Exemplars in Under-5 Mortality: Case Study

Dr. Lisa R Hirschhorn1,2, Amelia VanderZanden1, Kelechi Udoh1, Jovial Thomas Ntawukuriryayo1, Dr. Agnes Binagwaho1

1 University of Global Health Equity 2 Feinberg School of Medicine, Northwestern University

28 February 2020 Table of Contents LIST OF TABLES ...... 3 LIST OF FIGURES ...... 5 ACKNOWLEDGEMENTS ...... 6 ABBREVIATIONS ...... 7

1 EXECUTIVE SUMMARY ...... 10 1.1 Background ...... 10 1.2 Key Findings ...... 12 1.3 Cross-Cutting Contextual Factors ...... 16 1.4 Challenges ...... 16 1.5 Transferrable Knowledge for Other Countries ...... 16 1.6 Conclusions ...... 17 2 INTRODUCTION ...... 18 2.1 Exemplars in Global Health ...... 18 2.2 Exemplars in Under-5 Mortality ...... 18 2.3 Cambodia ...... 19 3 METHODS FOR CASE STUDY ...... 35

4 SPECIFIC CAUSES OF DEATH AND EVIDENCE-BASED INTERVENTIONS ...... 37 4.1 , Diarrhea, and Pneumonia ...... 40 4.1.1 Facility-Based Integrated Management of Childhood Illness ...... 40 4.1.2 Community-Based Integrated Management of Childhood Illness ...... Error! Bookmark not defined. 4.1.3 Other Diarrhea Interventions ...... 49 4.1.4 Other Pneumonia Interventions ...... 52 4.1.5 Other Malaria-Prevention Interventions ...... 56 4.2 Other -Preventable Diseases ...... 59 4.2.1 Haemophilus Influenzae Type B Vaccination ...... 60 4.2.2 Vaccination ...... 63 4.3 ...... 65 4.4 HIV ...... 68 4.4.1 Antiretroviral Therapy for Prevention of Mother-to-Child and Treatment for Infants and Children ...... 69 4.5 ...... 72 4.5.1 Severe Acute Malnutrition Interventions ...... 71 4.6 Vitamin A ...... 74 4.7 Neonatal Interventions ...... 75 4.7.1 Improving Antenatal Care Services, Access, and Uptake ...... 76 4.7.2 Improving Childbirth Delivery Services, Access, and Uptake ...... 84 4.7.3 Improving Postpartum Care ...... 91 4.8 Common Implementation Strategies ...... 98 5 CROSS-CUTTING CONTEXTUAL FACTORS FACILITATING UNDER-5 MORTALITY REDUCTION ...... 100 5.1 Effective Leadership and Accountability: Setting Clear Goals and Priorities (Facilitator) ...... 100 5.2 Culture and Process of Donor and Implementing Partner Coordination and Donor Resources (Facilitator) ... 101 5.3 Economic Growth and Poverty Reduction (Facilitator) ...... 101 5.4 Other Public Health Initiatives with Impact on U5M Reduction Including WASH (Facilitator and Barrier) ...... 102

5.5 Community Health System and Structure (Facilitator) ...... 102 5.6 Health Systems Structure and Strengthening (Facilitator and Barrier) ...... 102 5.7 Data Availability and Culture of Use (Facilitator) ...... 103 5.8 Existence of In-Country Research Capacity and Prioritization of Local Research (Facilitator) ...... 103 5.9 Expanding Private Health Sector (Facilitator and Barrier) ...... 103 5.10 End of Conflict (Facilitator) ...... 103 5.11 Health Insurance (Facilitator) ...... 104 5.12 Nutrition-Targeted Interventions (Facilitator and Barrier) ...... 104 5.13 Women’s Empowerment/Education (Facilitator and Barrier) ...... 105 5.14 Reproductive Health (Facilitator) ...... 106 6 CROSS-CUTTING AND REMAINING CHALLENGES ...... 107 6.1 Quality of Care ...... 107 6.2 Ongoing Health Inequity ...... 107 6.3 Out-of-Pocket Spending ...... 107 6.4 Neonatal Mortality ...... 107 6.5 Government Funding for Health ...... 108 6.6 Air Pollution ...... 108 6.7 Lack of Qualified Midwives and Physicians ...... 108

7 TRANSFERABLE KNOWLEDGE FOR OTHER COUNTRIES ...... 109 8 CONCLUSIONS ...... 113

REFERENCES ...... 115 APPENDIX A ...... 123

Exemplars in U5M: Cambodia Case Study 2 List of Tables Table 1. A Comparison Of Cambodia's U5M and Neonatal Mortality Rates With Those Of Its LMIC Regional Neighbors in Southeast Asia ...... 22 Table 2. Under-5 and Neonatal Mortality Rates (Per 1,000 Live Births) by Province (Source: DHS 2000 & 2014) ...... 23 Table 3. Causes of Death in Cambodia, Ordered By Rate Of Deaths Per 100,000 Of Under-5 Population (2000-2015) (IHME Modeling) ...... 33 Table 4. Causes of Death in Cambodia, Ordered by Rate of Deaths Per 100,000 of all Neonatal Population (2000-2015) (Source: IHME) ...... 33 Table 5. Coverage Of Selected EBIs In Cambodia (Based On Available Nationally Representative Data) (1993/4-2014) ...... 38 Table 6. Rural/Urban and Regional Differences in Key Coverage Indicators (Source: DHS 2000 & 2014) ...... 40 Table 7. Key Facility-Based IMCI Implementation Strategies ...... 41 Table 8. FB-IMCI Implementation Strategies and Outcomes ...... 44 Table 9. Community-Based IMCI Key Implementation Strategies ...... 47 Table 10. CB-IMCI Implementation Strategies and Outcomes ...... 48 Table 11. ORT Key Implementation Strategies ...... 49 Table 12. ORT Implementation Strategies and Outcomes ...... 51 Table 13. Rotavirus Vaccination Key Implementation Strategies ...... 52 Table 14. Pneumococcal Conjugate Vaccine Key Implementation Strategies ...... 53 Table 15. PCV Implementation Implementation Strategies and Outcomes ...... 55 Table 16. Other Malaria Interventions Key Implementation Strategies ...... 57 Table 17. Other Malaria Interventions Implementation Strategies and Outcomes ...... 58 Table 18. Other Vaccine-Preventable Diseases Key Implementation Strategies ...... 59 Table 19. Other Vaccine-Preventable Diseases Interventions Implementation Strategies and Outcomes ...... 62 Table 20. Measles Vaccination Implementation Strategies and Outcomes ...... 64 Table 21. Tuberculosis Key Implementation Strategies ...... 65 Table 22. Tuberculosis Implementation Strategies and Outcomes ...... 67 Table 23. HIV Program Key Implementation Strategies ...... 68 Table 24. HIV Program Implementation Strategies and Outcomes ...... 71 Table 25. SAM Interventions Key Implementation Strategies ...... 72 Table 26. SAM Intervention Implementation Strategies and Outcomes ...... 74 Table 27. Vitamin A Supplementation Key Implementation Strategies ...... 75 Table 28. Vitamin A Supplementation Implementation Strategies and Outcomes ...... 75 Table 29. Four or more antenatal care visits (ANC4) Key Implementation Strategies ...... 76 Table 30. ANC4+ Implementation Strategies and Outcomes ...... 79 Table 31. Maternal Tetanus Vaccination Key Implementation Strategies ...... 80 Table 32. Maternal Tetanus Vaccination Implementation Strategies and Outcomes ...... 82 Table 33. Iron and Folic Acid Supplementation Key Implementation Strategies ...... 83 Table 34. Iron and Folic Acid Supplementation Implementation Strategies and Outcomes ...... 85 Table 35. Skilled Birth Attendant Key Implementation Strategies ...... 86 Table 36. Skilled Birth Attendant Implementation Strategies and Outcomes ...... 88 Table 37. BEmONC and CEmONC Key Implementation Strategies ...... 89 Table 38. BEmONC and CEmONC Implementation Strategies and Outcomes ...... 91 Table 39. Newborn Resuscitation Key Implementation Strategies ...... 92 Table 40. Newborn Resuscitation Implementation Strategies and Outcomes ...... 93

Exemplars in U5M: Cambodia Case Study 3 Table 41. Postpartum Visits Key Implementation Strategies ...... 94 Table 42. Postpartum Visits Implementation Strategies and Outcomes ...... 96 Table 43. Global, National, MOH, Community, and Individual Contextual Factors ...... 101

Exemplars in U5M: Cambodia Case Study 4 List of Figures Figure 1. Map of Cambodia showing the different divisions (Source: Vector Stock, 2019) ...... 19 Figure 2. Under-5 Mortality Rate (per 1,000 live births) in Cambodia (Source: IHME, 2017) ...... 22 Figure 3. Neonatal Mortality Rate in Cambodia (Source: IHME, 2017) ...... 22 Figure 4. Map of Cambodia Showing the Trend of Under-5 Mortality across the Different Regions (Source: IHME 2018) ...... 23 Figure 5. Under-5 mortality across different wealth quintiles (Source: Victora, et al 2018) ...... 23 Figure 6. Map of Cambodia Showing the Trend of Neonatal Mortality across the Different Regions (2000-2016) (Source: IHME 2018) ...... 24 Figure 7. Neonatal mortality across different wealth quintiles (Source: Victora, et al 2018) ...... 24 Figure 8. Organizational structure of the MOH (2015) (Source: Cambodia MOH via WHO 2015) ...... 25 Figure 9. Cambodia’s Health Service Delivery Organizational Structure (Peat, 2013) ...... 25 Figure 10. Health workforce (physicians, nurses and midwives) in Cambodia (Source: World Bank) ...... 28 Figure 11. Theory of Change of Reduction of Amenable Under-5 Mortality ...... 35 Figure 12. Composite Coverage Index in Cambodia by Wealth and Year (Source: Victora et al, Countdown2030) ...... 38 Figure 13. Cambodia Equity Profile – Coverage of Selected Under-5 Mortality Interventions (Source: Countdown 2030 Equity Profile) ...... 38 Figure 14. Coverage and Equity Outcome: Care-Seeking for Diarrhea across the Different Wealth Quintiles in Cambodia (2000-2014) (Source: Victora, et al 2018) ...... 45 Figure 15. Coverage and Equity Outcome: Care-Seeking for Pneumonia across the Different Wealth Quintiles in Cambodia (2000-2014) (Source: Victora, et al 2018) ...... 45 Figure 16. Coverage and Equity Outcome: Care-Seeking for Fever across the Different Wealth Quintiles in Cambodia (2000- 2014) (Source: Victora, et al 2018) ...... 45 Figure 17. Coverage and Equity Outcome: ORS and Zinc across Wealth Quintiles in Cambodia (2010-2014) (Source: Victora, et al 2018) ...... 51 Figure 18. Equity and Coverage Outcome: Measles Vaccination in Cambodia across all Wealth Quintiles (2000-2014) (Source: Victora, et al 2018) ...... 64 Figure 19. New HIV Infections among Children (1990-2018) (Source: UNAIDS, 2019) ...... 68 Figure 20. Equity and Coverage Outcome – ANC4+ in Cambodia (2000-2014) (Source: Victora, et al 2018) ...... 79 Figure 21. Equity and Coverage Outcome – ANC (at least one visit) in Cambodia (2000-2014) (Source: Victora, et al 2018) .... 79 Figure 22. Equity and Coverage Outcome – Iron Supplementation in Pregnancy (2000-2014) (Source: Victora, et al 2018) .... 84 Figure 23. Equity and Coverage Outcome – Institutional (Facility-Based) Delivery in Cambodia (2000-2014) (Source: Victora, et al 2018) ...... 87 Figure 24. Equity and Coverage Outcome in Wealth Quintiles - Postnatal Care for all Babies (2010-2014) (Source: Victora et al 2018) ...... 96 Figure 25. Equity and Coverage Outcome in Wealth Quintiles - Postnatal Checkup for the Mother (2000-2014) (Source: Victora et al 2018) ...... 96 Figure 26. Equity and Coverage Outcome: Percentage of Underweight Children in Cambodia across all Wealth Quintiles (Source: Victora, et al 2018) ...... 105 Figure 27. Equity and Coverage Outcome: Percentage of Wasted Children in Cambodia across all Wealth Quintiles (Source: Victora, et al 2018) ...... 105 Figure 28. Equity and Coverage Outcome: Percentage of Stunted Children in Cambodia across all Wealth Quintiles (Source: Victora, et al 2018) ...... 105

Exemplars in U5M: Cambodia Case Study 5 Acknowledgements We would like to acknowledge the following groups for their support throughout the research and development of this case study: • Gates Ventures (formerly bgC3) and the Bill & Melinda Gates Foundation for funding support and input; • The Institute for Health Metrics and Evaluation and Simon Hay’s team for creation of Local Burden of Disease under-5 and neonatal mortality rate maps; • Cesar Victora and his team at the International Center for Equity in Health, Federal University of Pelotas, Brazil for equity analyses; • EvaluServe for initial desk review development.

Exemplars in U5M: Cambodia Case Study 6 Abbreviations

ACT: Artemisinin-based Combination Therapy ANC4+: Four or more Antenatal Care Visits ANC: Antenatal Care ARI: Acute Respiratory Infection ART: Antiretroviral Therapy ARV: Antiretroviral BCG: Bacillus Calmette–Guérin BEmONC: Basic Emergency Obstetric and Newborn Care BMZ: German Federal Ministry for Economic Cooperation and Development CBHI: Community-Based Health Insurance CB-IMCI: Community-Based Integrated Management of Childhood Illness CCI: Composite Coverage Index CDC/GAP: Centers for Disease Control and Prevention/Girls Achieve Power CDHS: Cambodia Demographic and Health Survey CDOTS: Community Directly Observed Therapy – Short Course CEmONC: Comprehensive Emergency Obstetric and Newborn Care CFIR: Consolidated Framework for Implementation Research CHW: Community Health Worker CMAM: Community-Based Management of Acute Malnutrition CNM: National Center for Parasitology, Entomology and Malaria Control/National Center for Malaria COD: Cause of Death DDT: Dichlorodiphenyltrichloroethane DHS: Demographic and Health Survey DOTS: Directly Observed Therapy – Short Course DPT: Diphtheria, Pertussis, and Tetanus EBI: Evidence-Based Intervention e-HIS: electronic Health Information System EmONC: Emergency Obstetric and Newborn Care EPI: Expanded Program on Immunization EPIAS: Exploration, Preparation, Implementation, Adaptation, and Sustainment FBD: Facility-Based Delivery FB-IMCI: Facility-Based Integrated Management of Childhood Illness GAVI: Global Alliance for and Immunization GDP: Gross Domestic Product GMS: Greater Mekong Subregion HBB: Helping Babies Breathe HCMC: Health Center Management Committees HEF: Health Equity Fund HepB: Hepatitis B Hib: Haemophilus Influenzae Type B HIV: Human Immunodeficiency Virus HIV/AIDS: Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome HMIS: Health Management Information System HR: Human Resource

Exemplars in U5M: Cambodia Case Study 7 HRH: Human Resources for Health HSSP: Health Sector Strategic Plan ICATT: IMCI Computerized Adaptation and Training Tool IEC: Information, Education, and Communication IFA: Iron and Folic Acid IGME: Inter-agency Group for Estimation IHME: Institute for Health Metrics and Evaluation IMCI: Integrated Management of Childhood Illness IMCI++: IMCI facilities receiving incentives IPD: Invasive Pneumococcal Disease IPPC: Integrated Postpartum Care IPT: Intermittent Preventive Treatment IRS: Indoor Residual Spraying ITN: Insecticide-Treated Net KMC: Kangaroo Mother Care LDSC: Church of Jesus Christ Latter-Day Saints Charities LLIN: Long-Lasting Insecticidal Net LMIC: Low- and Middle-Income Country LRI: Lower Respiratory Infection M&E: Monitoring and Evaluation MCH: Maternal and Child Health MCV: Measles-Containing Vaccine MDG: Millennium Development Goal MMR: Maternal Mortality Ratio MNCH: Maternal, Newborn, and Child Health MOH: Ministry of Health MTCT: Mother-to-Child Transmission NCHADS: National Centre for HIV/AIDS Dermatology and STDs NCHP: National Center for Health Promotion NGO: Non-Governmental Organization NIH: National Institutes of Health NIP: National Immunization Program NMR: Neonatal Mortality Rate NRHP: National Reproductive Health Program NTP: National Tuberculosis Programme STD: Sexually Transmitted Disease OOP: Out-of-Pocket ORS: Oral Rehydration Salt ORT: Oral Rehydration Therapy PATH: Program for Appropriate Technology in Health PCV: Pneumococcal Conjugate Vaccine PPD: Purified Protein Derivative PEPFAR: President's Emergency Plan For AIDS Relief PHC: Primary PMRS: Patient Management and Registration System PMTCT: Prevention of Mother-To-Child Transmission PNC: Postnatal Care

Exemplars in U5M: Cambodia Case Study 8 PSI: Population Services International RACHA: Reproductive and Child Health Alliance RDT: Rapid Diagnostic Testing RHAC: Reproductive Health Association of Cambodia RMNCH: Reproductive, Maternal, Newborn, and Child Health ROTA: Rotavirus Organization of Technical Allies RUTF: Ready-to-Use Therapeutic Food SAM: Severe Acute Malnutrition SARA: Service Availability and Readiness Assessment SBA: Skillled Birth Attendant SIA: Supplementary Immunization Activities STI: Sexually Transmitted Infection SWAp: Sector-Wide Approach SWiM: Sector Wide Management TB: Tuberculosis TBA: Traditional Birth Attendant TBCAP: Tuberculosis control and prevention TBCARE: Tuberculosis care TOC: Theory of Change TOT: Training of Trainers TT: Tetanus Toxoid U5: Under-5 U5M: Under-5 Mortality UGHE: University of Global Health Equity UNICEF: Children's Fund USAID: United States Agency for International Development US CDC: United States Centers for Disease Control VHSG: Village Health Support Groups VMW: Village Malaria Worker WASH: Water, , and Hygiene WFP: World Food Programme WHO: World Health Organization WPRO: Western Pacific Regional Office

Exemplars in U5M: Cambodia Case Study 9 1 Executive Summary 1.1 Background 1.1.1 Exemplars in Global Health Under-5 Mortality Project The Exemplars in Under-5 Mortality (U5M) project aims to identify lessons from countries’ successes in reducing amenable U5M through health system-delivered evidence-based interventions (EBIs) to inform the decision- making of leaders, policymakers, and funders working to accelerate country work to reduce U5M. The University of Global Health Equity (UGHE) has collaborated with Gates Ventures and the Bill & Melinda Gates Foundation to understand exemplar countries’ successful reduction of U5M – a high priority issue within global health. The project was designed to identify and disseminate cross-cutting implementation strategies and policy lessons that can be adapted and adopted in other countries working to achieve similar progress. The scope is limited to deaths amenable to improvement in health care delivery and quality, and focuses on the uptake of recommended health system-based EBIs to reduce U5M between 2000 and 2015. We applied an implementation science lens to understand from existing evidence in the peer-reviewed, gray literature, and other publicly available sources not just what was selected and quantitative outcomes, but also how and why the EBIs were implemented and the contextual factors which challenged or facilitated their impact and sustainability. 1.1.2 Cambodia Overview Cambodia experienced civil war and instability during the 1970s and 1980s, during which time up to one-fifth of the population was killed. Rebuilding began during the 1990s, with the end of the and the beginning of free elections and the country’s opening up to bilateral and multilateral development support. Between the second set of free elections in 1998 and the end of the study period, the country has experienced political stability and sustained peace. Maternal and U5 mortality rates were high during the period of conflict and during the early rebuilding years. Accompanied by significant economic growth, Cambodia’s focus on improving reproductive, maternal, neonatal, and child health beginning in the 1990s has paid large dividends in terms of decreasing mortality rates among these populations.

Development of the Economy and Health System The end of conflict and period of rebuilding resulted in steady growth in the gross domestic product between 2000-2015.1–3 A major consequence of the growth in Cambodia’s economy was the tremendous drop in the percentage of people living below the poverty line in Cambodia, from 53.2% in 20044 to 13.5% in 2014.5 However, the income growth has not been equitable, with 80% of the population living in rural areas continuing to be predominantly subsistence farmers with higher rates of poverty. Major structural and organizational reforms began in the health sector in the mid-1990s; the Ministry of Health (MOH) has partnered with development agencies and successfully played a leading role in Cambodia’s health system development. Cambodia has been working to establish community health worker (CHW) programs since 2001 with variable success; some of the infrastructure was put in place by the end of the study period and CHWs played an important part of some health services.

Exemplars in U5M: Cambodia Case Study 10 Mortality and Equity Under-5 mortality in Cambodia dropped from 94/1,000 live births in 2000 to 35/1,000 live births in 2015 – a decline of 63%.6,1 Neonatal mortality (NMR) in 2000 was 33/1,000 live births, dropping by 45% (to 18/1,000 live births in 2015), slightly lower than the decline in U5M.6 The drop in U5M in Cambodia occurred across wealth quintiles. Although the relative equity gap narrowed between the highest and lowest quintile (by 41%), it persisted: In 2000 U5M was 154/1,000 live births among the poorest quintile and 58/1,000 among the wealthiest quintile (a difference of 96/1,000 live births), dropping to 76/1,000 among the poorest quintile and 19/1,000 among the wealthiest quintile in 2014 (a difference of 57/1,000 live births).7 U5M also dropped across all regions in Cambodia – although the northeast and southwest (both rural areas and highlands which had the highest U5M at the start of the case study period) lagged behind the rest of the country.7,8 Similarly the drop in NMR occurred across wealth quintiles although the equity gap remained the same with a difference of approximately 13/1,000 live births in 2000 and 2014. Neonatal morality reduced from 27 to 11 per 1,000 live births in the wealthiest quintile and from 40 to 23 per 1,000 live births in the lowest wealth quintile, with a persistent absolute difference between the quintiles. Similar to overall U5M, the northeast and southwest lagged behind the rest of the country and showed persistent rural-urban disparities with NMR at 41/1,000 and 27/1,000 in rural and urban areas respectively in 2000 and 23/1,000 and 10/1,000 in rural and urban areas respectively in 2014.

1.1.3 Methods A desk review was completed of peer-reviewed and gray literature and publicly available data related to Cambodia’s general political, cultural, and economic context and health system-based EBIs implemented to reduce U5M. Different from other Exemplar country cases , the team was not able to carry out primary research or conduct key informant interviews with an in-country partner reflecting both resources and political changes during the time when the research was completed. The desk review was informed by a Theory of Change (TOC) for the pathways to reducing amenable mortality. The research was guided by an implementation science framework designed to understand the steps towards implementation and implementation outcomes and the contribution of contextual factors and actors involved at multiple levels: global, national, ministry, subnational, facility, and community. Our framework combined elements of existing frameworks: Aarons et al’s Exploration, Preparation, Implementation, and Sustainment (EPIS), Damroscher’s et al Consolidated Framework for Implementation Research (CFIR); and Proctor et al’s Implementation outcomes – including Feasibility, Fidelity, Acceptability, Reach, and Effectiveness. We added a new step – Adaptation – making it EPIAS. The TOC was developed to articulate the three pathways to Figure 1: Theory of Change of Reduction of Amenable Under-5 Mortality reducing amenable U5M, including factors

1 Cambodia’s DHS showed that between 2000 and 2014, the U5M drop was higher than IHME estimates at 124/1,000 live births in 2000 and 35/1,000 live births in 2014 – a decline of 72%.

