between different national programs set by each donor and NGO have distorted incentives for staff at health centers and resulted in allocation of personnel that do not reflect true local needs. This problem was also reported by MOH officials at the operational level who attended the thematic workshop organized by the study team. Several donor staff also indicated that this per diem issue is one of the major challenges to be addressed through aid coordination. However, the findings from our field study in Prey Veng were somehow inconsistent with the above arguments. As far as the officials interviewed at the local offices and health centers were concerned, the different per diem schedules were not perceived as a big issue. There may be a need for a study to find out where truth is and identify what measures are needed to address this issue through aid coordination and in a broader context of the health sector reform.

The importance of personal ties among individuals representing donors was earlier mentioned. In turn, the presence of donor representatives and staff committed to the SWiM process and based in country will be critical to continue this level of personal communication. Several donor representatives  stressed the importance of this during interviews. The availability of local committed donor representatives is an issue facing all donors who wish to improve aid coordination.

The low salary issue is seen by many as the root cause of many other problems in the civil service. Several MOH officials interviewed reported that the low salary problem causes a number of other problems, including the lack of staff motivation, weak commitment to their assignments, and brain drain, particularly of those trained by donor support. The low pay issue is particularly problematic in the health sector because the income opportunity of professional staff such as medical doctors and nurses outside the civil service is high. Another problem associated with low pay is the distribution of technical staff to remote areas. In Prey Veng, which is one of the poorest provinces in Cambodia, professional staff are in short supply, particularly in remote areas.

While government-wide pay reform is underway through the initiative of the Council for Administrative Reform, the MOH is taking some interim measures. For instance, the MOH has initiated the "contract-in" that targets 11 operational districts as part of the HSSP supported by World Bank, ADB and DFID. The contracting-in is intended to contract health service delivery to local NGOs, aiming to improve the performance of underserved areas. It was also suggested that the MOH might want to consider creating incentive schemes for technical staff to work in remote areas (e.g. incentive payments through PAP, which has been introduced in the education sector). Coordinated support for realistic, effective measures such as these will be critical until national administrative reforms start to take effect.

The PAP and ADD disbursement was raised as a key issue to be addressed in the Joint Annual Health Sector Review in April 2003 and the thematic workshops organized by the study team in November, 2003. For instance, in 2002 the amount of PAP release totaled 92 percent of allocated budgets, but the monthly distribution of the release was uneven and concentrated in the last quarter of 2002. The amount of PAP release in the first semester 2003 was reportedly less than 50 percent of allocated budget. The MOH has been making efforts to address this problem through working with MEF. As a recent initiative, the MOH formulated a PAP Taskforce jointly with MOEYS and MEF in September 2003. As was discussed in Chapter 6 (Education), in order to expedite this process, the Financial Reform Working Group and Social Development Working Group assisted the formulation of the Taskforce to support the efforts of the ministries. The collaboration of the two Working Groups may present a good practice of new partnerships, which should be actively sought in the future.

Historical background

Over the last decade, MOH has undertaken health sector reform with the overall strategy of improving equity and accessibility to essential health services. TB treatment has been addressed within this context. Institutional frameworks for TB control established during 1990s include the NTP Work Plan 1993-1997 and the Tuberculosis Plan 1997-2000. The National Committee for TB control, headed by the Prime Minister, was established in 1995 and is viewed as an indication of the government’s political commitment to TB control.

The key milestone in the history of NTP is the introduction of the Directly Observed Treatment, Short-course (DOTS) strategy in 1994. The DOTS, recognized as one of the most cost-effective health interventions by WHO, replaced previous longer-duration treatment strategies. NTP successfully extended the DOTS strategy country-wide within five years after its introduction.

Since 2000, the progress of NTP has accelerated with increased donor assistance. Major achievements in the recent years are listed below.

June 2001:        The second TAG Meeting was held in Beijing, with the focus on country needs, financial gaps and assisted partnerships.

July-Nov 2001:  The National Health Policies and Strategies for TB control in Cambodia (2001-2005) and the National Health Strategic Plan for TB Control (2001-2005) were developed in collaboration between the NTP and its partners.