Exemplars in U5M: Cambodia Case Study 11 which impacted health status and family resilience (such as female empowerment, stunting) and risk of disease outside of the targeted health system prevention EBIs, as well as other contextual factors which would influence implementation (Figure 1). This TOC guided work to understand how these factors were addressed directly or through strategies focused on implementing the EBIs.

The documents and data were analyzed to understand the implementation strategies, policies, and contextual factors most relevant to the success in reducing amenable U5M in Cambodia. Implementation strategies and broader approaches were synthesized to create transferable knowledge that could be implemented in other countries. Additional analyses from the International Center for Equity in Health, and cause of death analyses and geospatial mapping from the Institute for Health Metrics and Evaluation (IHME) were used to understand changes in equity for mortality and EBI coverage, and change in causes of death (CODs).

1.2 Key Findings 1.2.1 Coverage and Equity of Selected Under-5 Mortality Health System Evidence- Based Interventions EBIs targeting common U5M CODs and prevalence of selected conditions between 2000-2015 were examined and improvement and high coverage was seen in both preventative and curative EBIs and those specific to neonates. EBIs which achieved national coverage greater than 80% included facility-based delivery (FBD), delivery attended by skilled provider, HIV-testing during antenatal care (ANC) or labor, newborn’s first postnatal care in first two days after birth, tetanus protection at birth, proportion of households with at least one insecticide-treated bednet, children with symptoms of acute respiratory infection treated with antibiotics, and Hib vaccine (as part of pentavalent). Other EBIs also achieved high coverage although not as high as 80% including measles vaccination (with Cambodia achieving elimination status in 2015), four or more antenatal care visits (ANC4+), vitamin A supplementation, and full vaccination coverage, all of which improved substantially during the case study period.

Health Equity and Coverage of EBIs Despite the overall improvements, a more varied picture was seen in addressing equity coverage gaps. Hib vaccine coverage as part of pentavalent achieved high coverage in 2010, the year it was introduced (84%) and maintained this high coverage at 82% in 2014.7 Despite high coverage, wealth-based inequity gaps were seen in 2014 with pentavalent coverage among the poorest quintile at 72% and 96% among the wealthiest. For prevention of mother-to-child transmission of HIV, the percentage of pregnant women who were counseled, were offered and accepted an HIV test, and who received results during ANC was only 8% in 2005, increasing to 51% in 2014. In 2005 there were wide disparities in coverage among different wealth quintiles with only 1.4% in the poorest quintile compared to 28% in the wealthiest quintile. By 2014, this gap had largely closed (46% in the poorest quintile and 51% in the wealthiest).7,9 For ANC, the 2014 DHS reported that 95% of women who had a live birth in the preceding five years received ANC from a skilled provider, an improvement from just 38% in 2000. The equity gap between richest and poorest in access to at least one ANC visit narrowed dramatically from 2000 to 2014; in 2014 90% of women from the poorest wealth quintile (up from about 20% in 2000) and 99% from the highest quintile (from about 80% in 2000) received ANC – but the gap did not change substantially for ANC4.

Exemplars in U5M: Cambodia Case Study 12

Between urban and rural areas, absolute improvement was greater in urban areas in measles and full vaccination coverage, while greater absolute improvements were seen in rural areas in children with diarrhea taken to health facility, delivery attended by skilled provider, and facility-based delivery. Depending on the EBI this difference was sometimes a reflection of contextual factors and other times a reflection of successful implementation strategies targeting both urban and rural settings, but with more room for improvement often in rural areas. However, the rural/urban gaps grew between 2000 and 2014 including for measles vaccination coverage, diphtheria-pertussis- tetanus third dose (DPT3), and full vaccination coverage. Exceptions include delivery attended by a skilled provider (the gap shrank from 29 to 10, with both urban and rural coverage exceeding 85% by 2014) and facility- based delivery (the absolute gap decreased from 28 to 15, and urban and rural coverage both exceeded 80%). The gap between the highest to lowest preforming province in 2000 was often vast – for example, 77 percentage points for delivery attended by a skilled provider, and 69 percentage points for FBD. The equity gaps largely decreased, although there were still major gaps in EBI coverage in 2014 (often close to 50 percentage points). This difference was often due to low coverage of a single province or region. For example, Kratie, Preah Vihear/Stung Treng, and Mondul Kiri/Ratanak Kiri, all in the northeast corner of the country – an area with highly dispersed and remote populations – had the lowest coverage for both delivery by a skilled provider and facility-based delivery. Mondul Kiri/Ratanak Kiri also had the lowest measles vaccination, DPT3, and full vaccination coverage.

1.2.2 Common Implementation Strategies Cambodia was found to have utilized a range of strategies during implementation of EBIs, combining them to address identified contextual factors and key steps needed to achieve implementation outcomes. Many of these implementation strategies were shared across many or most EBIs such as community engagement and coordination with donors and implementing partners. Others were specific to individual interventions such as training village malaria workers to provide CB-IMCI. Implementation strategies identified across multiple EBIs included: • Integration and leveraging of existing systems and programs • Local research to produce evidence and data use for decision-making • Community engagement and sensitization • Adaptation of interventions to local setting • Training for health workers • Engagement and coordination of implementing partners and donors and leveraging resources and expertise • Pilot testing and rapid scale • National leadership and accountability; setting clear goals and priorities and planning for sustainability • Integration of equity focus into policy and implementation

While some of these strategies were successful in achieving national scale-up for both coverage – the geographic and population spread of an EBI (ex. facilities or areas which had the capacity to provide a an EBI) – and reach – the extent to which an EBI reached everyone intended, others were implemented with some inconsistency in coverage and reach. For example, some EBIs were piloted and scaled to selected districts and provinces but did

Exemplars in U5M: Cambodia Case Study 13 not reach national scale, while others identified as a priority and proposed for implementation were fully implemented.

1.2.3 Examples of Implementation of Health System-Delivered EBIs to Address Major Causes of Amenable Mortality Cambodia implemented many of the existing EBIs before or during the study period, while a number of others were only implemented towards the end or after the study period. The work started with interventions that addressed leading CODs across age groups, including vaccination, improving maternal care and early neonatal care, and recognizing the importance of a focus on improving neonatal outcomes early in the study period. The work in Cambodia also included initiatives addressing contextual factors and social determinants, including reducing diseases (ex. water, sanitation, and hygiene (WASH) programs) and improving resiliency, (ex. expansion of reproductive rights, stunting and nutrition, and economic development). Modeling from IHME found that throughout the period of interest (2000-2015), major amenable causes of death included newborn causes, pneumonia and lower respiratory infections, diarrhea, meningitis, and malaria. Injury was a significant cause of death during the study period but falls outside of the scope of the case study work. Mortality rates for each of these causes of death decreased over this time period. Similar to many other countries and reflecting the increased proportion of under-5 deaths in neonates, the relative proportion of neonatal causes of death increased. We describe two illustrative EBI implementations and the implementation strategies employed below. Complete descriptions of the range of initiatives and their implementation can be found in the full report.

Measles Cambodia’s MOH initiated a measles-control initiative in 1999 was designed to reduce the annual incidence of measles to <10,000 cases by 2005. The initiative included activities such as strengthening measles surveillance, improving routine vaccination coverage, implementing supplementary measles immunization activities (SIAs) to vaccinate children missed during routine services, and providing vitamin A during outbreak investigations and SIAs.10 The plan was to vaccinate all children aged 9 months to 5 years in two phases, regardless of their previous history of vaccination (initial and catch-up campaign). Phase I (December 2000 to May 2001) targeted 191,527 children under 5 living in remote border areas. The coverage for measles vaccination during this phase was 89%. Phase II (October 2001 – April 2002) targeted 2,489,761 children aged 9 months to 14 years living in eight provinces in densely populated central areas. The coverage during this phase was 97% and by 2005, national measles vaccination coverage increased to 77% from 2000 figures.

Reflecting a focus on equity, in 2011, Cambodia, supported by the World Health Organization (WHO), conducted two nationwide measles immunization assessments to identify the status of vaccination among women and children and to find the communities that were at the highest risk of missing vaccines. The campaign helped to identify 1,600 communities where children were not vaccinated, informing a successful measles SIA in 2011 in three provinces and community-level improvements to expanded program on immunization systems. The introduction of the Reaching Every Community Strategy also led to the engagement of community health workers to improve coverage. In 2013, the Cambodian MOH introduced a measles-rubella vaccine into the national immunization schedule to protect children against both measles and rubella.11,12 In preparation for introducing

Exemplars in U5M: Cambodia Case Study 14 the vaccine, the Country Multi-year Plan was updated in 2012 to incorporate measles-rubella vaccine into the routine expanded program on immunization schedule, reflecting an early focus on sustainability. In March 2015, WHO declared that Cambodia eliminated measles after no locally-transmitted, laboratory-confirmed measles cases were found after November 2011. The country became one of eight countries in the WHO Western Pacific Region to achieve this goal.13–15 Measles accounted for 73/100,000 (4%) of U5 deaths in 2000; with the introduction of SIAs, this dropped to <2/100,000 in 2005 and <1/100,000 in 2015.

Skilled birth attendance and facility-based delivery In Cambodia in 2000, just 10% of births in the previous five years took place in a health facility.8 Recognizing that gap, beginning that year, the government focused on increasing access to skilled birth attendants and facility- based deliveries. The MOH used strategies including human resources strengthening, setting a target of at least one primary midwife at each health center, and applied regulatory strategies, banning deliveries by unlicensed, untrained traditional birth attendants, and strongly discouraging home births.16 In 2007, the Secretary of State established a high-level Midwifery Taskforce to focus on the quantity and quality of midwives and maternal health services. Using strategies of national policies and collaboration across sectors, a Government Midwifery Incentive Scheme was introduced in 2007 through a joint initiative of the MOH and the Ministry of Economy and Finance. The scheme increased the government midwife salary scale, provided midwives with cash incentives, and allocated government budget to pay these incentives, reflecting national leadership and financial commitment.17 Skilled birth attendants were to be paid US$15 for each live birth attended in health centers and $10 for those in hospitals. The incentives were shared with other facility health personal in addition to Village Health Support Groups, village chiefs, and traditional birth attendants, designed with equity in mind to engage a range of stakeholders and increase community engagement. This strategy was also designed to encourage communities and traditional providers to refer women to facilities for delivery. Other policy initiatives included improving supply side barriers such as integrating traditional birth attendants into the health care system through trainings and job placements.16 Midwife recruitment was also prioritized – midwives represented more than half of all health personnel recruited between 2005 and 2015. Focusing on quality, technical standards were revised for consistency with international standards, supported by including the development of preservice and in-service training programs that emphasized clinical practice.17

Between 2000 and 2015 there were dramatic improvement in skilled birth attendance and FBD. Births delivered by skilled providers increased from 44% in 2005 to 89% in 2014.7,9 In 2014, 83% of births in the five years preceding the survey took place in a health facility. Only 11% of babies in 2014 were delivered with the assistance of a traditional birth attendant. While the disparity decreased, births to women in the highest wealth quintile in 2014 were still more likely (98%) to be assisted by a trained health professional than births to women in the lowest quintile (75%), compared to 90% vs and 21% in 2005.7,9 The Safe Motherhood Policy was updated/consolidated into the National Reproductive and Sexual Health Strategies (2006-2010, 2013-2016).18

Exemplars in U5M: Cambodia Case Study 15 1.3 Cross-Cutting Contextual Factors We identified a number of contextual factors at the global, national, subnational, community, and implementing partner levels that were critical to successes and challenges in implementing the targeted EBIs in Cambodia as well as others which more directly influenced risk or amenable U5M other causes of U5M. These factors influenced the relative role of the three pathways in the Theory of Change to reduce amenable U5M to varying degrees (health status and resiliency, prevention, and access and quality of care). The facilitating contextual factors were critical in creating the environment and providing the support that contributed to the country’s success, directly or indirectly. Some of these were effective leadership and accountability setting clear goals and priorities; culture and process of donor and implementing partner coordination; economic growth and poverty reduction; other public health initiatives with impact on U5M reduction including WASH; community health system and structure; broader work in health systems structure and strengthening; data availability and culture of use; existence of in-country research capacity and prioritization of local research; expanding private health sector; end of conflict; health insurance; nutrition-targeted interventions; increases in women’s empowerment/education; and improvements to reproductive health.

1.4 Challenges A number of challenges remained in Cambodia to continue its work to reduce U5M despite some of the successes. These included quality of care, ongoing health inequality, out-of-pocket spending, ongoing gaps in reducing neonatal mortality, sustainability and level of government funding for health, the disease burden associated with air pollution, and the ongoing need to increase the availability of human resources for health across the country including qualified midwives and physicians.

1.5 Transferrable Knowledge for Other Countries There were a number of implementation strategies from Cambodia that have the potential to be adapted and adopted by other countries looking to learn from Cambodia’s successes and challenges to accelerate their own declines in U5M. These included: • Implementation strategies should be informed by gap analysis and needs assessment to identify contextual factors that can be leveraged for implementation, which need to influence the implementation strategies for the EBI to overcome potential challenges, and which require direct addressing through interventions beyond the targeted health system EBIs. • Successful implementation required multiple strategies, and while many of these were shared across EBIs, each one required specific ones based on the EBI type and/or to address equity gaps. • Cambodia took a broad and holistic approach, working to strengthen and build on existing health system capacity through integrating new initiatives rather than developing vertical systems. • Priority was placed on creating laws, policies, and regulations, and enforcing them to ensure quality and delivery. • Leaders used evidence-based decision-making and created policies and strategies based on global and local scientific evidence and feasibility, valuing the local generation of research and evidence.

Exemplars in U5M: Cambodia Case Study 16 • There has been strong coordination of donor and implementing partner activities, and the country has engaged meaningfully with stakeholders and leveraged expertise across sectors and levels, including MOH, donors, implementing partners, and community members beginning at the Exploration stage through Sustainment. • National health leaders have engaged in multisectoral collaboration to address health and health-related determinants. Cambodia also planned for equity from the start of EBI implementation, prioritizing pro- poor policies.

1.6 Conclusions Cambodia has achieved remarkable drops in U5M and neonatal mortality despite challenges in regional access and coverage. The increase in coverage of EBIs has been more variable overall for some groups based on rural or urban geography and wealth. Improvements outside the health system and a strong commitment to other initiatives, which impacted social determinants, including economic growth, female empowerment, reduction in stunting, poverty reduction, and WASH, were identified as key factors influencing U5M addressing reduction in disease and improving overall health status and resiliency. Strong national leadership and health system strengthening efforts as well a strategic leveraging of donor and partner resources (financial, expertise, implementation) were credited with many of the successes. Challenges remain in areas including quality, continued improvements to equity in access and coverage, components of neonatal health, and continuing to grow and strengthen human resources for health.

Exemplars in U5M: Cambodia Case Study 17 2 Introduction 2.1 Exemplars in Global Health The Exemplars in Global Health project aims to identify lessons from countries’ successes in reducing amenable under-5 mortality (U5M) through health systems-delivered evidence-based interventions (EBIs) to inform the decision-making of leaders, policymakers, and funders working to accelerate country work to reduce U5M. The core of the project involves deep and rigorous content detailing the successes, as well as drivers of those successes, among “exemplars” – positive outlier countries or regions that have demonstrated outperformance relative to peers or beyond what might be expected given context and/or financing. The Exemplars U5M project was designed to apply implementation research methods to identify and disseminate cross-cutting implementation strategies and policy lessons for ensuring that health system-delivered preventive and curative EBIs known to reduce amenable U5M can be adapted and adopted in other countries working to achieve similar progress. This content, organized across several global health sub-topics, is designed to be accessible, broad, data-driven, and rigorous. Exemplars content is intended primarily for an audience of national policymakers, implementers, and funders – people with the potential to significantly impact global health policy and decision- making at scale. It will be complemented by delivery mechanisms such as a publicly accessible online platform that maximize its reach and impact.

2.2 Exemplars in Under-5 Mortality The University of Global Health Equity (UGHE) in Rwanda collaborated with Gates Ventures and the Bill & Melinda Gates Foundation to contribute to the understanding of Exemplar countries’ successful reduction of amenable U5M. This work was initially designed with two aims: 1. Developing and testing an implementation framework and mixed methods approach to understand the successes of these countries; and 2. Extracting actionable knowledge focused on implementation strategies and key contextual factors to inform other countries working towards the same goal.

By design, the work was limited to deaths amenable to improvements in health care delivery and quality – those potentially preventable with a stronger and higher quality health care system. It focused on the uptake of recommended health system-based EBIs to reduce U5M between 2000 and 2015. We also identified other interventions outside the health system EBIs known to reduce the risk of major causes of U5M as well as improve survival, but a similar in-depth analysis of how these were implemented was beyond the scope of the project. The work was divided into a number of activities. These included: 1. Identifying EBIs in use in low- and middle-income countries (LMICs); 2. Developing and applying an implementation science-based approach to understanding how the EBIs put into place by these Exemplar countries were prioritized, adapted, implemented, and sustained; 3. Understanding how the EBIs implemented by a country were prioritized, adapted, implemented, and sustained through both existing publicly available sources; and 4. Identifying the key contextual factors and policy interventions critical to each country’s success (See Appendix A).

Exemplars in U5M: Cambodia Case Study 18 The work was guided by a Theory of Change (TOC) to identify the three pathways to reducing amenable U5M. This included factors which impacted health status and family resilience and risk of disease outside of health system prevention EBIs, as well as other contextual factors which would influence implementation. This model allowed for a broader understanding of how these contextual factors were addressed directly or through strategies focused on implementing the EBIs.

We also developed an implementation science framework which was informed by a number of frameworks in use for U5M (e.g. Countdown 2015, WHO) and implementation science. Seven countries meeting “exemplar” criteria for U5M were chosen based on the rates of decline in U5M compared with countries in their region or similar economic resources. This selection process was performed with input from a Technical Advisory Panel. These countries were chosen to represent a range of locations and sizes, with the goal of identifying implementation success factors common to countries that have over-performed in U5M. The methodology for the Cambodia case differed slightly from the other six cases, in that it was a desk review only, without in-country interviews due to timing, resources, and in-country events. To understand the full methodology used in the other six countries please refer to the other full cases.

2.3 Cambodia Background Located in Southeast Asia, Cambodia is a predominantly low-lying country with the highlands to the north and south. Cambodia has a tropical climate, with two distinct seasons – a dry season from November to April and a monsoon season responsible for about three-quarters of the country’s rainfall, from May to October.19 Cambodia’s climate and its low-lying geography make it susceptible to flooding during the heavy rainy season.20 (See Cross-Cutting Contextual Factors section.)

Cambodia shares borders with , Laos, Vietnam, and the Gulf of Thailand.20,21 As of 2014, Cambodia had 24 provinces, with Phnom Penh as its capital and only major city (Figure 1). Phnom Penh was divided into 12 khans, or districts, and 96 sangkats/communes, and the 24 provinces were subdivided into 26 municipalities comprising 131 sangkats/communes, 159 districts, and 1046 communal subdivisions.22

Cambodia’s population increased during the case study period, rising from 11.4 million in 1998 to 13.4 million in 2008; there were 15.4 million people by 2014, with a population density of 75 people per km2. As of 2014, 81% of Figure 1. Map of Cambodia showing the different Cambodia’s population resided in rural areas, but divisions (Source: Vector Stock, 2019) urbanization is increasing with internal migration to the capital.7,23,24

Exemplars in U5M: Cambodia Case Study 19 In 2014, nearly 90% of the population were ethnically Khmer. Among ethnic minorities were Chams, Vietnamese, and Chinese.25 A high proportion (96%) of Cambodia’s population were Buddhist with other religions including Islam (1.9%), Animism (0.8%), and Christianity (0.4%) also present in smaller numbers.26 Khmer is the official and widely spoken language, however, French and English are also spoken especially in schools and administrative entities. Other minority languages spoken in the country included Cham, Vietnamese, Tumpoon, Lao, Jarai, and Yue Chinese.27

Political Context and Conflict Cambodia gained independence in 1953 followed by multiple conflicts until 1998. These included a civil war (1968-1975) between the forces of the communist party, the Kampuchea (known as the Khmer Rouge) and the Government of Cambodia, that occurred as a result of a deteriorating economic situation and an increasingly oppressive government. The war was followed by the (1975-1979) which targeted and killed 1.7 million people including professionals, academics, and several ethnic minorities such as Vietnamese, Thai, Chinese, and Chams. The Cambodian-Vietnamese war began in the late 1970s, with Vietnam’s invasion of Cambodia in late 1978 and lasting until Vietnam’s withdrawal in 1989. By the 1990s, with the signing of the Paris Peace Agreement, the intensity of the conflict lessened although it did not end entirely until 1998 when the Khmer Rouge were officially outlawed and completely dissolved by the government (see Cross-Cutting Contextual Factors).

Post-Conflict Political Context In 1993, United Nations-sponsored national elections were the beginning of the country opening to international cooperation. Rebuilding began during the 1990s, with the end of the Khmer Rouge and the beginning of free elections and the country’s opening up to bilateral and multilateral development support. Since the second set of free elections, in 1998, the country has experienced political stability and sustained peace. The country is now a constitutional monarchy with the King as head of state and a Prime Minister, appointed by the King on advice of the National Assembly, who is the head of government. Multiparty elections have taken place in 1998, 2003, 2008, and 2013, and the country has experienced a period of sustained peace and stability since the late 1990s. Cambodia has made great gains in rebuilding its infrastructure and human resources, a market economy, and multi-party democracy. In addition, development partners including bilateral and multilateral donors and non- governmental organizations have partnered with the government to help shape policy, which has made a substantial impact on the public health system.23

Economic Status and Development After independence in 1953, Cambodia’s economy was predominantly dependent on agriculture, especially rice cultivation for national consumption and export and rubber production for export. Between 1953 and the 1990s, the country implemented a number of policies which reflected the ideals of the different government regimes and their efforts to stabilize the economy and ensure territorial integrity, given persistent political unrest during this time period. These strategies often had disastrous results, with stability and improvement not seen until the 1990s and throughout the time of the study.

Exemplars in U5M: Cambodia Case Study 20 Between 1963 and 1968, the government implemented nationalist policies which transferred ownership of all companies, banks, and major industries to the government to limit the influence of other countries on Cambodia’s economy. However, these policies led to the devaluing of the Riel, Cambodia’s currency, resulting in economic deterioration.20,28

In the following years, the government initiated a number of reforms to restore the stability of the country’s currency and ultimately stabilize the economy through introduction of a flexible currency exchange system and simplification of the import system to ensure free movement of goods and address high inflation and limited rice production and exports, which had stalled the economy since the beginning of the civil war.20,29 However, these efforts were not successful and by 1975, in the midst of war, Cambodia’s economy had collapsed. The country had no monetary system and the population mainly survived on imported food financed by the United States government. At the end of Cambodia’s civil war, the new government regime adopted a communist ideology, banning all forms of capitalism and investing in improved agricultural practices with the view to increasing agricultural yield. These efforts were not sufficient and with the war with Vietnam through the 1980s, the economy was further undermined.