April-Dec 2002: The National TB Prevalence Survey was conducted with the support of JICA TB Control Project, the Disease Control and Health Development Project (World Bank) and WHO.

August 2002:   The National Framework for TB/HIV was established with the support of USAID (Center for Disease Control, US), JICA and WHO, and endorsed by MOH.

External technical collaboration has been led by WHO and JICA. WHO has assigned a TB specialist to the NTP since 1993 and collaborated closely with the NTP, especially since the inception of DOTS in 1994. JICA has been supporting laboratory activities in CENAT since 1993 by means of the placement of technical advisors and the provision of laboratory equipment. A Japanese grant has also been provided to rebuild the CENAT technical and administrative center in Phnom Penh. In addition, JICA started a 5-year technical assistance program in August 1999 with technical support from RIT/Japan.

The current principal financial partners are JICA and World Bank, additional support is provided by USAID and CIDA, and WFP contributes food to a nutritional support scheme for TB patients. In addition, Cambodia has submitted an application to the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM).

The government contribution to the NTP budget is relatively small (12% of existing resources), making NTP heavily dependent on continuing external support. Though disbursement figures are not available, budget figures and gaps are estimated in the WHO Report 2003. With the estimated donor funding of US$ 3.6 million and the NTP budget of US$ 0.5 million, a funding gap of US$ 0.8 million has been identified for 2003.

A number of efforts have been made to improve the coordination of aid for TB control in Cambodia. They include: partnership meetings for technical discussions and political dialogue; joint initiatives to develop strategies and policies; implementation of different activities in a harmonized manner; and co-financing for common activities such as training, surveys and workshops. Institutional frameworks and working arrangements that have played significant roles in aid coordination of the TB sub-sector are described below.

A multi-sectoral partnership chaired by the Prime Minister, the National Committee Against Tuberculosis, was established in 1995 in recognition of the need to include all key sectors to address TB problems. The Committee recognized that national resources are inadequate for complete TB control and acknowledged the need for coordinated international partnerships. It has served as a base to effectively manage partnership relations for TB control despite the severe constraints on staff capacity and competing demands.

A technical committee, the Interagency Coordinating Committee (ICC) for TB control, was established in April 2001. The committee gained a more formal institutional framework after the second meeting of the Technical Advisory Group (TAG) for Tuberculosis in Beijing, June 2001. ICC holds quarterly meetings and serves to coordinate among all the stakeholders in the TB sub-sector. The main terms of reference of the committee are to provide technical advice on program management and to assist the program in coordination as well as resources mobilization. So far, ICC has been functioning as the official forum for discussion and information exchange among NTP and donors.

Though not a formal institution, an alliance of project advisors (mainly from JICA, the World Bank and WHO) has played a significant role in the coordination of donor assistance to NTP. Based in CENAT, they have met with the NTP director and other staff frequently and served as a focal point for the partners of NTP. In particular, during the process of developing the policy and the strategic plan in 2001, the advisors of the JICA TB Control Project and the World Bank Project worked closely and intensively with the Working Group of NTP and provided technical advice in consultation with other partners.

Certainly, the capacity of the NTP staff has been strengthened over the past few years, as demonstrated by the improved performance of the TB sub-sector. In terms of the capacity to lead aid coordination, some development partners observed that the director of NTP has gained skill in coordinating donor agencies over the past years, especially through the process of developing joint policy and strategy documents. However, the capacity of the administrative staff, in particular the ability to better respond to donors’ and NGOs’ requirements (e.g. writing progress reports) is still in the process of improvement through technical assistance from donor advisors. The majority of the administrative staff within MOH, including NTP, has technical backgrounds such as nursing and are not formally trained in administration. This suggests that further intensive capacity development of the administrative staff is required.

ICC and other informal meetings have served as forums to share information among NTP staff and donors. Donor agencies have consequently become better informed of other donors’ plans and activities. The director of NTP and some development partners expressed their appreciation of the improved information flow that has enabled donors to coordinate with other agencies and avoid overlaps.