To address these economic challenges, in the 1980s and following the 1991 signing of the Paris Peace Agreement, Cambodia began to move away from nationalist policies and encouraged the growth of its private sector. This included redistribution of land and other private property previously repossessed by the government. The country also began to invest in improving the effectiveness and efficiency of its public sector. This work was reflected in the introduction of a Public Administrative Reform plan by the government to facilitate these improvements. The Public Administrative Reform was instrumental to the development of key health system structures such as the Ministry of Health (MOH) (see Ministry of Health System and Structure section).

As a result of these efforts, by 2000, at the start of the case study period, the private sector had expanded and the economy was predominantly driven by garment manufacturing and tourism.30,31 Further growth was experienced between 2000-2010 with gross domestic product (GDP) per capita growing by 8.2% annually. The trend in GDP per capita growth continued with a growth rate of 7% by 2015.1–3 Remittances from Cambodians living abroad also grew steadily and significantly between 2000 and 2015, from US$120.5 million in 2000 to US$542.4 million in 2015, although its percentage contribution to Cambodia’s economy remained at only 3%, reflecting the overall growth of the economy.32 A major consequence of the growth in Cambodia’s economy was the tremendous drop in the percentage of people living below the poverty line in Cambodia from 53.2% in 20044 to 13.5% in 2014.5 By 2015, Cambodia was moved from low-income to lower-middle-income country status.31 However, the income growth has not been equitable, with 80% of the population living in rural areas continuing to be predominantly subsistence farmers with higher rates of poverty. (Seven percent of the urban population versus 40% of those in rural areas.33)

Under-5 Mortality in Cambodia While maternal and U5M rates were high during the period of conflict and during the early rebuilding years, Cambodia’s focus on improving reproductive, maternal, neonatal, and child health beginning in the 1990s has paid large dividends in terms of decreasing mortality rates among these populations.

Exemplars in U5M: Cambodia Case Study 21

According to IHME estimates, U5M in Cambodia dropped from 94/1,000 live births in 2000 to 47/1,000 live births in 2010 and 35/1,000 live births in 2015 – a decline of 63% (Figure 2).6,2

IHME estimates showed that neonatal mortality in Cambodia in 2000 was 33/1,000 live births, with the reduction of 45% (to 18/1,000 live births in 2015), slightly lower than the drop in U5M (Figure 3).6 Cambodia made substantial improvements in U5M in comparison to its LMIC regional neighbors in Southeast Asia, namely Laos,

100 100 94 80 80 67 60 60 47 40 40 33 35 27 22 18 5 Mortality Rate

- 20 20 0 0 (per 1,000 live births) 1,000 (per (per 1,000 live births) 1,000 (per Under

2000 2005 2010 2015 Neonatal Mortality Rate 2000 2005 2010 2015 Year Year Figure 2. Under-5 Mortality Rate (per 1,000 live births) Figure 3. Neonatal Mortality Rate in Cambodia (Source: in Cambodia (Source: IHME, 2017) IHME, 2017) Thailand, and Vietnam. Improvements in neonatal

mortality rate were also major although less than Thailand (Table 1). Cambodia’s DHS data showed that between 2000 and 2014, neonatal mortality dropped from 95/1,000 live births to 28/1,000 live births, a decline of 71%.17,34 Maternal mortality also dropped between 2000 and 2014, with the maternal mortality ratio declining from 437 to 170 deaths per 100,00 live births.7,8

Table 1. A Comparison of Cambodia's U5M and Neonatal Mortality Rates with those of Its LMIC Regional Neighbors in Southeast Asia (Source: IHME, 2019)

Under-5 mortality rate (per 1,000 live births) Neonatal mortality rate (per 1,000 live births) Indicators 2000 2015 % change in rate 2000 2015 % change in rate

Cambodia 94 35 63 33 18 45 Laos 137 64 53 50 28 44 Thailand 18 9 50 9 4 56 Vietnam 27 14 48 14 8 43

2 Cambodia’s DHS showed that between 2000 and 2014, the U5M drop was higher than IHME estimates at 124/1,000 live births in 2000 and 35/1,000 live births in 2014 – a decline of 72%.

Exemplars in U5M: Cambodia Case Study 22 Equity and Mortality The drop in U5M in Cambodia occurred across wealth quintiles. Although the relative equity gap narrowed between the highest and lowest quintile (by 41%), inequity still persisted. In 2000 U5M was 154/1,000 live births among the poorest quintile and 58/1,000 among the wealthiest quintile (an absolute difference of 96/1,000 live births), then dropping to 76/1,000 among the poorest quintile and 19/1,000 among the wealthiest quintile in 2014 (a difference of 57/1,000 live births) (Figure 4).7 U5M also dropped across all regions in Cambodia – although the northeast and southwest (both rural areas and highlands which had the highest U5M at the start of the case study period) lagged behind the rest of the country (Figure 5).

Figure 5. Under-5 mortality across different wealth Figure 4. Map of Cambodia Showing the Trend of quintiles (Source: Victora, et al 2018) Under-5 Mortality across the Different Regions (Source: IHME 2018)

U5M in rural areas dropped by nearly 60% from 126/1,000 in 2000 to 52/1,000 in 2014; in urban areas it fell 80% from 93/1,000 to 18/1,000 – with no change in absolute rural/urban disparity. At the subnational level, drops in U5M were seen across all provinces, but differences were seen in the proportional change. For example, Pursat (in the west) had the largest relative decrease, reducing U5M by 79% (from 173/1,000 in 2000 to 36/1,000 in 2014). However, Preah Vihear/Stung Treng (in the northeast) lagged behind other provinces with U5M decreasing by 34%, respectively during the same period, from 120 to 79 per 1,000 live births (Table 2). U5M was higher among males than females during the whole study period (133 vs. 110 per 1,000 live births in 2000; 54 vs. 41 in 2014 respectively) although the gap decreased from 23 to 13 deaths per 1,000 live births.

Table 2. Under-5 and Neonatal Mortality Rates (Per 1,000 Live Births) by Province (Source: DHS 2000 & 2014)

Under-5 mortality per Neonatal mortality per Relative Relative Province 1,000 Live Births 1,000 Live Births change (%) change (%) 2000 2014 2000 2014 Phnom Penh 50 23 -54.0% 14 13 -7.1% Banteay Meanchey 108 32 -70.4% 31 20 -35.5% Kampong Cham 134 48 -64.2% 39 25 -35.9% Kampong Chhnang 160 55 -65.6% 42 27 -35.7%

Exemplars in U5M: Cambodia Case Study 23 Kampong Speu 90 31 -65.6% 26 19 -26.9% Kampong Thom 99 60 -39.4% 39 29 -25.6% Kandal 108 40 -63.0% 39 17 -56.4% Kratie 80 30 Prey Veng 151 75 -50.3% 52 33 -36.5% Pursat 173 36 -79.2% 51 14 -72.5% Siem Reap 56 17 Svay Rieng 130 63 -51.5% 56 20 -64.3% Takeo 119 31 -73.9% 38 16 -57.9% Otdar Meanchey 125 41 -67.2% 45 17 -62.2% Battambang/Pailin 127 37 -70.9% 38 12 -68.4% Kampot/Kep 124 44 -64.5% 42 20 -52.4% Koh Kong/ Preah Sihanouk 91 42 -53.8% 32 20 -37.5% Preah Vihear/ Stung Treng 120 79 -34.2% 26 25 -3.8% Mondul Kiri/ Ratanak Kiri 229 80 -65.1% 80 36 -55.0%

Similarly, the drop in neonatal mortality occurred across wealth quintiles although the equity gap remained unchanged with a difference of approximately 13/1,000 live births in 2000 and 2014. Neonatal morality reduced at similar absolute drop in the wealthiest quintile (from 27 to 11/1,000 live births) and lowest quintile (from 40 to 23/1,000 live births) (Figure 6), representing no change in absolute difference. While much progress has been made, areas remain with particularly vulnerable groups;35 the country continued to have persistent rural/urban disparities with NMR from 41/1,000 and 27/1,000 in 2000 to 23/1,000 and 10/1,000 in 2014 in rural and urban areas respectively. (See Contextual Factors and Remaining Challenges Section.) Like the overall U5M changes, the northeast and southwest lagged behind the rest of the country (Figure 7). As with U5M, Pursat (in the west) also had the highest drop in neonatal mortality rate (NMR) (72%) from 51/1,000 in 2000 to 14/1,000 in 2014. Preah Vihear/Stung Treng (in the northeast) also lagged behind other provinces in reducing NMR by only 4%, from 26 to 25 per 1,000 live births, during the same period. NMR was higher among males at the beginning of the study period (44 vs. 34 in females per 1,000 live births in 2000), but the gap between males and females decreased substantially by 2014 to 22 and 20 per 1,000 live births for males and females).7,8

Figure 7. Neonatal mortality across different wealth Figure 6. Map of Cambodia Showing the Trend of quintiles (Source: Victora, et al 2018) Neonatal Mortality across the Different Regions (2000- 2016) (Source: IHME 2018)

Exemplars in U5M: Cambodia Case Study 24

for national development called the Rectangular Strategy (see below Health System Organization and Governancefor further clarification) – are translated into policies, strategies and guidelines in order to reach their targets. During most of the study period Cambodia’s health system has been managed by a centralized MOH responsible Figure 2.1 Organization of the Ministry of Health and affiliated for health system planning and development, health infrastructure,institutions and public health care. At the same time, the less-regulated private sector and traditional practices have been involved in delivering the majority of curative care services.

Ministry of Health: System and Structure Due to Cambodia’s conflicts between 1953- 1990s, the health system was disorganized and unregulated, hospitals and health care professionals were scarce, and where they were available, they were mainly within the private sector and expensive, limiting access to formal health care services (see Cambodia’s Health System Structure and Capacity section). As a result, citizens often sought care from traditional healers who practiced with less regulatory oversight.36,37

In 1994, the MOH was restructured as part of the Public Administrative Reform to provide structure to the health system, with a special focus on districts and rural areas reflecting a focus on primary health care and equity.38 The MOH Figure 8. Organizational structure of the MOH (2015) (Source: structure included a cabinet responsible for high- Source: Ministry of Health The roleCambodia of the General MOH viaDirectorate WHO 2015) for Health, which is the most level oversight and effective functioning of the comprehensive of the three, is the formulation and implementation MOH management including the Minister of of MOH policies through its eight departments (Planning and Health Health, Secretaries of State for Health, and Under-

Secretaries of State for Health (Figure 8). 22

Since major structural and organizational reforms began in the health sector in the mid-1990s, the MOH has partnered with development agencies and successfully played a leading role in Cambodia’s health system development. Once established, policy implementation is organized Figure 9. Cambodia’s Health Service Delivery Organizational Structure (Peat, 2013)

Exemplars in U5M: Cambodia Case Study 25 through the three General Directorates for Health (Health, Administration and Finance, and Inspection).23

Each Directorate General includes several departments; within each department are several bureaus (Figure 9).39 To address priorities ranging from medication, human resources, care delivery, as well as inspections and trainings.

Cambodia’s Health System Structure and Capacity Between 2000 and 2015, Cambodia had a pluralistic health system in which the MOH was in charge of overall health system planning and development, health infrastructure, and public health care, while the private sector delivered the majority of curative care services.39

Public Health Sector The public health system in Cambodia is divided into three levels: central, provincial, and operational district levels (which included health centers and first-level referral hospitals) (Figure 9). The central level includes eight tertiary referral hospitals which provide specialized health services, all based in Phnom Penh. The provincial level has provincial health departments, and each provincial health department has a provincial referral hospital (secondary level of referral) and oversees health services in their catchment area. The provincial hospitals provide emergency health care services and other specialized medical services such as comprehensive obstetric care, but not at the level of tertiary referral hospitals.

By 2015, in the 24 provinces, there were 77 operational districts responsible for managing 1,085 health centers most of which had been built or reconstructed since 1995.39 During the study period, each operational district was meant to cover 100,000-200,000 people with referral hospitals (first level of referral) delivering general health services, obstetric care, and supervising health centers within their catchment areas. Each health center covered 10,000-20,000 people and provided a minimum package of activities consisting mainly of preventive and basic curative services such as immunization and antenatal consultations.38,40 Health centers were the focal point of service delivery in Cambodia (reflecting a strong focus on primary health care and equity). The government introduced policies and plans to ensure availability of health workers at these health centers especially in rural areas (see Human Resources for Health section) and invested in building them closer to communities to improve geographic access, with more than 500 built between 1995 and 2012. Midway through the study period, research conducted in 2006 found that geographic accessibility to health care services remained low in Cambodia; only 33% of the population were within 5km from a health center.41 In 2014, 35% (ranging from 5% in Phnom Penh to 74% in Banteay Meanchey) of women who sought care either for themselves or their children at health facilities reported that distance from their homes to the facilities of care was one of the serious barriers undermining access to health care services.7

Local Health Center Management Committees (HCMCs) oversaw the management of health centers (one committee per health center) and were introduced in 2004 with the view to mobilize communities to participate and engage in healthcare activities and strengthen the linkage between communities and health centers. Members of the HCMCs included a chairperson who was the vice-chief of the commune council (elected

Exemplars in U5M: Cambodia Case Study 26 representatives of communes who voted on their behalf in senate elections) and a vice-chairperson who was the head of the health center. Other members included one additional member from the commune council (usually the focal person for women and children), one additional health center staff (usually a midwife) who acted as the HCMC Secretary and four to seven leaders of Village Health Support Groups (VHSGs, see Community Health Program section below) from the health center catchment area. The leaders of VHSGs were selected to ensure that each commune/village covered by the health center was represented and also to ensure gender balance (equal participation of women and men). As of 2016, more than 85% of health centers had functioning HCMCs.42

Private Sector and Traditional Practices The formal private sector developed significantly in the late 1990s reflecting increased financial assets of the public and expanded health insurance. By 2015, there were 8,488 registered private health care facilities in Cambodia. The formal private sector accounted for the majority of the curative care-seeking in Cambodia overall, while health prevention activities and MNCH care were mainly within the domain of the public sector. In 2014, overall, only 23% of all (adult and children) sick or injured patients sought care from public sector providers compared to 64% in the private sector and 13% through self-care or traditional practices.43 There was also an important network of private, non-profit sector providers often funded and run by international non- governmental organizations (NGOs), that provide free or subsidized reproductive health care. This included a large hospital, Kantha Bopha, that provided free delivery services in Siem Reap, and 16 clinics in the Reproductive Health Association of Cambodia, which provided ante- and postnatal services to nearly half a million patients annually and were subsidized by United States Agency for International Development (USAID).44

In 2015 there were approximately 5,500 licensed providers in the private sector, compared to about 20,000 providers in the public sector. As many as two-thirds of public sector providers also worked in private practice.39 While there are not official numbers of coverage from the private sector workforce, in 2013 the World Bank estimated that in rural areas, 50% of health services were delivered by traditional or informal (non-licensed) providers, 29% from qualified private providers, and 20% from public providers.39

Cambodia was an early adopter of engagement in regulation of the private sector. Between 1996 and the early 2000s, Cambodia introduced laws and regulations to oversee the private sector, such as the 2000 Law on the Management of Private Medical, Paramedical and Medical Aid Services which mandated the registration of all private medical and paramedical facilities. However, adherence to these regulations has been limited by sub- optimal monitoring. The MOH planned to focus on addressing these challenges in a 2015 revision of regulations governing the private health sector.45

Health Service and Supplies A Service Availability and Readiness Assessment (SARA) conducted in 2008 assessed availability and supply of child and maternal health services in both public and private sector health facilities in Cambodia. It found varying readiness for providing MNCH services; 68% of all health facilities delivered child immunization, 47% provided family planning, 61% offered delivery services, and 62% malaria services. However, essential medicines such as paracetamol and amoxicillin were only available in 34% of health facilities, representing significant gaps in the

Exemplars in U5M: Cambodia Case Study 27 46 0.9 0.9 0.9 1 supply chain. Health system readiness 1 0.8 data from before or after 2008 and

0.5 disaggregated by types of health facilities 0.2 0.2 0.2 0.2 0.1 (public/private) and location (rural/urban) 0 were not available for the team to review. 2000 2008 2010 2012 2014

Physicians (per 1,000 population) Nurses and midwives (per 1,000 population)

Figure 10. Health workforce (physicians, nurses and midwives) in Cambodia (Source: World Bank)

Human Resources for Health During the study period, Cambodia prioritized expanding its health work force and particularly developing programs to encourage providers to locate outside of urban areas. These programs have been somewhat successful but like many countries, continuing to grow the workforce and ensuring equitable distribution has been an ongoing priority.

Cambodia like many LMICs has experienced shortages in health staff. As part of the reforms in the mid-1990s, the country prioritized and invested in improving the capacity of its human resources for health (HRH) including the introduction of Health Workforce Development Plans. The plans aimed at regulating and ensuring the quality and adequacy of Cambodia’s HRH, improving the technical skills of the country’s HRH through more and better training, and ensuring the availability and proper deployment of an adequate number of qualified health professionals at all levels of the health system, amongst other aims. WHO also began supporting the country to develop its health workforce through effective planning, training, and setting health workforce regulations.47 Further, the MOH developed a complementary recruitment and transfer policy to curb the flow of staff from rural to urban areas.39 These efforts were reflected in the equity of distribution of HRH. For example, by 2010, approximately 78% of registered/graduate/professional nurses, 60% of general physicians and 88% of midwives were working at subnational levels (provincial level and below). Research in 2016 also noted that implementation of these policies and plans contributed to increased numbers of trained health staff especially in rural areas, improved governance functions, and quality and responsiveness of health workers.39

A 2006 comprehensive midwifery review found that increasing the number of midwives was a key priority for lowering Cambodia’s high maternal mortality ratio (MMR). The MOH made placing midwives in all health centers the cornerstone of its MMR-reduction strategy, and made changes to help streamline direct-entry midwife training programs beginning in 2008. By 2009, all health centers had at least one primary midwife with one year of training and more than 50% had a secondary midwife with three years of training. By 2011 the country met the minimum global benchmark for midwives – six per 1,000 births that year – and by 2013 three-quarters of health centers had at least one secondary midwife.17

Exemplars in U5M: Cambodia Case Study 28 In 2012, of the 19,457 civil servants employed by the MOH, 46% were nurses, 24% were midwives, and 14% doctors.39 However, the number of physicians and nurses/midwives per population remained well below the WHO target of 2.28 doctors, nurses, and midwives per 1,000 population with an estimated 0.1 physicians per 1,000 population, and one nurse and midwife per 1,000 population, in 2011 (Figure 10).48 This persistent low coverage ratio of HRH in Cambodia resulted from both the country’s expanding population and only small increases in the absolute numbers of health workers have increased over time, for example from 18,133 in 2010 to 18,596 in 2011.49 The national goal is to expand the public health workforce to 32,000 by 2020, with continued efforts to ensure distribution across rural/urban areas.39

Community Health Program Cambodia has been working to establish community health worker (CHW) programs since 2001. While some of the infrastructure was put in place by the end of the study period and CHWs had been showed to improve use of health services, the program has faced challenges and is an area for future strengthening.

The National Centre for Parasitology, Entomology, and Malaria control introduced village malaria workers (VMW) – a cadre of CHWs – in 2001. However, it was not until 2003, as part of Cambodia’s ongoing commitment to primary health care and in response to lack of access to health care services for people who were living in remote areas that the country introduced a Community Participation for Health policy to improve community access to general health care services by introducing polyvalent CHWs.50 (See Community-Based Integrated Management of Childhood Illness [CB-IMCI] and Cross-Cutting Contextual Factors sections.) The CHWs were volunteers from their respective communities and selected by the head of the health center, with involvement and confirmation of the communities. Following their selection, they became members of the newly set up Village Health Support Group (VHSG) initiative which comprised volunteer community members selected from within communities by the operational districts and health centers. The VHSG was focused on facilitating the work of the CHWs, for example in cases of referrals to health centers.

The CHWs were generally responsible for linking communities to health centers through health education on childhood illnesses and other community health topics, diagnosing and treating illnesses such as simple malaria and diarrhea, and referring severe cases to health centers. They reported their activities to the supervising health centers. Based on identified community needs, each CHW was responsible for 10 to 50 households and received training and supervision from the health centers they were affiliated with. Provincial health districts provided financial support for the community health program in Cambodia while operational districts ensured overall program management and structure.50 In addition, local and international NGOs such as Save the Children, which supported capacity building and supervision, provided technical and financial support to the new CHW system in Cambodia.38,50

A 2010 study found that the work of the CHWs improved use of health services although the program faced financial challenges because the government relied on donor support to sustain the CHW activities, with implications for sustainability. In addition, the CHWs continued to face challenges including poor supervision, lack

Exemplars in U5M: Cambodia Case Study 29 of defined training program, and lack of adequate resources.50,51 This is an important are for growth potential in the future.

Health Management Information System, Surveillance Data Systems, and National Survey Data Overall, prior to and during the study period, Cambodia invested in data collection ranging from routine reporting to surveillance, surveys, and electronic patient record system. While full coverage has been a challenge, there have been successes, for example in terms of data quality and surveillance.

Health Management Information System By 1994, the MOH set up a number of health information systems and databases to ensure the availability of high quality health and health-related information for policy, decision-making, planning and budgeting, performance monitoring, evaluation, and research.52 The rollout faced some challenges, with a 2007 study to assess availability of HMIS in Cambodia finding that the system was available at only 41% of all facilities.53 However data quality by the end of the study was very good. According to research conducted in 2011, the data from the health management information system (HMIS) for many key indicators were valid and reliable, reported to be within about 5% of the results from household surveys. Routine data quality assessments were also done in 2011, 2012, and 2013, also found good concordance between source documents and monthly HMIS reported values.

In 2012, Cambodia introduced an e-HIS (the Patient Management and Registration System “PMRS”) – a national web-based application developed by the MOH and used by public health facilities in Cambodia for the management of individual patient data. Research in 2015 found that the full package of the system was not yet being used with health facility staff still recording patients’ data and summarizing monthly aggregate reports on paper.52

Surveillance Data Systems In 2013, the country introduced the Cambodia Early Warning and Response System, a national surveillance system for 10 diseases such as diarrhea and acute respiratory infection, based on weekly reports from health centers, referral hospitals, and two pediatric hospitals. In addition, Cambodia established other surveillance information systems specific to malaria, tuberculosis, and HIV/AIDS and sexually transmitted infections (STIs) to ensure routine monitoring of priority diseases across the country.52 (See EBI section for EBI-specific surveillance data systems.)

National Surveys Cambodia began conducting demographic and health surveys (DHS) in 1998 and with follow on surveys in 2000, 2005, 2010, and 2014. Other surveys such as AIDS and malaria indicator surveys were also conducted.

Exemplars in U5M: Cambodia Case Study 30 Health Funding The main source of financing for health care was household out-of-pocket (OOP) spending (from 64.1% in 2000 to 58.9% in 2010 and 63% in 2015) followed by the government and donors.

Government Funding for Health The growth in the national health budget was consistent with the country’s improving economic circumstances. All-cause government health spending in Cambodia increased from $93 million in 2000 to $176 million in 2010 and $259 million in 2015,54 with government spending on health as a percent of GDP around 1.2-1.5% from 2000- 2015.55 The government’s per capita expenditure on health in Cambodia also increased from an estimated $7.8 in 2008 to $12.7 in 2014 and the public health expenditure, as a proportion of total health expenditure, increased from 20% in 2000 to 23% in 2010.24,39 However the health budget as a proportion of total budget only increased from 6.8% in 2008 to 7.6% in 2014.24,39

Donor Funding for Health Donors increasingly financed the health system from 12% in 2000 to 20.6% in 2008, though this decreased to 14.1% in 2015.54 The proportion of all-cause development assistance for health, as a percentage of overall health expenditure remained quite low until 2005,56 and substantially increased from $6.4 million in 2008 to $28.9 million in 2014 although the actual percent decreased.57 Since 2008, donor funding for health in Cambodia has mainly been funneled through the Sector-Wide Approach (SWAp), a broader health sector fund, as opposed to funding for vertical programs (see Cross-Cutting Contextual Factors section).58

Out-of-Pocket Expenditure for Health Out-of-pocket spending in Cambodia remained extremely high and peaked at 84% of total health expenditure in the late 1990s with the expansion of private health care delivery, introduction of user fees at government facilities, and widespread informal charging at government health care facilities. However, by 2014, OOP spending had reduced somewhat to 62% in part because of the expansion of the Health Equity Fund (see Health Insurance section).39

Health Insurance and Other Health Service Coverage Other health financing mechanisms that promoted access to effective and affordable health care prioritizing the poor and vulnerable also existed in Cambodia. The mechanisms included direct tax-funded health services plus user fees for the non-poor and exemptions for the poor, including monks, disabled war veterans, the elderly, and eligible poor people.

In 1996, Cambodia introduced a health sector reform plan which included user fees at public health facilities, with the aim of generating additional revenues for health facilities. User fees generated a small amount of additional revenue, though this represented a large part of health centers’ discretionary income. However, the fees also represented a barrier to access for the poor.23 In 2000, the Health Equity Fund (HEF) was introduced which paid

Exemplars in U5M: Cambodia Case Study 31 public health providers on behalf of poor people. The HEF paid for prenatal care, delivery, comprehensive postpartum care, and other MNCH services. HEF-funded patients were provided care, with costs for their care, transport to the facility, and reimbursement to the facility by an inspection authority in Phnom Penh, which repaid the facilities. These funds reflected up to 60% of facility revenue with a portion used for health care worker bonuses. As a result, depending on the number of patients and facility type, health workers’ incomes most times rose as a result of HEF. The HEF scheme led to a reduction in OOP health expenditure among the poor (Cambodia Socio-Economic Survey 2004–2009), increased utilization of government services, and reduced debt and asset sales for health care.39 By 2013, about 16% of the population or 2.2 million people below the poverty line had coverage from HEFs. HEF coverage was expanded beyond referral hospitals to about 45% of health centers, with national coverage anticipated for 2015. The HEF was mainly financed by the Cambodian government with donor support, with plans to have the scheme fully government funded by 2021.

There were a number of community-based health insurance (CBHI) programs largely operated by NGOs and focusing on non-poor rural populations and urban workers. The first CBHI scheme was piloted in 1998 in a single health center and expanded around 2005. By 2012, 19 CBHI programs covered over 150,000 people, operating in 231 health centers nationally.39 In 2015, a national policy framework for social security, including social health protection and health insurance was developed, with a long-term vision of establishing a broad, national social security system.59

Other Payment Schemes Vouchers for pregnant women have been provided by a few organizations to provide free maternity care to any woman attending a government health center; the vouchers would reimburse the facility if it provided a package of service including four antenatal care visits, facility delivery, and one post-natal visit.44

In 2007, the government began an incentive scheme called the live-birth incentive, to provide cash bonuses to health centers and hospitals for every live birth, as a measure to increase facility-based delivery (see Skilled Birth Attendant and Facility-Based Delivery section).44

Gender Equity Cambodia saw improved gender equity between 2000-2015. For example, the literacy rate for adult females in Cambodia increased from 67% in 2000 to 76% in 2014, higher than the South Asia average of 61.2% in 2015, but lower than adult male literacy rate of 84% in 2014.7,8 According to the 2014 Cambodia Demographic and Health Survey (CDHS), nearly three-quarters of married women who were employed were able to make independent decisions about how to spend their earnings. Also among married women, 92% reported participation in decisions pertaining to their own health care, either as the main (46%) or joint decision-maker (45%); representing an increase from 2000 in proportion who reported being the main decision-maker (37%).7,8 Despite these achievements, gender equity remained a challenge in Cambodia. The World Economic Forum’s 2012 Global Gender Gap Report, which assessed women’s parity with men in economic opportunity, educational attainment, and political empowerment, ranked the country 103 out of 135 in gender equity, and Cambodia was the lowest- ranked country in its region.62 (See Cross-Cutting Contextual Factors section.)

Exemplars in U5M: Cambodia Case Study 32

Causes of Death Among Children Under-5 All of the rates of the leading CODs declined substantially, reflecting the reduction in amenable mortality during the study period. Lower respiratory infections (LRIs), neonatal disorders, diarrhea, and measles were the top four causes of death among under-5s in Cambodia in 2000 (Table 3). IHME modeling found that in 2015, while neonatal disorders, LRIs, and diarrhea were still the leading CODs among children under 5, meningitis became the fourth leading cause replacing measles which dropped significantly as a COD, reflecting Cambodia’s strong measles vaccination program (see Other Vaccine Preventable Diseases section). Other leading CODs, although lower proportion between 2000 and 2015, included tuberculosis, tetanus, HIV/AIDS, whooping cough, malaria, and nutritional deficiencies.

Table 3. Causes of Death in Cambodia, Ordered by Rate of Deaths per 100,000 Of Under-5 Population (2000-2015) (Source: IHME Modeling)

Rate of deaths per 100,000 population (% of deaths) Relative change (%) Cause of Death (U5) 2000 2005 2015 2000-2015 Neonatal disorders3 409 (22%) 361 (26%) 246 (34%) -40% Lower respiratory infections (LRIs) 674 (36%) 458 (33%) 196 (27%) -71% Diarrhea 129 (7%) 84 (6%) 19 (3%) -85% Meningitis 44 (2%) 29 (2%) 11 (2%) -74% Malaria 26 (1%) 22 (2%) 10 (1%) -61% Tuberculosis 43 (2%) 26 (2%) 9 (1%) -79% HIV/AIDS 35 (2%) 28 (2%) 8 (1%) -78% Whooping cough 32 (2%) 18 (1%) 8 (1%) -74% Nutritional deficiencies 22 (1%) 15 (1%) 4 (1%) -80% Tetanus 37 (2%) 11 (1%) 3 (0%) -93% Measles 73 (4%) 2 (0%) 1 (0%) -99%

In the neonatal period, the main COD in Cambodia between 2000-2015 remained prematurity with only a limited drop in rate followed by LRIs which dropped by one-third and birth asphyxia or trauma which increased in frequency. Sepsis also increased, while others such as tetanus, diarrhea, and hemolytic disease had large decreases, although remaining among leading CODs among neonates (Table 4).

Table 4. Causes of Death in Cambodia, Ordered by Rate of Deaths Per 100,000 of all Neonatal Population (2000-2015) (Source: IHME)

Rate of deaths per 100,000 population (% of deaths) Relative change (%) Neonatal Causes of Death 2000 2005 2015 2000-2015 Preterm birth 32,662 (36.9%) 32,537 (39.2%) 31,531 (39.6%) -3.5% Lower respiratory infections 21,607 (24.4%) 18,910 (22.8%) 14,746 (18.5%) -31.8%

3 Neonatal disorders include preterm birth complications, neonatal encephalopathy due to birth asphyxia and trauma, neonatal sepsis and other neonatal infections, Hemolytic disease and other neonatal jaundice, and other neonatal disorders.

Exemplars in U5M: Cambodia Case Study 33 Encephalopathy due to birth 16,927 (19.1%) 17,859 (21.5% 19,017 (23.9%) 12.3% asphyxia and trauma Neonatal sepsis and other 4,507 (5.1%) 5,246 (6.3%) 6,926 (8.7%) 53.7% neonatal infections Tetanus 4,343 (4.9%) 1,428 (1.7%) 516 (0.7%) -88.1% Diarrheal diseases 2,993 (3.4%) 1,168 (1.4%) 638 (0.8%) -78.7% Hemolytic disease and other 756 (0.8%) 658 (0.8%) 501 (0.6%) -33.7% neonatal jaundice Other 4,814 (5.4%) 5,196 (6.3%) 5,726 (7.2%) 18.9%

Exemplars in U5M: Cambodia Case Study 34 3 Methods for Case Study

The methodology for this research was designed to generate new and actionable insights through applying implementation science methods to selected Exemplar countries. This was done by identifying and evaluating the steps countries employed in deciding on the policies and EBIs to reduce U5M, their implementation strategies and execution, as well as understanding the contextual factors which either obstructed or facilitated the implementation of these EBIs within these countries, between 2000 and 2015.

The case study was informed by a Theory of Change (TOC) for the pathways to reducing amenable (Figure 11). The research was guided by an implementation science framework designed to understand the steps towards implementation and implementation outcomes and the contribution of contextual factors and actors involved at multiple levels: Figure 11. Theory of Change of Reduction of Amenable Under-5 Mortality global, national, ministry, subnational, facility, and community. Our framework combined elements of existing frameworks: Aarons et al’s Exploration, Preparation, Implementation, and Sustainment (EPIS), Damroscher’s et al Consolidated Framework for Implementation Research (CFIR); and Proctor et al’s Implementation outcomes – including Feasibility, Fidelity, Acceptability, Reach, and Effectiveness. We also added a new step – Adaptation – making it EPIAS (see Appendix for more detail). The TOC was developed to articulate the three pathways to reducing amenable U5M, including factors which impacted health status and family resilience (such as female empowerment, stunting) and risk of disease outside of the targeted health system prevention EBIs, as well as other contextual factors which would influence implementation. This TOC guided work to understand how these factors were addressed directly or through strategies focused on implementing the EBIs.

An initial review of available information and published data on the rates and progress of U5M in Cambodia included policies, strategies, EBIs available to potential Exemplar countries, the uptake and implementation of these EBIs in Cambodia, and key global and national contextual factors. The literature review was done through MEDLINE (PubMed) and Google, using search terms such as “child mortality” or “under-5 mortality” and “Cambodia.” Further searches included specific EBIs, causes of death, or contextual factors as search terms (e.g. “insecticide-treated nets,” “malaria,” or “community health workers”). Different from other Exemplar country cases, the team was not able to carry out primary research or conduct key informant interviews with an in- country partner reflecting both resources and political changes during the time when the research was completed.

The desk review was an iterative process, with ongoing additions throughout the initial research and case study development processes as additional sources (published articles, reports, case studies, policy and other country

Exemplars in U5M: Cambodia Case Study 35 documents or data) were identified. The desk review focused on the list of health systems-delivered EBIs targeting amenable causes of death (see Appendix for the full list). However, work was also done to explore important broad interventions that may have contributed to U5M reduction. These included education, poverty reduction, water and sanitation, and programs designed to improve nutritional status; and were reflected in the contextual factors section and in the synthesis to explore their contribution to the U5M and neonatal mortality reductions. Following this, the UGHE team supplemented the review to expand the capture of published literature and other relevant documents relevant to the work. The documents and data were analyzed to understand the implementation strategies, policies, and contextual factors most relevant to the success in reducing amenable U5M in Cambodia. Implementation strategies and broader approaches were synthesized to create transferable knowledge that could be implemented in other countries. Additional analyses from the International Center for Equity in Health (Federal University of Pelotas), and cause of death analyses and geospatial mapping from the Institute for Health Metrics and Evaluation (University of Washington) were used to understand changes in equity for mortality and EBI coverage, and change in causes of death.

Human Subjects Review The ethics review committees of University of Global Health Equity exempted this study.

Exemplars in U5M: Cambodia Case Study 36 4 Specific Causes of Death and Evidence-Based Interventions

Based on a global review of EBIs and the results from IHME, we focused on EBIs addressing specific and major causes of death for children under 5 in Cambodia. See Appendix A for a complete list of U5M causes of death and EBIs considered in this case study.

The table below shows coverage of EBIs targeting common U5M causes of death and prevalence of selected conditions between 2000-2014 from the DHS and other nationally representative surveys. Large increases in some of the EBIs were seen with a number achieving coverage greater than 80% (in bold) and included delivery attended by skilled provider, proportion of households with at least one insecticide-treated net (ITN), newborn’s 1st postnatal care (PNC) in first two days after birth, facility-based delivery, tetanus protection at birth, HIV-testing during ANC or labor, children with symptoms of acute respiratory infection (ARI) treated with antibiotics, and haemophilus influenzae type B (Hib) vaccine (as part of pentavalent). Other EBIs also achieved high coverage although not as high as 80% including measles vaccination (which achieved elimination status in 2015), four or more antenatal care visits (ANC4+), vitamin A supplementation, and full vaccination coverage, all of which improved substantially during the case study period (Table 5).

Table 5. Coverage of Selected EBIs in Cambodia (Based on Available Nationally Representative Data) (1993/4-2014) (Cambodia DHS 2000, 2005, 2010, & 2014; Sau et al., 2016)

U5 Causes of Intervention 2000 2005 2010 2014 Death Acute Children with symptoms of ARI taken to a health facility 37% 54% 67% 69% respiratory Children with Symptoms of ARI who received antibiotics 40% 83% infections Vaccination: Hib (as part of pentavalent) 84% 82% (ARI) U5 with symptoms of ARI – 2 weeks preceding survey 20% 9% 6% 6% Oral Rehydration Therapy (Either ORS or RHF) 23% 37% 35% 34% Diarrheal Treatment of diarrhea with zinc supplements 3% 6% diseases Children with diarrhea taken to health facility 24% 48% 62% 55% U5 with diarrhea – 2 weeks preceding survey 19% 20% 15% 13% Advice or treatment for fever sought from a health facility or 36% 55% 63% 61% provider Malaria Treatment of children with fever by Artemisinin-based 0.2% 0.2% 0.3% Combination Therapy (ACT)* U5 with fever – 2 weeks preceding survey 35% 35% 28% 28% Proportion of households with at least one ITN 36% 43% 75% 90% Other Proportion of children under 5 years old who slept under an ITN 26% 28% 56% 63% malaria the previous night causes** Proportion of pregnant women who slept under an ITN the 13% 59% 62% previous night Measles Measles vaccination coverage 55% 77% 82% 79% Exclusive breastfeeding from 0-5 months 11% 60% 74% 65% U5 receiving vitamin A supplements in the six months preceding 28% 34% 71% 70% Malnutrition survey U5 stunted 50% 43% 40% 32% U5 wasted 17% 8% 11% 10%

Exemplars in U5M: Cambodia Case Study 37 U5 underweight 39% 28% 28% 24% Other Full vaccination coverage with 3 doses DPT, 3 doses , 40% 67% 79% 73% vaccine measles, and BCG preventable diseases HIV counseling during ANC 15.7% 46.6% 57.1% HIV HIV-testing during ANC or labor 85% Total fertility rate (15-49) 4% 3% 3% 3% Teenagers who are pregnant with their first child 3% 3% 3% 5% Tetanus protection at birth 69% 85% 87% Neonatal Antenatal care: 4+ visits 9% 28% 62% 76% causes of Delivery attended by skilled provider 33% 47% 76% 92% death Facility-based delivery 10% 24% 62% 87% Delivery by Cesarean Section 1% 2% 4% 7% Newborn’s 1st PNC in first two days after birth 42% 64% 70% 90% Doctor/nurse provided 1st PNC 1% 41% 65% 98% *Data not available for children with diagnosed malaria ** Uses CMS data for 2004, 2007, 2010, and 2013

Health Equity and Coverage of EBIs

Figure 12. Composite Coverage Index in Cambodia by Figure 13. Cambodia Equity Profile – Coverage of Wealth and Year (Source: Victora et al, Countdown2030) Selected Under-5 Mortality Interventions (Source: Countdown 2030 Equity Profile) The Composite Coverage Index used by Countdown 20304 also showed an overall increase in coverage of many of the key reproductive, maternal, newborn, and child health indicators with major narrowing of the wealth-based equity gap between 2000 and 2014, a relative decline of 78%, as noted in the Economic Status and Development and U5M in Cambodia sections (Figure 12).63 This narrowing was also seen, though to a lesser extent, in rural- urban disparities which dropped 17%. Although the composite coverage index (CCI) showed narrowing of wealth- based gaps overall, Figure 13 shows that it was not universal. There was a narrowing of the equity gap in demand for family planning satisfied and ANC by skilled provider, while other selected interventions showed persistent wide equity gaps such as skilled birth attendant (SBA).

4 The CCI is widely used by the Countdown to 2030 initiative to track progress in coverage for reproductive, maternal, newborn and child health, and represents a proxy for Universal Health Coverage in this area and includes skilled birth attendant, early initiation of breastfeeding, family planning need satisfied etc. (Wehrmeister, Restrepo-Mendez et al. 2016)

Exemplars in U5M: Cambodia Case Study 38 Table 6. Rural/Urban and Regional Differences in Key Coverage Indicators (Source: DHS 2000 & 2014) Urban/Rur Best Lowest Province Indicator Period Urban Rural al Equity performing performing Equity Gap Gap province province Children with 2000 32 20 12 45 4 41 diarrhea taken to 2014 47 57 10 85 30 50 health facility (%) Absolute change 15 37 Measles 2000 61 55 6 74 27 47 vaccination 2014 91 77 14 94 56 38 coverage (%) Absolute change 30 22 2000 54 48 6 74 12 62 DPT3 2014 93 82 11 98 56 42 Absolute change 39 34 2000 46 39 7 62 12 50 Full vaccination 2014 86 71 15 91 44 47 coverage (%)* Absolute change 40 32 Delivery 2000 57 28 29 89 12 77 attended by 2014 98 88 10 98 52 46 skilled provider (%) Absolute change 41 60 2000 34 6 28 71 2 69 Facility-based 2014 96 81 15 97 46 51 delivery (%) Absolute change 62 75 Newborn’s first 2000 No data No data No data No data No data No data PNC within 2 2014 84 78 6 99 6 93 days of birth (%) Absolute change * 3 doses DPT, 3 doses polio, measles, and BCG

There were differences in changes between different EBIs in where improvement was seen in urban and rural areas (Table 6). Absolute improvement was greater in urban areas in measles and full vaccination coverage, while greater improvements were seen in rural areas in children with diarrhea taken to health facility, delivery attended by skilled provider and FBD. Depending on the EBI this difference was sometimes a reflection of contextual factors and other times a reflection of successful implementation strategies targeting both urban and rural settings, but with more room for improvement often in rural areas (see Cross-Cutting Contextual Factors). For some the rural/urban gaps grew between 2000 and 2014 including measles vaccination coverage, DPT3, and full vaccination coverage. Exceptions include delivery attended by a skilled provider (gap shrank from 29 to 10, with both urban and rural coverage exceeding 85% by 2014) and facility-based delivery (gap decreased from 28 to 15, and urban and rural coverage both exceeded 80%).

The gap in highest to lowest preforming province in 2000 was often vast – for example, 77 percentage points for delivery attended by a skilled provider, and 69 percentage points for FBD. The equity gaps largely decreased, although there were still major gaps in EBI coverage in 2014 (often close to 50 percentage points) in some areas.

Exemplars in U5M: Cambodia Case Study 39 This difference was often due to low coverage of a single province or region. For example, Kratie, Preah Vihear/Stung Treng, and Mondul Kiri/Ratanak Kiri, all in the northeast corner of the country – an area with highly dispersed and remote populations – had the lowest coverage for both delivery by a skilled provider and FBD. Mondul Kiri/Ratanak Kiri also had the lowest measles vaccination, DPT3, and full vaccination coverage.

4.1 Malaria, Diarrhea, and Pneumonia According to estimates by IHME, LRIs (including pneumonia), diarrhea, and measles accounted for approximately 44% of all U5 deaths in 2000 with LRIs causing the greatest burden (36% of all deaths), followed by diarrhea (7%), and a smaller fraction from malaria (1%). There were a number of EBIs which targeted malaria, diarrhea, and pneumonia in under-5 (U5) children in Cambodia and these are considered together in this case study.

Across the three conditions, care-seeking increased from 24% (diarrhea) and around 36% (ARI and malaria) to around 60% by 2014. The proportion of children with diarrhea and ARI taken to a health facility and those with fever taken to a health facility or other provider began improving between 2000-2005 after facility-based integrated management of childhood illness (FB-IMCI) was introduced in 2001, suggesting both elements of success in implementation and acceptability of the intervention. Treatment of ARI with antibiotics also improved from 40% in 2010 to 83% in 2014 (these was not measured in 2000). Oral Rehydration Therapy (ORT) and zinc coverage however did not improve much, consistent with the challenges in implementation of those EBIs discussed in the Other Diarrhea Interventions section. Treatment of fever cases with Artemisinin-based Combination Therapy (ACT) remained low (below 0.5%) potentially due to the low burden of malaria, use of Rapid Diagnostic Testing (RDT) (introduced in 2001 to reduce use of treatment of confirmed cases), and the effectiveness of malaria EBI prevention strategies such as ITNs – the proportion of U5s who slept under an ITN increase from 28% in 2007 to 63% in 2013. Data on ACT treatment of confirmed malaria cases (rapid diagnostic testing was introduced in 2001) were not available.

For vaccines, Hib vaccine (as part of pentavalent) coverage reached 84% in 2010, the year it was introduced, and remained high at 82% in 2014. The proportion of U5s with symptoms of ARI decreased from 20% to 6% suggesting effectiveness of the vaccine as well as other interventions not related to health system EBIs (for example, indoor and outdoor pollution death rates for U5M decreased substantially over the study period64) given that Pneumococcal Conjugate Vaccine (PCV) was not introduced until 2015.

4.1.1 Facility-Based Integrated Management of Childhood Illness

Table 7. Key Facility-Based IMCI Implementation Strategies

Implementation Strategies • Development of policies and guidelines • Leveraging, adapting, and integration into existing systems o Adaptation of existing training and guidelines to reflect local context • Leveraging partner support • Leveraging donor support

Exemplars in U5M: Cambodia Case Study 40 • Data use for decision-making • Pilot testing • Data use for adaptation • National leadership and accountability • Focus on equity • Phased scale-up • HR strengthening o Training and re-training (Training of Trainers, TOT)

EXPLORATION By 1995, WHO and United Nations Children's Fund (UNICEF) developed the Integrated Management of Childhood Illness (IMCI) strategy to guide the prevention and treatment of the most common childhood illnesses including diarrhea, pneumonia, and malaria.65 IMCI focuses on improving health providers’ abilities to diagnose and treat the common illnesses in high child mortality countries (including ARI, diarrhea, and malaria) and improving family and community health behaviors through integrating health education.66 Cambodia was an early adopter, beginning FB-ICMI in 1996 based on recommendations from WHO and UNICEF and a recognition of the need to improve the quality of care for sick children offered at first-level health facilities.67

PREPARATION Preparations for introducing FB-IMCI were led by the MOH with support from partners such as WHO, UNICEF, Roll Back Malaria Initiative, and international NGOs like PATH. A FB-IMCI policy was developed in 1998 reflecting Cambodia’s early focus on sustainability, and protocols and guidelines were also developed leveraging generic WHO and UNICEF templates but adapted to the country’s context.17,68

The preparation phase also involved research to determine the effectiveness and cost-efficiency of the newly developed FB-IMCI protocols before roll-out. For example, research was conducted locally by Cambodian researchers in 2000 to test the sensitivity and specificity of the FB-IMCI fever chart (which included a set of screening criteria and use of a low-cost – US$2 – malaria rapid diagnostic test/dipstick) in identifying malaria cases. The study was implemented in selected low-risk areas (Siem Reap province) and high-risk areas (Odtar Meanchey province) to ensure the results were representative of the entire country’s context. Selection of study sites was also based on accessibility to the area, security, and NGO presence for feasibility. Fever cases (determined by axillary temperature or history) and anemia cases (determined by palmar pallor) were tested with RDTs and if found to be positive for malaria, treated with anti-malarial medicine. Plasmodium falciparum and Plasmodium vivax RDTs were used because they accounted for 92% and 7% of blood smear positive malaria cases, respectively, in Cambodia.68

The study found that the draft IMCI fever chart identified children with malaria effectively, at 93% sensitivity level and 95% specificity. Findings confirmed the usefulness of malaria RDTs and overall validity of the IMCI fever chart as a part of IMCI case management. The study also found that the selective IMCI strategy of assessing (with RDTs) and treating only children with confirmed malaria was less expensive ($491.17) than a non-selective approach

Exemplars in U5M: Cambodia Case Study 41 ($556.79).68 Results of the study informed the finalization of a national FB-IMCI fever chart for identifying children with malaria.