The policy and strategic plan documents in 2001 resulted from intensive joint working efforts involving the Working Group of NTP and project advisors based in CENAT as well as other partners. These documents have provided guidelines to match donor support more closely with sub-sector priorities. In fact, since 2001, CIDA/WHO, GFATM, TB Coalition for Technical Assistance (TBCTA) have initiated new project activities explicitly based on priorities identified in the strategic plan.

Institutional development of NTP has been achieved by means of various approaches. In the context of aid coordination, the policy and strategic plan documents were developed by NTP with technical support of the advisors of JICA and World Bank as well as participation of a wide range of other development partners. These documents were the first of their kind in the TB sub-sector in Cambodia, and provide a base for further coordination in planning and implementation of donor assistance.

In contrast to the two national work plans developed in 1990s, the sub-sector strategic plan 2001-2005 has been used as a practical tool to direct NTP and donor assistance under the leadership of the NTP director. Factors for the success may vary, but (according to several interviewees) might include the effective working process taken during the development of the documents. In practice, the JICA Project Leader and the World Bank advisor closely worked with the NTP director and staff, provided timely technical support and efficiently liaised with other partners. A policy and strategic plan that is understandable by the NTP staff, applicable in practice, and acceptable by donor agencies was thus developed.

ICC has served as a forum for dialogue and information sharing among partners in the TB sub-sector. On the other hand, informal working arrangements among advisors of major donors including JICA, World Bank and WHO have also significantly contributed to enhanced information sharing among stakeholders. For example, the project leader of JICA and the WHO consultant meet with the director of NTP both regularly and on an ad hoc basis, and share critical information arising from the small meeting with other partners. Weekly newsletters published by the JICA project leader have been used to update donors on issues surrounding NTP. An additional example of informal information sharing activity is a briefing on NTP activities voluntarily provided by a group of donor advisors when there is a new partner joining the TB sub-sector.

Thus, much of the coordination within the TB sub-sector has been efficiently managed by a small group of donor advisors. The reasons this has been possible, as identified through interviews, include: (1) the donor advisors have sufficient capacity to lead donor coordination, (2) the NTP director has high personal motivation to cooperate with the donor advisors, and (3) ease of communication due to physical presence of donor advisors within the CENAT premises.

Different donors have different rules and regulations applied to their own project assistance. Some donors reserve the authority to make large parts of management decisions for the headquarters office, whereas others delegate some financial authority to local project offices. The agency specific schemes often constrain efficient implementation of projects, but the allies of donors supporting NTP have turned them into an advantage by consciously allocating tasks so that the strengths and weaknesses of different donor assistance schemes complement each other. For example, several workshops organized in connection with the National TB Prevalence Survey (2001) were sponsored jointly by the Disease Control and Health Development Project of the World Bank and JICA TB Control Project. The World Bank covered direct costs for the workshops, and JICA covered transportation fees and incentives for participation – the items that had not been included in the World Bank’s project items and could have required another month for authorization. Thus, donor assistance was combined in such a manner to increase efficiency of program implementation.

In other words, the aid coordination in the TB sub-sector has involved not only increased alignment of donor assistance to the policy framework, but intensive collaboration among donor projects in the implementation of project activity components. The donor advisors involved in these processes stressed that their close personal relationship was a key for effective aid coordination at the project operation level.

Information sharing among partners has been facilitated over the past a few years. However, there still is no organized system to collect data and information relating to donor support, e.g. project list, funding figures, etc. Establishing such a system through the collaborative efforts of NTP and its partners is one of the next challenges for the TB sub-sector. This issue, alongside other challenges facing NTP, is expected to be addressed at a joint review of the TB sub-sector scheduled for February 2004.

The issue of coordination with other national programs may have to be addressed within the overall context of health sector reform rather than dealt with from the aid coordination aspect. As earlier mentioned under the "Future Challenges" of the health SWiM, the problem of the different per diem schedules among different national programs was raised as an issue that may possibly have distorted incentives for staff at health centers and resulted in allocation of personnel not reflecting true local needs. Another study with the focus on this issue should be initiated to identify practical measures to address the problem in the context of aid coordination as well as in a broader context of the health sector reform.