Responsibility for implementing FB-IMCI was assigned to the Department of Communicable Disease Control at the MOH during preparation.69 Further, Cambodia decided that its FB-IMCI would focus on six target conditions. These included ARI, diarrhea, and measles, reflecting the high burden of these diseases but also malaria and malnutrition based on WHO and UNICEF recommendations.66,68,70 (See COD data in 2000 in Table 3.) In addition, Cambodia’s FB-IMCI focused on dengue hemorrhagic fever given the high prevalence in the country.71

IMPLEMENTATION In 2001, early implementation of FB-IMCI started with small-scale testing in two operational districts.67 The small- scale testing phase was part of a multi-country evaluation (also implemented in two other Exemplar countries, Peru and Bangladesh). NGOs such as World Vision, Reproductive Health Association of Cambodia (RHAC), and Reproductive and Child Health Alliance (RACHA) provided technical support for the initial FB-IMCI implementation. For example, RACHA supported the MOH to train health workers using a TOT approach.

According to a 2010 health facility survey, the proportion of children checked for the presence of cough, diarrhea, and fever was high and increased slightly from 79% in 2006 to 84% in 2010 although other components of IMCI implementation had lower fidelity – only approximately 43% of all facilities had supervisory visits with observation. The proportion of facility-based health workers trained in IMCI continued to increase from 63% in 2006 to 83% in 2010. Other research conducted in the same year found that 89% of health centers had all essential medicines for IMCI while 83% of sick children under 5 in IMCI areas needing an antibiotic and/or an antimalarial were prescribed the drug correctly.71

ADAPTATION DURING IMPLEMENTATION In 2006, Cambodia updated its IMCI guidelines for treatment of diarrhea to include zinc, based on WHO recommendations. In the same year, reflecting a recognition of the increasing contribution of neonatal mortality to overall U5M (26% by 2005), the MOH with support from WHO updated Cambodia’s national IMCI guidelines to expand the program’s scope to include neonatal interventions such as clean cord care and management of neonatal infections in recognition of the importance of neonatal conditions contributing to U5M.66 As a result of this adaptation, refresher trainings were conducted for health facility workers in 2007.72

Global Alliance for Vaccines and Immunization (GAVI) began supporting Cambodia’s FB-IMCI program in 2007 through incentives paid to health facilities (called IMCI++ facilities or IMCI facilities receiving incentives) for each IMCI case reporting form completed. The IMCI++ system was found to be effective. Although similar proportions of facilities (83% of regular IMCI5 and 89% of IMCI++) were found to have checked children (aged 2 months to 5 years) for the presence of cough, diarrhea, and fever when examining them, supportive supervision visits occurred on average once a month in IMCI++ facilities compared to regular IMCI facilities where they occurred

5 Defined as a facility with at least 2 health workers trained in the IMCI strategy but not receiving the GAVI incentive.

Exemplars in U5M: Cambodia Case Study 42 less frequently. Similarly, 62% of IMCI++ facilities had supervisory visits that included observation of case management practices with immediate feedback and problem solving compared to only 30% of regular IMCI facilities.

In 2008, Cambodia adopted the IMCI Computerized Adaptation and Training Tool (ICATT) to reduce cost of training away from the workplace and to facilitate ongoing update of knowledge and skills.73 A study conducted in 2009 found that all medical, nursing, or other health worker training schools had begun providing preservice IMCI training in Cambodia, reflecting Cambodia’s focus on sustainability.71

FB-IMCI coverage in Cambodian first-level health facilities increased from 41% in 2006 to 82% in 2010, though this may be a high estimate given the 2008 SARA found substantial gaps in supplies.46,67,72 According to a 2013 evaluation of Cambodia’s health system it was implemented in 1,242 health facilities and in all health centers by 2012.74

Care-seeking behavior had some increases for diarrhea, ARI, and fever. The percentage of children with diarrhea taken to a health facility was 24% in 2000 (before the introduction of FB-IMCI), rising to 55% in 2014. For ARI, the percentage of children taken to a health facility rose from 37% in 2000 to 69% in 2014 while for fever, care- seeking from both facility and other providers improved from 36% (2000) to 61% (2014). These improvements suggested high acceptability. For diarrhea this may not be entirely due to FB-IMCI given the introduction of CB- IMCI.

Table 8. FB-IMCI Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcomes (+) Addressed leading causes of death (at start and adapted to reflect growing burdens).

(+): Introduction of FB-IMCI reflected high burden of targeted diseases such as diarrhea, pneumonia, and measles. Cambodia’s Data use for decision-making FB-IMCI also focused on hemorrhagic fever given its high burden in the country. Appropriateness Adaptation of global guidelines for local context (+): Study during preparation found the IMCI fever chart identified children with malaria effectively and provided the basis for finalizing and adopting the chart.

(+): FB-IMCI introduced to improve coverage and quality of EBIs are identified as a gap. (+): Significant improvements in care-seeking rates suggested Acceptability Pilot testing high acceptability. (Introduction of CB-IMCI may also have contributed to fever care-seeking.) Leveraging partner support – (+): FB-IMCI able to be implemented in health centers. WHO, PATH, World Vision, Feasibility UNICEF, Roll Back Malaria (+): The proportion of health workers trained in IMCI increased Initiative, RACHA, RHAC from 63% in 2006 to 83% in 2010.

Exemplars in U5M: Cambodia Case Study 43 Leveraging existing protocols and guidelines Data use for decision-making Phased scale up Leveraging donor support – GAVI Data use for decision-making including selection of study sites to ensure results of malaria chart (+): FB-IMCI coverage in Cambodian health facilities increased Effectiveness were representative of entire from 41% in 2006 to 82% in 2010 and 100% in 2012 and coverage country context (reach) (+): Deaths attributable to LRIs, measles, malaria, diarrhea, and Data use for adaptation – zinc use nutritional deficiencies dropped (potential contribution) (Table for diarrhea treatment and 3). neonatal focus (+/-): Supportive supervision visits occurred monthly on average in IMCI++ facilities compared to less frequent visits at regular IMCI facilities.

(+/-): 62% of IMCI++ facilities had supervisory visits that Training and re-training (TOT) included observation of case management practices with immediate feedback and problem solving compared to 30% of Guideline development regular IMCI facilities.

Fidelity Data use for adaptation – (+): The proportion of children checked for the presence of

introduction of ICATT cough, diarrhea, and fever during examination was high and increased slightly from 79% in 2006 to 84% in 2010. National leadership and accountability (+): Research in 2009 found 89% of health centers had all essential medicines for IMCI while 83% of sick children aged U5 in IMCI areas needing an antibiotic and/or an antimalarial were prescribed the drug correctly, though these may be high estimates given the 2008 SARA assessment found gaps in essential medicines. Data use for decision-making – to (+): Study found that testing to treat only children with determine cost-efficiency confirmed malaria was less expensive ($491.17) than a non- Cost selective approach ($556.79). Results of the study informed roll- Data use for adaptation – out. introduction of ICATT (+): FB-IMCI had reached national coverage by 2012

Sustainability Integration into systems (+): FB-IMCI added into pre-service training for doctors, nurses, and other health workers Focus on equity – selection of (+): Figures 14, 15, and 16 show the narrowing of gaps in care- high-risk areas to ensure results of seeking rates for pneumonia, diarrhea, and fever among the Equity IMCI fever chart test were different wealth quintiles in Cambodia mainly as a result of representative of the whole improvements in care-seeking for the poorest quintile. country’s context

Exemplars in U5M: Cambodia Case Study 44 SUSTAINMENT Efforts which may contribute to sustainment include integration of ICATT into pre-service training and national policy from the start. Focusing on malaria treatment, a study in late 2015 found that availability and distribution of first-line ACT were high and malaria diagnostic testing was widely available among the more than 26,000 outlets that were screened, particularly in the public sector, helping to support the country’s halving of its malaria burden during the study period. However, the study found key gaps in the availability of malaria commodities for case.

Figure 15. Coverage and Equity Outcome: Care-Seeking Figure 14. Coverage and Equity Outcome: Care-Seeking for Pneumonia across the Different Wealth Quintiles in for Diarrhea across the Different Wealth Quintiles in Cambodia (2000-2014) (Source: Victora, et al 2018) Cambodia (2000-2014) (Source: Victora, et al 2018)

Figure 16. Coverage and Equity Outcome: Care-Seeking for Fever across the Different Wealth Quintiles in Cambodia (2000-2014) (Source: Victora, et al 2018)

Exemplars in U5M: Cambodia Case Study 45 4.1.2 Community-Based Integrated Management of Childhood Illness

Table 9. Community-Based IMCI Key Implementation Strategies

Implementation Strategies • Community engagement • Policy development • Leveraging existing CHWs • HR strengthening/Training • Leveraging partner support • Leveraging donor support • Phased scale-up • Data use for decision-making • Pilot testing

EXPLORATION AND PREPARATION As noted in the Community Health Program section, the National Centre for Parasitology, Entomology, and Malaria control (CNM) introduced VMWs in 2001.75 Two VMWs (one female and one male) were chosen by the community members, from each village, beginning with 36 villages in Ratanak Kiri province and eventually scaling up to 1,528 villages in 17 provinces by 2012. The VMWs provided malaria prevention, diagnosis, and treatment services using RDTs and ACT.75 However, by 2005, the Cambodian government realized that while care-seeking from formal providers was improving, community-based care-seeking continued to be largely from unlicensed practitioners and drug sellers. The government began discussions with community leaders to develop a solution and these discussions revealed a lack of knowledge about when and why to seek care for sick children, limited availability of child-focused health care services (especially among geographically remote and poorer populations), and limited availability and high cost of transportation (remote areas were less likely to have regular transportation available). These findings, in addition to recognition of the need for an integrated approach to community-based management of childhood illnesses, provided the basis for the decision to adopt CB-IMCI with the view to improving access to care and overall care-seeking practices at the community level.71 Cambodia decided to expand the roles of the VMWs to include diarrhea treatment and ARI management.

IMPLEMENTATION Implementation of CB-IMCI in Cambodia began with small-scale testing in 400 villages in 2009. VMWs were trained with technical and financial support from WHO and the Global Fund. Cambodia also leveraged local NGOs such as RACHA to provide technical support for training. VMWs were required to assess and treat ARI, malaria, and diarrhea cases as well as refer severe cases to nearby health centers. They also provided counseling and health promotion services such as breastfeeding and sanitation education.

In 2012, research comparing villages that had implemented CB-IMCI and those which had not found that, overall, the first care provider in villages implementing CB-IMCI was the VMWs compared to villages where CB-IMCI was not yet rolled out. For example, for ARI, 51% of caregivers who sought care for their children did so first from a

Exemplars in U5M: Cambodia Case Study 46 VMW compared to only 20% in non-CB-IMCI areas where 75% of care was sought from other care providers, including at health facilities. Similarly, for diarrhea, 43% of caregivers sought care first from a VMW compared to only 9% in non-CB-IMCI areas, where 84% sought care from other non-formal community-based providers. For fever, 48% sought care first from VMWs in CB-IMCI areas compared to only 23% (from VMWs) and 68% (facility) in non-areas. These results suggested high acceptability.75

The polyvalent VMW project scaled up gradually, expanding from 315 villages in seven provinces in 2004 to eventually reach 1,528 villages in 17 (of 24) provinces in 2012. The addition of child health services in 2009 took place with technical and financial support from WHO and the Global Fund.75 In 2011, 15,898 children received child health services, including prescription and provision of basic medications including antibiotics, cotrimoxazole, antipyretics, paracetamol, oral rehydration salts, and zinc, as well as reference of severe cases and provision of basic preventive education.75

ADAPTATION DURING IMPLEMENTATION In 2011, the MOH signed a national policy on control of ARI and diarrheal diseases at community level. National treatment guidelines for malaria were updated in 2010.76

Table 10. CB-IMCI Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcomes (+): Introduction of CB-IMCI reflected need to expand and integrate care for malaria, ARI, and diarrhea at community level and improve care-seeking overall based on uptake of FB-ICMI and residual care- seeking from informal community providers.

Data use for decision- Appropriateness (+): Research conducted in 2006 found geographic accessibility to making health care facility services remained low in Cambodia; only 33% of the population were within 5km from a health center.

(+): Cambodia’s CB-IMCI was designed to include the main CODs for U5s (ARI and diarrhea) in 2005 as well as malaria. Data use for decision- (+): Research conducted in 2012 found that overall, the first care making Acceptability provider in villages implementing CB-IMCI was the VMWs compared

to villages where CB-IMCI was not yet rolled out. Pilot testing Leveraging existing systems

Feasibility Leveraging partner support (+/-) Implemented in most but not all provinces by 2012.

Leveraging donor support (+) The polyvalent VMW project scaled up gradually, expanding from Pilot testing Effectiveness and 315 villages in 7 provinces in 2004 to 1,528 villages in 17 provinces in

coverage (reach) 2012. Leveraging existing systems

Exemplars in U5M: Cambodia Case Study 47 (+): In 2011, 15,898 children received child health services from VMWs.

See also changes in COD (+) above and ACT resistance (-) below. A study published in 2012 found the total cost of community case Cost management per child treated in Cambodia was US$1.34.77 (+): In 2011, the MOH signed a national policy on control of ARI and Sustainability Policy development diarrheal diseases at the community level. (+): Figures 14, 15, and 16 show the narrowing of gaps in care- seeking rates for pneumonia, diarrhea, and fever among the different wealth quintiles in Cambodia mainly as a result of improvements in care-seeking for the poorest quintile (32% in poorest and 52% in highest in 2000 with narrowing of the gap in 2014 (68% and 67%, respectively). Similar narrowing of wealth- Equity Focus on equity related disparities was seen for care-seeking for fever. (29% for the poorest and 46% for the richest to 62% and 59% in 2014) and diarrhea, (21% of the poorest quintile versus 34% of the wealthiest in 2000 improving to higher rates among the poorest (62%) compared to the wealthiest (only 44%). This could be from IMCI or from iCCM/CB-IMCI.

SUSTAINMENT This is important as most Cambodians seek malaria treatment from private sector providers.78 Strategies to further increase access and coverage, which have taken place after the study period, include doubling the number of villages with VMWs, mapping all existing providers (public and private) and registering new providers, and targeting unlicensed providers for training and licensing in malaria diagnosis, treatment, referral, and reporting.78

4.1.3 Other Diarrhea Interventions 4.1.3.1 Oral Rehydration Therapy and Zinc Supplementation for Diarrhea Table 11. ORT Key Implementation Strategies

Implementation Strategies • Leveraging partner support and expertise • Leveraging donor support • Integration into existing systems • Policy development • Data use for decision-making • Evidence-based decision-making • Monitoring and evaluation (M&E) • Stakeholder engagement See also FB-IMCI/CB-IMCI

Exemplars in U5M: Cambodia Case Study 48 EXPLORATION Although diarrhea was a major cause of child mortality in Cambodia in the 1980s and 1990s, outdated policies on diarrhea treatment limited access to ORT. Research from 2014 suggested that Cambodia’s reluctance to update its diarrhea treatment policies despite the high burden of disease resulted from the country’s prioritization of other health issues. As a result, much of diarrhea treatment efforts in Cambodia (including ORT use) during this time period, were funded and implemented by international organizations, although these were not sufficient and uptake remained very low with the percentage of U5s who received ORS packets or pre-packaged ORS fluids remaining below 20% (data on all ORT use were unavailable for the team to review).79,80 By 2000, according to DHS data, ORT (including oral rehydration salt – ORS) use for diarrhea treatment in U5s was at just 23%.34 This reflects a fidelity gap as care-seeking grew (see above).

In 2004, WHO and UNICEF recommended diarrhea treatment with low-osmolarity ORS and zinc to reduce mortality of diarrhea episodes.79,81 Following the recommendation, a Child Survival Partnership Workshop was hosted by the MOH National Center of Maternal and Child Health the same year. The importance of behavioral changes to improve practices of caregivers around the treatment of diarrhea was highlighted, including the need for an emphasis on ORS and zinc use.72

PREPARATION Following the workshop, by 2006, Population Services International (PSI), an international NGO, conducted a study on ORS and zinc uptake in Siem Reap and Pursat districts, selected because of their higher U5M rate and lower rates of ORT use (12.2% in Siem Reap and 9.3% in Pursat). This study was implemented in coordination with the MOH, with technical support from WHO and funding support from USAID, with the view to determine the acceptability of ORT (including ORS) and zinc for diarrhea treatment.81 The study identified high levels of acceptability and satisfaction with ORS by health care providers and caregivers; episodes of acute and persistent diarrhea decreased by 29% with the treatment regimen, and death from diarrhea severity or treatment failure declined by 40%.72,81 However, despite these positive results, Cambodia did not change its diarrhea treatment policy and guidelines to include ORS and zinc, which meant that they remained largely unavailable to children with diarrhea.79 The desk review was not able to determine why the treatment guidelines were not changed.

In 2008, recognizing the need for better advocacy for the introduction of ORS and zinc, PATH, another international NGO, developed an evidence base for Cambodia policymakers with the help of a detailed gap analysis of the existing policy landscape and latest research on diarrhea.79 Together with key partners including World Vision, Save the Children, WHO, UNICEF, and local organizations such as RACHA and RHAC, PATH brought this evidence to the MOH. The advocacy efforts led to the development of an action plan to address the gaps in Cambodia’s diarrhea treatment guidelines and update relevant policies. During this process, specific recommendations were advocated, which included reclassification of ORS and zinc from prescription medicines to over-the-counter diarrhea treatments to improve availability and distribution of ORS and zinc at the community level through CHWs (as part of CB-IMCI which began implementation in 2009).

Exemplars in U5M: Cambodia Case Study 49 IMPLEMENTATION In 2007, the use of ORS and zinc was integrated into Cambodia’s FB-IMCI guidelines for diarrhea case management and were included in CB-IMCI guidelines during preparation.66 In December 2011, the Cambodian MOH launched its new national diarrhea disease policy, which supported the use of low-osmolarity ORS and zinc as essential medicines for treating diarrheal diseases.79

Despite integration into IMCI, the proportion of children with diarrhea who were treated with ORT (including ORS) during diarrhea episodes remained largely the same, and low, at 37% in 2005 and 34% in 2014 despite high levels of availability at health facilities and care-seeking, with approximately 95% of all health facilities having ORS according to the 2010 Health Facility Survey as well as the availability through CHWs. This low reach despite high levels of availability suggested low acceptability by either caregivers and/or health workers or low availability at the community level. For zinc, the proportion of children treated was only 3% in 2010 and 6% in 2014. The very low proportion of diarrhea cases treated with zinc also suggested low acceptability or low availability at community level, but also reflected the low availability at health facility level given that the Health Facility Survey (2010) found that zinc was only available in approximately 49% of health facilities.67

Despite these challenges of reach of this EBI, the rate of U5 deaths attributable to diarrhea per 100,000 of U5 population in Cambodia dropped tremendously from 84/100,000 in 2005 to 19/100,000 in 2015, and the percentage of deaths attributable to diarrhea dropped 50%. However, ORT’s contribution to this drop is likely limited given the persistent low coverage, although other non-EBI interventions for prevention and factors were associated with improving resilience (reducing exposure and overall improved health – see Cross-Cutting Contextual Factors).

Table 12. ORT Implementation Strategies and Outcomes

Implementation Outcomes (ORT Strategy Evidence and zinc) Data use for decision-making

(+): Program introduced based on evidence of disease burden and Appropriateness Leveraging partner support policy gaps.

Stakeholder engagement (Undetermined): Low reach of both ORS and zinc despite comparatively high coverage (availability in facilities) suggested low Acceptability Community engagement acceptability but also may have also been due to low availability at community level. Leveraging donor support (-): Program implemented but reached low coverage of specific EBI. Leveraging partner support and Feasibility expertise (+): Very high levels of availability at health facilities – approximately 95% of all health facilities had ORS in 2010. Evidence and data use for decision-making

Exemplars in U5M: Cambodia Case Study 50 (-): By 2000 ORT use remained low at 23%; the proportion of children with diarrhea treated with ORT during diarrhea episodes remained largely the same at 37% in 2005 and 34% in 2014 while the proportion of children treated with zinc was only 3% in 2010 Effectiveness Integration into existing and 6% in 2014. and Coverage systems (?): Rate of U5 deaths attributable to diarrhea per 100,000 of U5 population in Cambodia dropped tremendously from 84/100,000 in 2005 before ORT was introduced to 19/100,000 in 2015 and the % of deaths attributable to diarrhea dropped 50%. (see text) (+/-): A study conducted in 2010 found that zinc was available in 45% of health facilities as a first line treatment for watery diarrhea. Fidelity M&E (Health Facility Survey)

(-) Low fidelity. Sustainability Policy development (-): Persistent low coverage. (-): Overall coverage remained very low, with a slight improvement in ORS and zinc use among the poorest quintile (Figure 17). In 2000, 1% of both the poorest and wealthiest quintile used ORS and zinc, Equity increasing only to 5% and 2% respectively, by 2014. These findings align with overall care-seeking for diarrhea (from both facility and provider) as noted in the FB-IMCI and CB-IMCI sections that showed that the poorest quintile sought care more than the wealthiest.

Figure 17. Coverage and Equity Outcome: ORS and Zinc across Wealth Quintiles in Cambodia (2010-2014) (Source: Victora, et al 2018) 4.1.3.2 Rotavirus Vaccination Table 13. Rotavirus Vaccination Key Implementation Strategies

Implementation Strategies

• Data use for decision-making • In-country research • Advocacy • Stakeholder engagement

Exemplars in U5M: Cambodia Case Study 51 EXPLORATION Globally rotaviruses were responsible for more than one-third of deaths in children with diarrhea and the most common cause of severe gastroenteritis among children under 5 in the early 2000s.82 In 2009, WHO recommended universal rotavirus vaccination; following this recommendation Gavi began offering funding for the vaccine.83 A prospective hospital-based surveillance study was conducted between March 2005 and February 2007 at a national hospital in Phnom Penh to estimate the burden of rotavirus hospitalizations among children under 5 and to understand strain patterns.82 The study found that 56% of children with diarrhea tested positive for rotavirus antigen, suggesting that there was a need for improving prevention and control of rotavirus in Cambodia.82

An active surveillance study for rotavirus gastroenteritis, carried out from January 2010 to December 2016, was published in 2018. The study reported that 50% of admitted children under 5 were suffering from severe rotavirus gastroenteritis.84 In a rotavirus advocacy workshop of 2017, after the study period, organized by Rotavirus Organization of Technical Allies (ROTA) council, a chief of the Gastroenterology Department in Cambodia’s National Pediatric Hospital presented 2013 data on rotavirus gastroenteritis as a significant cause of morbidity and mortality among children under 5. In the workshop it was also reported that there were tentative plans to introduce rotavirus vaccine in Cambodia in 2020.85

Preparation, implementation, adaptation, and sustainment of the rotavirus vaccine were beyond the scope of this study. Details on the delay from the initial study and conclusions to implementation of the vaccine were not found.

4.1.4 Other Pneumonia Interventions 4.1.4.1 Pneumococcal Vaccination Table 14. Pneumococcal Conjugate Vaccine Key Implementation Strategies

Implementation Strategies • Data use for decision-making • In-country research • Leveraging donor support • Leveraging partner support • Cold chain strengthening • National leadership and accountability • Community engagement including mass media • Leveraging and strengthening existing systems • Ensuring government financing through budgeting and integration into budget • Human Resource (HR) Strengthening: Supervision and Training • Surveillance • Focus on equity

Exemplars in U5M: Cambodia Case Study 52 EXPLORATION In 2000, GAVI began supporting the introduction of PCV into the immunization programs of developing countries (including Cambodia); WHO recommended its introduction in 2007. As a result, between 2007-2012, surveillance studies to determine the burden of invasive pneumococcal disease among U5 children and inform the introduction of PCV were carried out at the Angkor Hospital for Children in Siem Reap, Cambodia. These studies found that the burden of disease was high, with invasive Streptococcal pneumoniae responsible for around 10% of blood infections in hospitalized children with a case fatality rate of 16%. At the same hospital, the prevalence of pneumonia was found to be approximately 52% among children attending the outpatients’ department.86,87 This evidence provided the basis for the introduction of PCV in Cambodia.

By 2013, based on Cambodia’s recognition of the significant burden of pneumonia as a major cause of U5 mortality, with LRIs accounting for most (33%) amenable U5 deaths in 2005, the country decided to introduce PCV. In the same year, Cambodia submitted a proposal to GAVI to facilitate the introduction of the vaccine. The cause of the delay in implementation was not identified.

A study was carried out at the Angkor Hospital to determine the most appropriate PCV vaccine type for Cambodia’s serotype prevalence. The study found that 63% of cases were due to PCV13 serotypes. Other studies conducted during the same time period also found that PCV13 serotypes accounted for most pneumonia infections among U5s. As a result of these studies and the lower cost of PCV13 (given the lower wastage factor of PCV13 – 1.05 compared to PCV10 – 1.11), Cambodia decided to introduce PCV13.87,88

Cambodia also decided to select PCV13 because of its higher serotype coverage and the fact that PCV13 presented in a single dose vial compared to the two dose PCV10 vial with cold chain management and cost implications given the lower wastage factor of PCV13 with annual PCV vaccine cost in 2015 to achieve 95% coverage (excluding freight and buffer) estimated at $3,808,500 for PCV10 and $3,602,635 for PCV13.

PREPARATION Under the leadership of the Director of Maternal and Child Health (MCH) (MOH) and NIP, in coordination with partners such as WHO and UNICEF, preparations began with development of an introduction plan including assessing the requirements for financing of PCV introduction and cold chain strengthening requirements.

A cold chain impact assessment of PCV introduction was carried out. It found that at national level, the four positive walk-in cold rooms (2oC to 8oC) would sufficiently accommodate the proposed additional volume doses of PCV13. At the provincial level, the assessment determined that one additional refrigerator was required for each of the 24 provinces, as well as an increase in frequency of supply from three months to monthly in the six most populated provinces while for Phnom Penh, the frequency was increased to bi-weekly or weekly shipments given higher requirements. At the district level, nine out of 77 operational district stores also needed one additional refrigerator for PCV introduction.

Exemplars in U5M: Cambodia Case Study 53 Preparations also included development of training materials and adaptations of HMIS and vaccination cards to reflect PCV introduction. Social mobilization and advocacy activities were also carried out through mass media: television, radio, and pamphlets. These materials emphasized the importance of full immunization and access to health services in general and aimed to ensure acceptability. Advocacy focused on pediatricians through sensitization seminars conducted by pneumococcal experts.

Preparations concluded with the incorporation of Cambodia’s share of the co-funding cost of PCV13 into the government’s 2015 budget.

IMPLEMENTATION As planned, in 2015, the Government of Cambodia introduced PCV13, with $0.20 per dose covered by the government and co-financing support from GAVI. TOTs were conducted for health workers with a focus on administration of the vaccine and monitoring adverse events following immunization.

Routine supervisory visits were required to make detailed reports on how PCV13 was being administered at service delivery points. These supervisions were focused particularly on high-risk communities – those with higher rates of invasive pneumococcal disease, in keeping with the country’s Reaching Every Community strategy, (discussed in the Other Vaccine Preventable Diseases section). A sentinel surveillance site was also established with training and equipment support from WHO, at the National Pediatric Hospital, Phnom Penh for Hib/pneumococcal testing, to monitor impact. This surveillance site leveraged on existing meningo- encephalitis/ surveillance system for children under 5. If found to be negative, the specimens from children under 5 presenting with meningo-encephalitis were sent to the National Institutes of Health (NIH) Korea for additional testing for Hib and Pneumococcus. This is part of the existing regional laboratory network.

According to WHO and UNICEF data, coverage of PCV13 in Cambodia in 2015 was 68%, likely due to the timing of data collection in relation to vaccine introduction that year as shown by the increase to 87% in 2016, only one year after introduction.89

ADAPTATION DURING IMPLEMENTATION Beyond the desk review.

Table 15. PCV Implementation Strategies and Outcomes Implementation Implementation Strategy Evidence Outcomes (+): High disease burden and case fatality rate informed Data use for decision-making PCV introduction Appropriateness

Local research (+): PCV13 (as opposed to PCV10) was introduced based

on evidence on serotype prevalence

Exemplars in U5M: Cambodia Case Study 54 Acceptability Community engagement (+): High coverage suggested high acceptability Leveraging partner support including through inter-agency coordinating committee (+): PCV13 introduced instead of PCV10 because of

PCV13’s lower wastage factor Feasibility Data use for decision-making

(+): PCV13 introduction in 2015 Leveraging donor support

Cold chain strengthening (+): In 2015, coverage was 68% likely due to the timing of data collection in relation to vaccine introduction as shown by the increase to 87% in 2016.

(+): Death rate among children under the age of 5 due to LRIs decreased from 458/100,000 in 2005 to 196 per 100,000 of the U5 population in 2015. Also, death rate among children under the age of 5 due to meningitis decreased from 29/100,000 in 2005 to 11/100,000 in 2015. While PCV may have contributed to these Effectiveness and Data systems strengthening reductions in death rate, any impact was minimal given its coverage introduction at the end of the case study period.

(+): Research published in 2019 found PCV13 to be effective. The study compared 2014 with 2016–2018 (post-introduction of PCV) and found a 26% decline in Invasive Pneumococcal Disease (IPD) incidence by 2018, with a decrease of 36% in IPD caused by PCV13 serotypes.

Data on ARI incidence after 2015 (when PCV was introduced) was unavailable for the team to review. Surveillance

Leveraging existing systems Fidelity Not found HR Strengthening – Training (TOT), supervision

Monitoring and evaluation Data use for decision-making – Cost introduction of PCV13 based on Not found lower wastage factor Data systems strengthening – The (+): Incorporation of PCV into national budget. HMIS system and vaccination cards Sustainability were updated to include PCV. (+): High coverage achieved rapidly. Leveraging existing supply chain Focus on equity (focusing Data on equity of PCV coverage were unavailable for the Equity supervisions on high-risk team to review although given high coverage, inequity was communities) unlikely.

Exemplars in U5M: Cambodia Case Study 55 SUSTAINMENT Cambodia has continued to invest in monitoring the impact of PCV13. In addition to the sentinel surveillance efforts noted in the implementation section, following the introduction of PCV13, research published in 2019 found PCV13 to be effective. The study compared 2014 with 2016–2018 (post-introduction of PCV) and found that there was a 26% decline in IPD incidence by 2018, with a decrease of 36% in IPD caused by PCV13 serotypes.90

4.1.5 Other Malaria-Prevention Interventions Cambodia’s malaria control efforts began in 1951, with a focus on prevention, using dichlorodiphenyl- trichloroethane (DDT) formula in indoor spraying campaigns which resulted in malaria prevalence reduction from 60% in the starting year to 1% in the early 1960s. However, the conflicts of the 1970s limited activities.91 In 1984, Cambodia established the CNM in charge of providing technical and equipment support to health facilities as well as developing and implementing national malaria control strategy.92 Through the introduction of VMWs, a cadre of CHWs in 2001 (discussed in the Community Health Program section), and with support from donors such as Global Fund, the CNM was able to successfully provide Cambodians with access to malaria diagnosis and treatment, and ITNs.93

Table 16. Other Malaria Interventions Key Implementation Strategies

Implementation Strategies • Community-based care delivery • Stakeholder engagement • HR strengthening – training • Data use for decision-making o Small-scale testing o Focus on equity

4.1.5.1. Insecticide-Treated Nets IMPLEMENTATION BEFORE 2000 Cambodia introduced ITNs in the 1980s under the leadership of the CNM, following recommendations from a workshop of regional stakeholders. Nets were impregnated with deltamethrin or permethrin solution by individuals.94 By 1990, Cambodia moved to pre-treated ITNs. The move to pre-treated nets provided benefits of reduced skin exposure and inhalation of the insecticide.

IMPLEMENTATION AFTER 2000 In 2004, with funding from Global Fund, Cambodia replaced the ITNs with improved long-lasting insecticide- treated nets (LLIN) which did not require frequent impregnation during use and were distributed to community members for free in collaboration with the neighboring countries.94 Preparations for introducing LLINs in 2004

Exemplars in U5M: Cambodia Case Study 56 included small-scale testing of the VMW program to deliver the nets in areas with high risk of malaria transmission.91

The Cambodia Malaria Survey conducted in 2013 found a great improvement in the coverage of mosquito nets with 99.7% of households with any type of a mosquito net and 77.8% of households with at least one LLIN as opposed to 80% and 25%, respectively, in 2007. Nevertheless, the survey found that, in high malaria risk areas, only 53% of the households had enough mosquito nets (one mosquito net per two people) with 49.9% of the household members sleeping under LLINs the previous night.95 This indicates good distribution but an ongoing need for more behavior change and improved adoption. By contrast, the proportion of U5 children who used LLINs rose from 26% in 2004 to 63% in 2014.

Table 17. Other Malaria Interventions Implementation Strategies and Outcomes

Implementation Strategy Evidence Outcomes Stakeholder engagement Feasibility (+): ITNs introduced and reached relatively high coverage Small-scale testing (+): The Cambodia Malaria Survey conducted in 2013 found a great improvement in the coverage of mosquito nets with 99.7% of households with any type of a mosquito net and 77.8% of Community-based care households with at least one LLIN as opposed to 80% and 25%, Effectiveness and delivery respectively, by 2007. The proportion of U5 children who used LLINs Coverage improved from 26% in 2004 to 63% in 2014. Change to LLIN (-) In high malaria risk areas, only 53% of the households had enough mosquito nets, with 49.9% of all household members sleeping under LLINs the previous night. Focus on equity – targeting Equity Not found. high-risk areas

4.1.5.2 Intermittent Preventive Treatment for High Risk Groups Cambodia recommended malaria screening and treatment in the treatment guidelines, this decision was not included in most of the national policies.96 No further records found for ITN use in Cambodia.97,98

4.1.5.3 Indoor Residual Spraying As noted above, indoor residual spraying (IRS) started in 1950s and a six-year related campaign led to tremendous malaria prevalence reduction from 60% to 1% in 1960s. However, malaria cases resurged soon after malaria prevention activities stopped due to political conflict.91 In 2015, IRS activities including training of operating district/health center staff, spraying campaigns, and monitoring coverage and quality of IRS activities were included in the Cambodia Malaria Elimination Action Framework 2016-2020.99

Implementation of IRS as part of the elimination action plan was beyond the scope of this case study.

Exemplars in U5M: Cambodia Case Study 57 4.1.5.4 Ongoing Challenges for Malaria Control and Treatment Challenges of malaria treatment in Cambodia include growing antimalarial resistance and gaps in availability of ACT, especially in the private sector (see also IMCI).

Antimalarial drug resistance has been a growing concern in Cambodia and neighboring countries since the beginning of the study period. Partial resistance to ACT was first reported in Cambodia in 2008, but resistance has likely been growing since before 2001.100 A high ACT failure rate (>10%) has been measured for four ACTs. Regional efforts to contain the growth of resistance began after initial reports, coordinated by the WHO. In 2015 the WHO announced its Strategy for Malaria Elimination in the Greater Mekong Subregion (GMS), and in 2018 (after the study period) senior MOH representatives from Cambodia and other GMS countries (China, Lao PDR, Myanmar, Thailand, and Vietnam) signed on to a Ministerial Call for Action to Eliminate Malaria in the GMS before 2030.100

4.2 Other Vaccine-Preventable Diseases

Table 18. Other Vaccine-Preventable Diseases Key Implementation Strategies

Implementation Strategies • Leveraging, strengthening, and integration into existing systems o Data systems strengthening • National leadership and accountability • Data use for decision-making o Data use to understand disease burden o Monitoring and evaluation o Surveillance o Needs assessment • Policy and plan development and adaptation • Focus on equity • Community engagement • Phased scale-up • Stakeholder engagement • Leveraging partner support • Leveraging donor support • Community engagement through mass media • HR strengthening: Training and use of Information, Education, and Communication (IEC) materials

Cambodia launched its EPI in 1986 in Phnom Penh and extended its activities to all provinces by 1988.101 Despite reaching national scale, national coverage for fully immunized children aged 12 months remained between 30%- 35% until 1994 because of ongoing conflict and a practically non-existent health system structure, as discussed in the introduction.

Between 1986–1999, the EPI program was managed by the central level as a vertical program with management teams at provincial, district, and community levels. This centralized approach facilitated implementation of the EPI

Exemplars in U5M: Cambodia Case Study 58 program because the existing health infrastructure in Cambodia especially in rural areas was inadequate to manage the program. In 2000, at the beginning of the case study period, Cambodia’s immunization program provided six vaccinations for children: polio, DPT, BCG, and measles vaccines. Given challenges with the health system and centralization of management, the proportion of children who had received all basic immunization doses was only 40% in that year.

In 2001, the MOH combined EPI and polio eradication activities into one platform, the National Immunization Program (NIP), to facilitate more efficient and effective management, reflecting Cambodia’s focus on sustainability.101,102 Following this merger, the NIP was under the management of the Maternal and Child Health (NMCH) Center at the MOH, which was responsible for improving maternal and child health and reducing maternal and child mortality. The proportion of children who had received all basic immunization doses increased to 67% in 2005 after this integration.

Reflecting Cambodia’s culture of data use for decision-making, the NIP conducted a review in 2010 and found that there were specific populations at higher risk of being unimmunized including immigrants, rural residents, mobile populations, the urban poor, and ethnic minorities. As a result of this assessment, the NIP introduced the Reaching Every Community Strategy in 2011 to improve coverage and reduce inequity. For example, for measles vaccination, the aim was to improve the microplanning process and communication strategies to reflect a prioritization of these key populations, to increase coverage up to 95%. Following the introduction of this strategy, the proportion of children who had received all basic immunization doses remained relatively steady between 2010 (79%) and 2014 (73%). However, at the provincial level, coverage was quite variable. For example, in 2014, Mondul Kiri/Ratanak Kiri (44%), Preah Vihear/Stung Treng (57%), and Kampong Cham (57%) all had coverage below 60%, while Banteay Meanchey (91%) had coverage above 90%.

During the case study period, Cambodia introduced four new vaccines to its NIP, including hepatitis B vaccine (introduced in 2002 as part of DPT-HepB) and Hib (introduced in 2010 as part of pentavalent, discussed below), and rubella vaccine (discussed below). PCV was also introduced (see Other Pneumonia Interventions).

4.2.1 Haemophilus Influenzae Type B Vaccination

EXPLORATION Through much of the late 1980s and 1990s, 50% of all high-income countries had introduced Hib vaccine into their immunization programs. However, the high cost of the vaccine despite understanding of Hib disease burden limited expansion into some LMICs. For Cambodia, although Hib disease was a public health concern, decision- makers did not prioritize the introduction of the vaccine given the ongoing challenges of the country’s immunization program and overall health system.

In 2008, led by the WHO country office which recognized the role that Hib vaccine could play in reducing child mortality,103 a symposium on pneumonia prevention was held.103 The symposium was supported by the Hib initiative – a consortium established in 2005 by GAVI and consisting of four academic and public health

Exemplars in U5M: Cambodia Case Study 59 organizations: the London School of Hygiene and Tropical Medicine, Johns Hopkins Bloomberg School of Public Health, WHO, and the US Centers for Disease Control (US CDC), with the aim to accelerate evidence-based introduction of Hib vaccine.103 After the symposium, all stakeholders agreed that Hib vaccine would be beneficial based on disease burden (with the rate of 29 deaths per 100,000 children U5 in 2005, accounting for 2% of U5 deaths). The decision to introduce the vaccine was also anchored on evidence from a study done in Kantha Bopa hospital in Phnom Penh indicating that about half of all bacterial meningitis cases among children under 2 years was due to Hib. The country applied for assistance from GAVI in September 2008 to support the introduction of the vaccine (as part of pentavalent vaccine, replacing DPT-HepB, which was introduced in 2002).103

PREPARATION Preparations for introducing Hib were led by the MOH technical working group on immunization with supervision from the Immunization Coordination Sub-Committee, chaired by the Deputy Director General for Health with members including partners such as WHO, UNICEF, World Bank, and USAID. Preparations included a cold chain capacity analysis at national and sub-national levels. The analysis found that there was sufficient capacity to accommodate the new vaccine introduction. In addition, because Hib (as part of pentavalent vaccine) presented in single dose vials, it was projected to greatly reduce the vaccine wastage rate, which at the time was estimated to be 25-30% for DTP-HepB vaccine which presented in ten-dose vials, to 5%. HMIS reporting forms, immunization registers at the health facility, and immunization cards were revised to reflect introduction of pentavalent vaccine.

At the end of the preparation phase, a detailed vaccine introduction plan was developed and included training, IEC, community engagement, and surveillance components.104

IMPLEMENTATION In 2010, with co-financing support from GAVI, Cambodia rolled out Hib vaccine as part of pentavalent vaccine (DPT-HepB-Hib).105 The co-financing arrangement required that Cambodia pay US$0.20 per dose in 2010 and US$0.30 by 2011. According to the GAVI application, the plan was for the country to fully fund the vaccine from its own domestic resources by 2015, reflecting Cambodia’s focus on sustainability, though as of 2019 (after the study period) Gavi was still co-financing pentavalent.106

Introduction of the new vaccine was supported by mass media campaigns highlighting the importance of the vaccine for preventing Hib and the reduced number of injections required. Community engagement activities targeted at mothers were also conducted. Health workers were trained and IEC materials on pentavalent vaccine were developed and distributed to various facilities to ensure adherence to standards and protocols of administration.

Post-introduction activities included monitoring coverage (using DHS) by the NIP and technical working group. In addition to reporting and monitoring of vaccine coverage data, existing sentinel surveillance systems for meningoencephalitis at five hospitals were leveraged to assess the impact of the vaccine. Data on hospital admissions for meningitis and pneumonia among U5 children as reported through the HMIS was also regularly monitored.

Exemplars in U5M: Cambodia Case Study 60 Hib vaccine coverage achieved high coverage in 2010, the year it was introduced (84%) and maintained this high coverage at 82% in 2014.35

Table 19. Other Vaccine-Preventable Diseases Interventions Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcomes Data use to understand disease burden (+): High burden of disease of bacterial meningitis and Stakeholder engagement Appropriateness meningitis as a cause of death (accounting for 2% of all U5

deaths in 2005) Leveraging partner support – Hib initiative Community engagement (+): High coverage (especially very early on i.e. in 2010) Acceptability suggested high acceptability Stakeholder engagement Leveraging partner support e.g. WHO, UNICEF, World Bank Leveraging donor support Feasibility National leadership and (+): Hib rolled out as planned. accountability Data systems strengthening Leveraging existing systems surveillance systems (+): Hib vaccine coverage achieved high coverage in the year it was introduced (2010) at 86% and maintained this high coverage at 92% in 2015.

(+): According to IHME estimates, deaths per 100,000 of U5 Effectiveness and population attributable to meningitis decreased from See fidelity below. coverage 29/100,000 (in 2005 before Hib was introduced) to 11/100,000 in 2015 although the percentage of deaths accounted for remained the same at 2%. This drop in U5 deaths attributable to meningitis may also have been due to PCV. HiB also may have contributed to the drop in pneumonia-related deaths and incidence. M&E HR strengthening – IEC materials

Fidelity Not found. Surveillance National leadership and accountability (+): Lower wastage rate of pentavalent vaccine compared to Cost Not found. DPT-HepB Government funding (+): High coverage achieved and sustained. Integration into EPI Sustainability Integration of Hib into HMIS, adaptation of vaccination cards, Data systems strengthening and data reporting forms. Leveraging existing systems

Exemplars in U5M: Cambodia Case Study 61 (+/-): Despite high coverage, wealth-based inequity gaps were Equity Not found. seen in 2014 with pentavalent coverage among the poorest quintile at 72% and 96% among the wealthiest.7

SUSTAINMENT Hib vaccine achieved and sustained high coverage reflecting both MOH commitment and integration into existing EPI.

4.2.2 Measles Vaccination

IMPLEMENTATION PRE-2000 Measles vaccine was introduced in 1986 as part of Cambodia’s EPI. Between 1986-1990, one dose of the measles vaccine (MCV1) was administered to children, through facility-based vaccination sessions. By 1990, Cambodia introduced outreach sessions (every four to eight weeks) to improve access to measles vaccine and other health services (e.g. vitamin A supplements) reflecting a focus on equity. As a result, coverage increased from 34% in 1990 to 55% in 2000. Overall, pre-2000 coverage remained well below the level needed to stop transmission.

IMPLEMENTATION AND ADAPTATION POST-2000 Cambodia’s MOH initiated a measles-control initiative in 1999 with the view to reduce the annual incidence of measles to <10,000 cases by 2005. The initiative included activities such as strengthening measles surveillance, improving routine vaccination coverage, implementing supplementary measles immunization activities (SIAs) to vaccinate children missed during routine services, and providing vitamin A during outbreak investigations and SIAs.10

The plan was to vaccinate all children aged 9 months to 5 years in two phases, regardless of their previous history of vaccination (initial and catch-up campaign). Phase I (December 2000 to May 2001) targeted 191,527 children under 5 living in remote border areas. The coverage for measles vaccination during this phase was 89%. Phase II (October 2001 – April 2002) targeted 2,489,761 children aged 9 months to 14 years living in eight provinces in densely populated central areas. The coverage during this phase was 97% and by 2005, national measles vaccination coverage increased to 77% from 2000 figures.

In 2011, following the introduction of the Reaching Every Community Strategy, Cambodia with support from WHO conducted two nationwide measles immunization assessments to identify the status of vaccination among women and children and to find the communities that were at the highest risk of missing vaccines. The campaign helped to identify 1,600 communities where children were not vaccinated and informed the successful measles SIA in 2011 in three provinces and community-level improvements to EPI systems. The improvements were planned to expand into three more provinces in the 2nd quarter in 2013.15 The introduction of the Reaching Every Community Strategy also led to the engagement of CHWs to improve coverage. Health center staff communicated through mobile phones with CHWs, who in turn alerted the communities about upcoming measles immunization

Exemplars in U5M: Cambodia Case Study 62 sessions and encouraged them to attend. The CHWs also helped in bringing mothers and children to the immunization sessions.

In 2013, the Cambodian MOH introduced a measles-rubella vaccine into the national immunization schedule to protect children against measles and rubella.11,12 In preparation for introducing the vaccine, the Country Multi- year Plan was updated in 2012 (an addendum was added) to incorporate the inclusion of measles/rubella vaccine into the routine EPI schedule, reflecting an early focus on sustainability.

In March 2015, the WHO declared that Cambodia eliminated measles after no laboratory-confirmed measles cases of endemic transmission were found in Cambodia after November 2011. The country became one of eight countries in the WHO Western Pacific Region to achieve this goal.13–15

According to IHME estimates, measles accounted for 73/100,000 (4%) of U5 deaths in 2000. However, with the introduction of SIAs, this dropped to <2/100,000 in 2005 and <1/100,000 in 2015.

Table 20. Measles Vaccination Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcomes (+): SIAs introduced to reduce annual incidence to Appropriateness Data use to understand disease burden below 10,000 cases per year (+): High coverage of SIAs suggested high Acceptability Community engagement acceptability (+): Measles program implemented and achieved Feasibility Leveraging existing systems – CHWs measles elimination (+/-): Measles vaccination coverage increased from 34% in 1990 to 55% in 2000. Overall, pre-2000 coverage remained well below the level needed to stop transmission. Leveraging existing systems – CHWs SIAs (+): Phase I SIA reached 89% coverage and phase II reached 97% coverage. Needs assessment Effectiveness and (+): Nationwide measles vaccination coverage coverage Leveraging existing systems – providing increased from 55% in 2000 to 79% in 2014. vitamin A during outbreaks and SIAs (+): Measles accounted for 73/100,000 (4%) of U5 Community engagement deaths in 2000. However, with the introduction of SIAs, this dropped to 2/100,000 in 2005 and 1/100,000 in 2015.

(+): Measles eliminated in Cambodia in 2015 Surveillance Fidelity Not found.

Integration into Sustainability Policy and plan adaptation (+): Measles elimination achieved.

Exemplars in U5M: Cambodia Case Study 63 (-): By 2014, measles vaccination coverage was at 79%, below levels required to stop transmission although measles had been eliminated in Cambodia. This relatively low coverage posed challenges for sustainment of the elimination status. (+/-): Although measles vaccination coverage increased across wealth quintiles between 2000- 2014 (more so for the poorest quintile – Figure 18), Focus on equity – SIAs targeted remote gaps in coverage between the poorest and border and densely populated areas wealthiest quintiles persisted between 2000 and Equity 2014 although narrowed in 2005 (following the initial Needs assessment SIAs in 2000-2002). 44% and 66% coverage were seen among the poorest quintile in 2000 and 2014 respectively, compared to 82% and 95% for the wealthiest quintile in 2000 and 2014, respectively.

SUSTAINMENT By 2014, measles vaccination coverage was at 79%, below levels required to stop transmission mainly due to low (66%) coverage among the poorest quintile, although measles had been eliminated in Cambodia. This disparity in coverage and overall relatively low coverage may pose challenges for sustainment of the elimination status.

Figure 18. Equity and Coverage Outcome: Measles Vaccination in Cambodia across all Wealth Quintiles (2000-2014) (Source: Victora, et al 2018) 4.3 Tuberculosis

Table 21. Tuberculosis Key Implementation Strategies

Implementation Strategies • Engagement of partners in preparation and implementation • Adaptation of existing training and guidelines to reflect local context • Data driven adaptations for cost and feasibility • Expansion and adaptation of existing programs • Stakeholder/community engagement for local support • Pilot testing • Provider training/Human resources strengthening

Exemplars in U5M: Cambodia Case Study 64 EXPLORATION Through the 1990s Cambodia had one of the highest rates of tuberculosis (TB) globally.107 In high-burden countries globally, childhood TB is estimated to make up 10–20% of total TB cases. In Cambodia’s provinces, this proportion ranged from 1.3% to 39.4% of cases.108 In 2000, there were an estimated 43 deaths per 100,000 among children under 5 from TB, making it a leading cause of death among children.109

PREPARATION AND IMPLEMENTATION Evidence from Cambodia’s National TB Program 2002 national TB prevalence survey informed a new approach to TB treatment. Cambodia began to decentralize its hospital-based Directly Observed Therapy – Short Course (DOTS) TB treatment program, as part of its focus on creating decentralized health care services at the community level. Nationwide expansion was achieved in 2005.107 As a pro-poor strategy to reduce financial barriers, free, universal access to DOTS TB treatment began to be provided at the community level (CDOTS), allowing people to be treated effectively at home, with local support, reducing spread of infection. The MOH worked with a number of funders and partners to implement this new approach, including the Global Fund, Japan International Cooperation Agency (JICA), WHO, USAID, World Food Programme (WFP), Centers for Disease Control and Prevention/Girls Achieve Power (CDC/GAP), and Tuberculosis control and prevention/ Tuberculosis care (TBCAP/TBCARE).110

In 2000 only 60 community health centers provided CDOTS. This rose to 1,000 by 2005. During the same time period the number of health workers trained in TB control rose from 800 to 2,500. This supported Cambodia in achieving global TB targets in 2005, including a case detection rate of 70% and treatment success of 85%.111 By 2009 C-DOTS covered more than 70% of Cambodia’s health centers. Community volunteers played an increasingly important role, providing DOTS to patients within their communities in addition to providing community education around TB symptoms and facilitating early case detection.110

In 2008 the first national guidelines focused on childhood TB was developed, and trainings were conducted based on that guidance. Pilot projects were implemented in six Operational Districts, focusing on strengthening the management of childhood TB by building capacity and providing adequate supplies including purified protein derivative (PPD) and X-ray films to facilitate diagnosis of childhood TB; streamlining the referral process; promoting systematic contact tracing; and intensifying supportive supervision. In 2000 only about 1% of TB cases were notified among children. After the guidelines and pilots, this rose to close to 10% by 2009. Also beginning in 2008, a grant from the Global Drug Facility made a pediatric formulation of anti-TB drugs available.110

In 2011, a national survey found that TB prevalence had fallen from more than 1,500 cases per 100,000 in 2002 to 820 cases per 100,000 people, a reduction by nearly half (45%).111 According to the 2012 Global Tuberculosis Report, “there was a significant decline in prevalence rates for all age groups but the biggest reduction was observed in younger age groups.”107 Estimates have shown U5 mortality from TB declining, from 43 per 100,000 in 2000 to 9 per 100,000 in 2015.

Exemplars in U5M: Cambodia Case Study 65 ADAPTATION DURING IMPLEMENTATION In 2013, the National Tuberculosis Programme (NTP) began implementing routine services for childhood TB in 13 provinces. However, diagnosing childhood TB continued to be a challenge in Cambodia (and globally).108 The MOH found that as diagnosis of childhood TB was possible only at the referral hospital, it presented a burden to families as it required time away from work for parents and transportation cost were incurred. Further, systematic contact tracing, including IPT for eligible children, was resource-intensive given its requirement for outreach work, and extensive community education was required around the benefit of a six-month course of treatment for a seemingly healthy child.110

The 2011-2015 TB Strategic Plan included a number of child-focused activities to make diagnosis and treatment of children with TB part of routine NTP activities including C-DOT. It recognized the need to build staff capacity for the specialized expertise required to diagnose and treat childhood TB; to strengthen the referral system for diagnosing suspected pediatric TB cases; to conduct systematic contact tracing and investigation of child TB contacts particularly household contacts who were children under 5; and to foster collaboration between national programs and pediatric hospitals in the public and private sectors to strengthen child TB management, in addition to continuing to promote BCG vaccination as an important part of the national immunization program.110

Table 22. Tuberculosis Implementation Strategies and Outcomes Implementation Implementation Strategy Evidence Outcome (+) Community volunteers were trained to provide DOTS to Stakeholder/community patients within their communities, provide community engagement for local support education around TB symptoms, and facilitate early case detection including among U5s. Acceptability Engagement of partners in preparation and implementation (-) Systematic contact tracing was resource-intensive given its requirement for outreach work, and extensive community Leverage CHW program education was required around the benefit of a six-month course of treatment for seemingly healthy children. Engagement of partners in preparation and implementation (+) “Dr Mao Tan Eang, national TB programme manager in the Adaptation of existing training and Cambodian Ministry of Health, said that the TB programme guidelines to reflect local context owed its success to a clear evidence-based policy and plan, strong technical expertise, government commitment and Feasibility Data driven adaptations for cost and leadership, as well as sustained support from international feasibility donors and partners, including WHO, JICA, the World Bank, United Nations World Food Programme, the United States Pilot testing Agency for International Development, United States Centers for Disease Control and Prevention and the Global Fund.”111 Provider training/Human resources strengthening Pilot testing (+) In 2000 only about 1% of TB cases were notified among Effectiveness children; after the guidelines and pilots, this rose to close to and Coverage Data driven adaptations for cost and 10% by 2009. feasibility

Exemplars in U5M: Cambodia Case Study 66

Expansion and adaptation of existing programs (+) In 2008 the first national guidelines focused on childhood TB was developed, and trainings were conducted based on Pilot testing that guidance. Pilot projects were implemented in six Operational Districts, focusing on strengthening the Fidelity Provider training/Human resources management of childhood TB by building capacity and strengthening providing adequate supplies; streamlining the referral process; promoting systematic contact tracing; and intensifying supportive supervision.

SUSTAINMENT While the burden of TB among children under 5 has been declining, it has continued to be a challenging disease. The vast majority of Cambodian practitioners interviewed in a late 2015 study (92.5%) reported a desire for the NTP to help improve diagnosing childhood TB at their facility through increased training, on how to diagnose childhood TB as well has how to use diagnostic tools. Recommendations included ensuring basic equipment such as stethoscopes and thermometers be available at 100% of facilities, and that efforts be made to improve opportunities for patient transport to facilities with chest X-rays and equipment for bacteriological TB confirmation.108

4.4 HIV

Table 23. HIV Program Key Implementation Strategies

Implementation Strategies • National leadership and accountability • Policy and guideline development and adaptation • Training • Stakeholder engagement • Leveraging partner support and expertise • Leveraging donor support • Infrastructure development • Decentralization • Integration into and strengthening existing systems • Data use for decision-making o Data use for prioritization o Data use to understand disease burden

Exemplars in U5M: Cambodia Case Study 67 4.4.1 Antiretroviral Therapy for Prevention of Mother-to-Child Transmission and Treatment for Infants and Children

EXPLORATION In the 1990s, Cambodia had one of the highest HIV prevalence rates in Asia at 3%. As a result, the country established its National AIDS program in 1993 (later, the National Center for HIV/AIDS, Dermatology and Sexually Transmitted Diseases (STDs) [National Centre for HIV/AIDS Dermatology and STDs, NCHADS]) to coordinate all HIV/AIDS programmatic efforts with a focus on high-risk groups including sex workers and their clients and partners, police officers, mobile populations (e.g. cross-border workers), and men who have sex with men. These programs focused on promoting condom use as well as ensuring treatment and care for these populations. It resulted in declining rates among the targeted groups, for example, among brothel-based sex workers, HIV prevalence dropped from 43% in 1997 to 21% in 2003.112,113

However, because of Cambodia’s focus on high- risk populations and absence of effective regimens, the country did not prioritize Prevention of Mother-To- Child Transmission (PMTCT) or ARVs for pediatrics with children born to HIV-positive mothers remaining at high risk of HIV transmission Figure 19. New HIV Infections among Children (1990-2018) (Source: UNAIDS, 2019) throughout the 1990s.112 Towards the end of the 1990s, Cambodia decided to implement a PMTCT and ARV for pediatrics program because of the spike in new Human Immunodeficiency Virus (HIV) infections among children between 1992-1999 from less than 100 cases in 1992 to over 1,000 in 1999 (Figure 19).

Preparation Preparations for rolling out a PMTCT and ARV for pediatrics program involved the establishment of a technical working group coordinated by NCHADS with donors, civil society, and partners, to develop national guidelines and policy.114 Preparations also included the development of a training curricula for health workers – doctors, nurses, and pharmacists. Systems strengthening was also critical, including building laboratories, transportation of samples, and improving transportation to ensure early infant diagnosis.

Implementation PMTCT With technical and funding support from UNICEF, the US CDC, Japan International Cooperation Agency, and international NGOs like CARE and Family Health International and in-country NGOs such as RACHA, the PMTCT program was rolled out in Cambodia in 2001.

Exemplars in U5M: Cambodia Case Study 68

Implementation of the PMTCT program involved training midwives in counseling and performance of a rapid HIV test and point of care testing was incorporated into routine antenatal and maternity services. The PMTCT program focused on providing maternal ARV or prophylaxis, ensuring delivery at health facility, infant ARV prophylaxis at birth, infant co-trimoxazole prophylaxis at 6 weeks, and providing infant HIV testing.

Pediatric ARV Program Cambodia’s pediatric antiretroviral (ARV) program was implemented in 2001 with funding from Roche and with technical support from the National Centre in HIV Epidemiology and Clinical Research (Australia) and Clinton Foundation.115 The pediatric ARV program was implemented through a flagship program called Amplicare which, as part of efforts to improve infant testing and adherence to ARVs, built and equipped laboratories and trained health care workers to diagnose and monitor adherence to medication.115 Amplicare also worked with Roche to develop an efficient method to gather and transport blood samples from remote locations to laboratories, which improved the accessibility to infant early diagnosis. The program also provided trainings to doctors and nurses on viral load testing.

ADAPTATION DURING IMPLEMENTATION PMTCT In September 2005, Cambodia’s HIV program received funding support from the Global Fund which accelerated the process of scaling up PMTCT services with the number of treatment facilities for PMTCT increasing from 24 in 2005 to 69 in 2007. The MOH adopted a demonstration program, Linked Response to support PMTCT interventions, in two areas to strengthen existing reproductive health services and increase access to comprehensive testing and treatment through decentralizing HIV counseling and testing services.116 In 2010 following a successful demonstration, this program was rolled out nationally, leading to at least 92% of all health facilities in Cambodia (921) offering antenatal care services along with HIV counseling and testing to pregnant women.116

According to the CDHS 2005, although knowledge of HIV transmission through breastfeeding was high with 87% of women and 84% of men knowing that HIV could be transmitted by breastfeeding, less than one-third (31%) of women and about one-fourth (21%) of men knew that the risk of mother-to-child transmission (MTCT) could be reduced through the use of Antiretroviral Therapy (ART) during pregnancy. Between 2005 and 2014, the proportion who knew about transmission through breastfeeding remained high and awareness about preventive drug therapies for PMTCT improved to 56% (2010) and 62% (2014) among women and 34% (2010) and 54% (2014) among men. Also, the percentage of pregnant women who were counseled, were offered and accepted an HIV test, and who received results during ANC was only 8% in 2005; coverage increased to 51% in 2014.7–9,117 The number of new HIV child infections dropped from 1100 in 2000, before the PMTCT program was introduced, to less than 200 in 2015.118 Early infant diagnosis increased from 43% in 2010 to 73% in 2015.119 Further, the coverage of pregnant women who received ARV for PMTCT increased from 33% in 2010 to 77% in 2015 and continued improving so that by 2017, after the case study period ended, it was 94%.120

Exemplars in U5M: Cambodia Case Study 69 Likely reflecting both better prevention and treatment, HIV/AIDS mortality rates among U5s in Cambodia decreased from 35/100,000 in 2000 to 27/100,000 in 2005 and 8/100,000 in 2015.109

Table 24. HIV Program Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcomes (+/-): Early prioritization of at-risk groups and lack of effective interventions led to de-prioritization of PMTCT and Data use for prioritization pediatric ARV program. Appropriateness Data use to understand disease (+/-): Decision to implement a PMTCT and ARV for pediatrics burden program based on spike in new HIV infections among children between 1992-1999 from less than 100 cases in 1992 to over 1,000 in 1999. (+): High rates of early infant diagnosis and ARV treatment for pregnant women suggested high acceptability. Acceptability Integration into ANC

Data on pediatric ARV treatment were not found. National leadership and accountability (technical working group, NCHADS) Stakeholder engagement Leveraging partner support (+): PMTCT and pediatric ARV program implemented. Feasibility Leveraging donor support Integration onto existing systems Decentralization Infrastructure development Systems strengthening (+): The number of treatment facilities for PMTCT increased from 24 in 2005 to 69 in 2007. By 2010, 92% of all health facilities in Cambodia offered HIV counseling and testing to pregnant women.

(+): Knowledge of HIV transmission through breastfeeding was high between 2005 to 2014 and awareness about preventive drug therapies for PMTCT improved during the Systems strengthening same time period for both men and women.

Effectiveness and Leverage partner expertise (+): Early infant diagnosis increased from 43% in 2010 to 73% coverage (reach) in 2015. Decentralization

(+): The coverage of pregnant women who received ARV for PMTCT increased from 33% in 2010 to 77% in 2015 and by 2017 after the case study period ended, it was 94%.

(+): Number of new HIV child infections dropped from 1100 in 2000 before the PMTCT program was introduced to <200 in 2015.

Exemplars in U5M: Cambodia Case Study 70 (+): HIV/AIDS mortality rates among U5s in Cambodia decreased from 35/100,000 in 2000 to 27/100,000 in 2005 and 8/100,000 in 2015. Guideline development and adaptation (+) Facility – components in place. Fidelity

Training Individual-data not found.

Systems strengthening Policy development (-): Continued dependence on donor funding Sustainability Integration onto existing systems (+): Sustained high coverage and reach of PMTCT (-): The percentage of pregnant women who were counseled, were offered and who accepted a HIV test, and who received results during ANC showed wide disparities Equity Systems strengthening among different wealth quintiles with only 1.4% in the poorest quintile compared to 28% in the wealthiest quintile, in 2005. By 2014, this gap had closed significantly (46% in the poorest quintile and 51% in the wealthiest).7,9

SUSTAINMENT By 2014, most funding for HIV programs in Cambodia came from donors with 84% of the nearly US$50.2 million spent on HIV programming coming from donors such as President's Emergency Plan For AIDS Relief (PEPFAR) and Global Fund with implications for sustainability.24

4.5 Malnutrition Children under the age of 5 are classified as malnourished on the basis of three anthropometric indices – stunting (height-for-age), wasting (weight-for-height), and underweight (weight-for-age). Malnutrition was the focus of U5M reduction activities in Cambodia mainly after 2000 and continued during the study period. Overall, stunting, wasting, and underweight prevalence decreased between 2000-2014 in Cambodia but stunting and underweight remained at high levels. Stunting decreased from 50% in 2000 to 32% in 2014 while wasting was at 17% in 2000 but dropped to 10% in 2014. Similarly, prevalence of underweight children dropped from 39% in 2000 to 24% in 2014. The focus of the case study was on severe acute malnutrition as a health system EBI.

4.5.1 Severe Acute Malnutrition Interventions

Table 25. SAM Interventions Key Implementation Strategies

Implementation Strategies • Local production • Leveraging partner support • Leveraging donor support • National guidelines

Exemplars in U5M: Cambodia Case Study 71 • Integration into existing systems • National leadership and accountability • Policy development

EXPLORATION The National Nutrition Program was set up to in 1995 as a vertical program to coordinate nutrition program planning and implementation in Cambodia. This was primarily implemented through hospitals and health systems. In 2000, 25% of children under 5 in experienced severe stunting, 13% were severely underweight, and 4% had severe wasting, highlighting a need for change in strategy.34

PREPARATION Facility-based care was traditionally used to manage severe acute malnutrition (SAM) cases, essential in situations where children have life-threatening medical complications. With support from UNICEF and health sector support project, facility-based care started in the early 2000s. Though programs were in place to treat SAM, a high proportion of children did not completely recover and were at risk of irreversible stunting. It was recognized that there were wide variations in coverage and nutrition status by geographic area in Cambodia, as well as reduced coverage in poorer, less educated rural populations.17

In 2007, a joint statement by WHO, the World Food Programme, the United Nations System Standing Committee on Nutrition, and UNICEF called for community-based management of SAM. It also recommended the use of ready-to-use therapeutic food (RUTF) to combat SAM among children.121 As a result, Cambodia introduced its first long-term National Nutrition Strategy (2009–2015) which focused on scaling up community-based management of acute malnutrition.122

IMPLEMENTATION In 2010, the Government of Cambodia collaborated with partners such as the US CDC, WHO, World Food Programme, USAID, Reproductive Health Association of Cambodia, RACHA, World Vision Cambodia, Hellen Keller International, International Relief and Development, and UNICEF to develop the first national interim guidelines for the management of SAM (including community-based management of acute malnutrition – CMAM using RUTF), introduced in 2011.122 UNICEF also helped implement community screening and health center-based outpatient treatment with RUTF. The interim guidelines involved community-based approach to identify children early for treatment, inpatient management of SAM, outpatient management of SAM without medical complications at health centers, and management of moderate acute malnutrition at health centers.123

Between 2011 and 2013, data were collected from 19 hospitals in 13 provinces of Cambodia with more than three years of experience in implementing SAM treatment. The study found success in implementation outcomes that drop-out decreased from 11% to 5%.124 Attendance of three follow-up visits by children increased from 26% to 43% and those who made three follow-up visits were found to no longer be moderately malnourished. Regarding coverage, health facilities providing facility-based management of SAM doubled between 2008 and 2014; 35 out of 73 hospitals in 2012 were providing SAM treatment.

Exemplars in U5M: Cambodia Case Study 72 Table 26. SAM Intervention Implementation Strategies and Outcomes Implementation Implementation Strategy Evidence Outcomes (+): Introduction of facility-based management of SAM Appropriateness Data use for decision-making reflected high burden of malnutrition (+): In hospitals implementing SAM treatment, drop-out decreased from 11% to 5% and attendance of 3 follow-up Acceptability Data use for decision-making visits made by the children increased from 26% to 43% suggesting high acceptability. Leveraging donor support (+/-): Facility-based care for management of SAM Feasibility Leveraging partner support e.g. USCDC, implemented although achieved only about 50% coverage WHO, WFP, USAID (+): In hospitals implementing SAM treatment, 3 follow-up visits made by the children increased from 26% to 43% and Policy development it was found that children who made 3 follow-up visits were no longer moderately malnourished. Guideline development Effectiveness and (+/-): Hospitals providing hospital-based management of coverage (reach) Integration into existing systems SAM doubled between 2008 and 2014; 35 (out of 73 hospitals) hospitals in 2012 were providing SAM treatment. Leverage donor and partner resources (+/-): Prevalence of stunting, underweight, and wasting dropped although remained high Guideline development Fidelity Not found. National leadership and accountability Integration into existing systems Sustainability (+): National Nutrition Strategy (2009-2015) developed Policy development Equity Policy development No data found

SUSTAINMENT In 2018, after the study period, a new fish-based wafer called ‘Nutrix’ was developed by the Government of Cambodia in collaboration with UNICEF, Copenhagen University, the French National Research Institute for Sustainable Development and Danish Care Foods to treat SAM. Nutrix replaced existing imported RUTF made with peanut and dairy. Nutrix was produced in Phnom Penh to ensure availability and because ingredients were locally sourced, it was more cost-effective – costing 20% less to produce.125 According to research conducted in 2018, Nutrix was also developed based on a non-blinded crossover taste trial, to suit local tastes and ensure acceptability.126 Follow-on data is beyond the time period of the study.

Exemplars in U5M: Cambodia Case Study 73 4.6 Vitamin A

Table 27. Vitamin A Supplementation Key Implementation Strategies

Implementation Strategies • Leveraging existing systems • Policy development • Data use for decision-making • Outreach

IMPLEMENTATION PRE-2000 Vitamin A deficiency is an underlying determinant of child mortality, increasing risk of morbidity and mortality from common causes of death, including respiratory issues, measles, and diarrheal diseases.127 Several studies carried out in different countries also demonstrated that vitamin A supplementation (bi-annual dosing with high- dose capsules) was a health system EBI which significantly reduced mortality among children 6-59 months of age. WHO and UNICEF recommended setting up programs to supplement vitamin A in all countries with infant and child mortality rates higher than 70 per 1,000 live births, which included Cambodia.128

In 1993, Cambodia made a formal commitment to achieve the complete elimination of vitamin A deficiency and as a result began distributing vitamin A capsules during biannual immunization days. In 1998, national immunization days were phased out with the interruption of polio transmission. The government integrated the distribution into biannual routine immunization outreach, as well as supplemental immunization campaigns, such as measles outbreak responses, and subnational immunization days.

IMPLEMENTATION POST-2000 After several years of review and revision, in 2009, the government developed an updated National Vitamin A Policy which ensured a sustainable distribution channel for vitamin A supplements to children between ages 6 and 59 months.7 Vitamin A continued to be provided through biannual outreach sessions. Coverage increased from 28% in 2000 and 35% in 2005 to 70% in 2014.9 Vitamin a supplementation coverage was fairly equitably distributed, with similar proportions of coverage among children of from all quintiles, with slightly higher uptake in rural (71%) than urban (64%) areas.7 Limited evidence on implementation and sustainment was seen.

Table 28. Vitamin A Supplementation Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcomes Appropriateness Data use for decision-making (+): Vitamin A program introduction reflected burden of disease Feasibility Leveraging existing systems, (+): Vitamin A program implemented and achieved high integrating into other campaigns coverage Effectiveness Leveraging existing systems (+): Coverage increased from 28% in 2000 to 70% in 2014 and coverage (reach) Outreach Sustainability Policy development (+): Development of National Vitamin A Policy

Exemplars in U5M: Cambodia Case Study 74 4.7 Neonatal Interventions Cambodia was aware of the need to prioritize NMR early on69 and its reproductive, maternal, newborn, and child health programming focused on EBIs that would decrease MMR and NMR, including dramatically increasing skilled birth attendance and facility-based delivery, increasing access to and utilization of ANC and PNC services, improving tetanus vaccination coverage, and expanding access to EmONC services.

The MOH released the National Strategy for Reproductive and Sexual Health in Cambodia 2006-2010 in February 2006. The strategy identified essential and comprehensive neonatal and postnatal care as a service to be expanded or introduced. It proposed an essential service package for reproductive health, which featured a basic set of reproductive and sexual health services. Postnatal care was included in the essential service package, which advised provision of targeted visits for every postpartum woman and her baby at six hours, six days, six weeks, and six months after delivery.

The specific services proposed to be provided at these visits included: • Early detection and management of puerperal complications • Birth spacing planning and service provision • Iron/folate supplementation • Vitamin A supplementation • Detection and treatment of anemia in mothers • Detection and treatment of malaria in mothers • Tetanus immunization (if not provided during ANC) • Screening for syphilis (if not provided during ANC) • Provision of mebendazole • Voluntary confidential counselling and testing for HIV (if not provided during ANC) • Counseling • Availability of EmOC.129

As noted, the reduction in neonatal mortality was less than overall U5M with a relative decline of 51% – from 37/1,000 live births in 2000 to 19/1,000 live births in 2014.8 Similar to overall U5M, Cambodia’s DHS data showed that between 2000 and 2014, the drop in neonatal mortality was greater than estimated by IHME – from 95/1,000 live births to 28/1,000 live births – a decline of 71%.17,34

4.7.1 Improving Antenatal Care Services, Access, and Uptake 4.7.1.1 Improving Access to Antenatal Care

Table 29. Four or more antenatal care visits (ANC4) Key Implementation Strategies

Implementation Strategies • Data use for decision-making • Engagement of partners in preparation and implementation

Exemplars in U5M: Cambodia Case Study 75 • Community-based care delivery • Community engagement and education, including mass media • Provider training/Human resources strengthening • National policies and guidelines

EXPLORATION In 2000, just 9% of women received at least four ANC visits from any provider.17 That year, the median gestation of pregnant women coming to a first ANC visit was 5.8 months representing delay in 1st ANC.17

PREPARATION AND IMPLEMENTATION PRE-2000 In response to Cambodia’s high maternal mortality, the MOH and the National Maternal and Child Health Centre began developing a series of National MCH Program Plans covering the period of 1994 to 2000.

The MOH released the national Safe Motherhood Policy in December 1997. This policy was based on four main pillars: 1) Family planning, 2) Antenatal care, 3) Clean labor and delivery, 4) Essential obstetric care. It provided guidelines for improving maternal care services in Cambodia at all levels of the health care system. These guidelines identified ANC with at least two visits during pregnancy as a key component of comprehensive maternal services for pregnant women. These visits were expected to include risk screening/early detection of danger signs with appropriate treatment and referral, tetanus toxoid immunization, anemia prophylaxis, diagnosis and treatment of anemia, treatment of STDs, and health education. This care was to be delivered at the health center level. At the community level, the policy encouraged village health committees to ensure that every pregnant woman in their group receives ANC. Recognizing the role of traditional birth attendants (TBAs) as the most commonly used maternal care providers in villages, the policy committed to integrating outreach and access to ANC into the role. The policy expected TBAs to encourage every pregnant woman to attend ANC by a midwife at least twice during pregnancy but also planned to add some services of ANC to the TBA role. For example, TBAs were expected to distribute iron/folate tablets, recognize danger signs during pregnancy, and counsel women and their families on topics such as breastfeeding, birth spacing, STDs and HIV/AIDS, and postnatal care. The policy also planned revision of pre-service training of health workers, including incorporation of clinical midwifery and ANC into the new basic pre-service nursing curriculum. Safe Motherhood Activities supporting this policy were financed by the government of Cambodia, local NGOs and communities, individuals, and external supporting agencies.130

PREPARATION AND IMPLEMENTATION POST-2000 A 2007 review of the 2003-2007 Health Strategic Plan identified large disparities in utilization of ANC between geographical areas and educational levels based on 2005 DHS data. For example, while about 60% of women who had a live birth prior to 2005 received ANC from a midwife (the most common provider), it was less than half that in Mondul Kiri/Ratanak Kiri (28%). More than three-quarters of women with secondary education or higher received ANC services, but only 44% of women with no education had.9 It therefore included widespread and accessible ANC as a main element of care requiring integration and scale up in Cambodia.131

Exemplars in U5M: Cambodia Case Study 76 The MOH released the Health Strategic Plan 2008-2015 in April 2008. Recognizing the country’s slow improvement in maternal mortality relative to progress towards other Millennium Development Goals (MDGs), the plan set an objective of improving access to essential maternal and newborn health services. It identified ANC as an essential service for reduction of maternal, newborn, and child morbidity and mortality. The policy identified strengthening integrated outreach and community-based models as a strategy for scaling up maternal, newborn, and child survival interventions.132

In 2008, the National Center for Health Promotion (NCHP) developed an ANC communication campaign to promote ANC services. This campaign used the Communication for Behavioral Impact planning model to develop a communication strategy with technical support from UNICEF. Following consultations and pre-testing of communications materials, the NCHP and Provincial Health Promotion Units oversaw training of around 300 health workers and 4,400 village health volunteers in seven provinces, focused on promotion and provision of quality ANC services.

The year-long ANC campaign launched in seven provinces in January 2009. It used mass media, including national television and radio messages repeated several times a day, to communicate to women to make their first ANC visit within one month of missing their period. Mobile ring tones, posters, banners, and leaflets also communicated this message. The message was reinforced at the community level by trained interpersonal communicators.

The ANC campaign aimed to increase the percentage of women seeking ANC services within the first eight weeks of pregnancy from 5% to 25%. An external evaluation conducted in 2011 found that the program exceeded these expectations – within the first 12 months of the campaign, 36% of potentially pregnant women sought their first ANC visit within the first eight weeks of pregnancy. As a result of the campaign’s success, it was expanded to 16 of Cambodia’s 24 provinces by 2012.133

In 2013, UNICEF worked with health centers to launch outreach teams in remote and hard-to-access areas of Cambodia. These outreach teams followed MOH guidelines for outreach services from health centers, visiting remote villages four times a year. During these visits, the teams provided a basic package of health services, including ANC.134

The 2014 DHS showed progress in ANC utilization in Cambodia. It reported that 95% of women who had a live birth in the preceding five years received ANC from a skilled provider, an improvement from just 38% in 2000. The survey found provincial differences in utilization of ANC, reporting that while nearly 100% of women in several provinces received ANC from a skilled provider, only 73% of women in Kratie and 76% of those in Mondul Kiri/Ratanak Kiri received care from a skilled provider during pregnancy. Women with secondary or higher education were also more likely (99%) than those with primary level (95%) or no education (86%) to receive ANC from a skilled provider, however the equity gap had narrowed substantially from 2005. Overall, 76% of women attended at least four ANC visits, compared to 9% of women in 2000.7,8 The median gestation of pregnant women attending their first ANC visit had decreased to 3.4 months by 2010.17

Exemplars in U5M: Cambodia Case Study 77 ADAPTATION Though the MOH originally promoted utilization of 2+ ANC visits, the revised Safe Motherhood Clinical Management Protocols for health centers and referral hospitals released in July 2010 and June 2013, respectively, updated the recommended frequency of ANC visits to include at least four visits.135

Table 30. ANC4+ Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcome (+) Intervention introduction reflected identified need. In 1995, Data use for evidence-based Appropriateness only 40% of women who gave birth attended any ANC visits and 9% decision-making attending at least four ANC visits in 2000. (+) Within the first 12 months of the campaign, 36% of potentially Community engagement and Acceptability pregnant women sought their first ANC visit within the first eight education, including mass media weeks of pregnancy. Engagement of partners in preparation and implementation (+) The yearlong ANC campaign launched in seven provinces in Feasibility Community-based care delivery January 2009 with successful delivery of community messages. Data use for decision-making (+) Following consultations and pre-testing of communications materials, the NCHP and Provincial Health Promotion Units oversaw training of around 300 health workers and 4,400 village health volunteers in seven provinces, focused on promotion and provision Effectiveness Provider training/Human of quality ANC services. and Coverage resources strengthening

(+) In 2014, 95% of women who had a live birth in the preceding five years received ANC from a skilled provider, rising from 38% in 2000. (-) Provincial differences in utilization of ANC: nearly all women in Provider training/Human some provinces received ANC from a skilled provider, only 73% of resources strengthening women in Kratie and 76% of those in Mondul Kiri/Ratanak Kiri did Reach so. National policies and guidelines (+) Improvement in overall reach (-) The Health Strategic Plan 2008-2015 recognized the country’s slow improvement in maternal mortality relative to progress towards other MDGs, identifying ANC as an essential service for reduction of maternal, newborn, and child morbidity and mortality. Fidelity National policies and guidelines

(+) The median gestation of pregnant women attending their first ANC visit had decreased to 3.4 months by 2010 indicating more timely first ANC. Engagement of partners in preparation and implementation (+) The program was expanded to 16 of Cambodia’s 24 provinces by Sustainability Community engagement and 2012. education Community-based care delivery (+/-) Rates were very high among women with secondary or higher education (99%) or primary level (95%) with lower rates if no Equity Community education and education (86%) to receive ANC from a skilled provider. outreach

Exemplars in U5M: Cambodia Case Study 78 (+/-) While equity gap in wealth for access to at least one ANC visit narrowed dramatically from 2000 to 2014, the gap did not change substantially for ANC4 (Figures 20 and 21).

SUSTAINMENT Beyond the desk review.

Figure 21. Equity and Coverage Outcome – ANC (at Figure 20. Equity and Coverage Outcome – ANC4+ in least one visit) in Cambodia (2000-2014) (Source: Cambodia (2000-2014) (Source: Victora, et al 2018) Victora, et al 2018)

4.7.1.2 Maternal Tetanus Vaccination

Table 31. Maternal Tetanus Vaccination Key Implementation Strategies

Implementation Strategies • Focus on equity • Data use for decision-making o Needs assessment o Data use for adaptation o Surveillance • Leveraging, integrating, and strengthening existing systems o Data systems strengthening • Community engagement • HR strengthening • Leveraging donor support

EXPLORATION Tetanus toxoid injections are given to women during pregnancy to prevent neonatal deaths from tetanus, which is caused if sterile procedures are not followed in cutting umbilical cord after delivery.7 Tetanus generally develops during the first and second weeks of life and is fatal in 70–90% cases. In 2000, only 30% of Cambodian women

Exemplars in U5M: Cambodia Case Study 79 who had given birth in the previous five years had received two or more doses of tetanus toxoid.34 The neonatal mortality rate from neonatal tetanus that year was 1.2 per 1,000 live births.136

PREPARATION PRE-2000 Cambodia officially launched its EPI in October 1986 in collaboration with UNICEF. The program began immunizing pregnant women against tetanus in 1989.137 Pre-2000 coverage data were unavailable for the team to review. In 1999, the Maternal and Neonatal Tetanus Elimination initiative was launched by UNICEF, WHO, and UNFPA to reduce cases of neonatal tetanus to less than one case per 1,000 live births in all districts within countries that had not achieved the standard for elimination.

IMPLEMENTATION In 2000, the MOH, with support from WHO and UNICEF, began working to eradicate maternal and neonatal tetanus across the nation by expanding the target group for tetanus toxoid (TT) and providing TT injections to women of child-bearing age, providing them access to improved antenatal care, and motivating them to deliver in a health facility with skilled birth attendants who use sterilized equipment and clean cord delivery practices.138 The TT injection was provided free of cost to girls and women between ages 15 and 44 including pregnant women.

As noted, in 2001, the MOH combined EPI and polio eradication activities into one platform – the National Immunization Program.139 It planned to include neonatal tetanus elimination plan under the NIP by 2008, with an aim to achieve maternal and neonatal tetanus elimination. Neonatal tetanus elimination was to be implemented using a number of approaches including: determining areas with the most need and categorizing districts and health centers into high, medium, and low risk; conducting SIAs in high-risk areas (districts with low TT coverage, low levels of delivery or ANC by skilled attendants, and/or high rates of neonatal tetanus cases) and high-risk population groups e.g. unvaccinated women of reproductive age working in factories who missed vaccination sessions; improving community awareness around maternal and neonatal tetanus; strengthening the surveillance system in medium and low-risk districts through strengthening reports of neonatal death; improving the quality of investigation, data collection, and analysis; improving the system of registering women of reproductive age and determining their vaccination status; and focusing supervision on high-risk districts.40

Between 2000 and 2011, SIA campaigns were conducted in 52 operational districts and 244 factories covering nearly 1.3 million women of reproductive age, resulting in a sharp decline in neonatal tetanus cases from 295 in 2000 to 19 in 2010.40

As of 2007, the total cost for three traditional antigens (BCG, measles, OPV) for children under 1 year of age along with tetanus immunization for pregnant and child-bearing age women per the existing immunization schedule was estimated to be about $771,692 per year. These vaccines were financed by Government of Cambodia, as of 2007,40 although GAVI Alliance supported NIP between 2002-2007 including contributing in tetanus toxoid injections.140

Exemplars in U5M: Cambodia Case Study 80 As a result of these efforts, Cambodia achieved maternal and neonatal tetanus elimination in June 2015 with fewer than 1/1,000 live births per district year.139 Cambodia also maintained a high rate of tetanus protection at birth: 69% in 2005 and 87% in 2014. According to IGME estimates, drop neonatal deaths attributable to tetanus in Cambodia represented a success, reducing by 20% between 2000-2015 from 1.2/1,000 live births in 2000 to 0.04/1,000 in 2015.

Table 32. Maternal Tetanus Vaccination Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcomes (+): Maternal and neonatal tetanus elimination Acceptability Community engagement resulting from high reach suggested high acceptability Integration into existing systems: NIP

(+): Maternal and Neonatal Tetanus Elimination Leveraging existing systems: MCH Feasibility program implemented and achieved tetanus committee elimination

Leveraging donor support: GAVI (+): Between 2000 and 2011, SIA campaigns were conducted in 52 operational districts and 244 factories (covering nearly 1.3 million women of reproductive age), resulting in a sharp decline in Data systems strengthening – improving the neonatal tetanus cases from 295 in 2000 to 19 in system of registering women of 2010. reproductive age and determining their Effectiveness and vaccination status (+): Cambodia maintained a high rate of tetanus coverage protection at birth: 69% in 2005 and 89% in 2014. Data use for decision-making – needs Neonatal deaths attributable to tetanus in Cambodia assessment, data use for adaptation, dropped by 97% between 2000-2015 from 1.2/1,000 surveillance, targeted supervision live births in 2000 to 0.04/1,000 in 2015.

(+): Cambodia achieved maternal and neonatal tetanus elimination in June 2015 with fewer than 1/1,000 live births per district year. (+): As of 2007, the total cost for tetanus immunization for pregnant and child-bearing age women as per the existing immunization schedule Sustainability Integration into existing systems was estimated to be about $771,692 per year. These vaccines were financed by the Government of Cambodia, as of 2007. (+) 89% of last-born children were fully protected against tetanus in the five years before 2014; 83% Focus on equity – focus on high risk groups, among the lowest quintile and 94% among the Equity free care delivery highest.7 This represents a narrowing of the equity gap from 2005, when 59% of the lowest quintile and 81% of the highest quintile were fully covered.9

Exemplars in U5M: Cambodia Case Study 81 4.7.1.3 Maternal Iron and Folic Acid Supplementation

Table 33. Iron and Folic Acid Supplementation Key Implementation Strategies

Implementation Strategies • Community engagement and education/sensitization and behavior change communication • Leveraging partner expertise • National policies and treatment guidelines • Culture of learning and adaptation • Pilot testing • Local research and data collection prior to implementation

EXPLORATION One of the key measures recommended by WHO to improve the care of mothers during pregnancy and childbirth included administering standard doses of 30–60 mg of iron and 400 μg of folic acid (IFA) supplementation daily – either alone or in combination with other vitamins and minerals for women in the preconception period.141 The 2000 DHS found that 58% of women of reproductive age in Cambodia were anemic.

PREPARATION In 1998, WHO’s Western Pacific Regional Office (WPRO) supported pilot effectiveness projects from 1998 to 2002 and launched ‘Master Protocol’ to study the impact and process of implementation of weekly IFA supplementation.142 With the financial and technical support of WPRO and the Japanese government, the Cambodian MOH, in collaboration with Ministry of Social Affairs, Labor, Vocational Training, and Youth Rehabilitation and Education and the Ministry of Youth and Sport, with national and international participating organizations for the program undertook a pilot weekly iron-folic acid supplementation program for women of reproductive age in 2001-2002.143,144 A national steering committee was created to formulate a social marketing framework intervention strategies for Cambodia. This was based on various contextual elements and additional rapid situational assessments with the program teams, which included the National Nutrition Program of the MOH.

This program was implemented without supervised control among girls and women in selected secondary schools, garment factories, and rural areas.143 Interactive sessions with games were brought to five secondary schools, where girls received one-month supplies of IFA tablets and student leaders were trained as peer educators; based on follow up evaluations, 55% of schoolgirls complied in taking the supplements. The social marketing strategy for garment factory workers included peer education training for team leaders, who were trained in peer counseling and organized educational activities to promote IFA supplementation and improved nutrition. Supplements were provided as employee benefits, and lotteries were organized for women who took their supplements for three months; follow-up questionnaires showed about 57% of female workers complied in taking the supplements. In 13 randomly selected villages in in Kong Pisei and Samraong Tong districts of the Kampong Speu Province, two peer educators were chosen to be responsible for the village development committee health activities, training other selected villagers to promote and raise awareness about IFA supplementation. Supplements were sold for a

Exemplars in U5M: Cambodia Case Study 82 small cost or made available for free depending on income status, and the money raised went to the village revolving fund. In follow-up visits approximately 71% of rural women were found to have complied in taking their iron supplements.

The pilot study concluded that utilizing social marketing strategies in the context of a complex of multisector collaborators demonstrated effectiveness in the dissemination of knowledge about anemia and nutrition. The study provided future direction and generated further support relating to issues that impact on prevention and control of anemia.

IMPLEMENTATION These positive results from the pilot program encouraged the Cambodian Ministry of Health to provide weekly iron-folic acid supplementation to women of reproductive age and to introduce the program on a larger scale. The National Nutrition Program of the MOH received some funding from UNICEF and WHO to further examine the delivery mechanism through the school system.

In 2003– 2004, the National Nutrition Program implemented the weekly IFA program in eight secondary schools in one operational district, and 1500 schoolgirls were enrolled. The program showed very encouraging results, including high coverage and compliance and improved knowledge about the causes, effects, and prevention of anemia.143

In 2005, with support from the World Bank-funded Health Sector Support Project, the National Nutrition Program planned to expand the weekly iron folic acid supplementation program in three provinces where other nutrition interventions are also implemented. The program was aimed to cover approximately 35,000 schoolgirls.

There was an overall 13% decrease in the prevalence of anemia among women from 58% in 2000 to 45% in 2014.

ADAPTATION DURING IMPLEMENTATION The MOH introduced National Guidelines for IFA Supplementation in 2007, which recommended at least 90 fully funded iron/folic acid tablets to pregnant and post-partum women during each pregnancy; and first-ever National Nutrition Strategy in 2009 to combat burden of disease related to malnutrition and micronutrient deficiency.145

By 2014, 76% of women aged between 15-49 years with a live birth in last five years took iron supplements for 90 or more days during pregnancy, up from 57% in 2010.7 This was however lower than rates in women who attended ANC who received iron tablets or syrup – 66% in 2005 and 96% in 2014 – reflecting persisting low ANC rates as an implementation barrier.

Exemplars in U5M: Cambodia Case Study 83 Table 34. Iron and Folic Acid Supplementation Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcome Community engagement and education/sensitization and behavior (+) High coverage and compliance and improved knowledge Acceptability change communication about the causes, effects, and prevention of anemia resulted from weekly IFA program in eight secondary schools Culture of learning and adaptation Pilot testing (+) By 2014, 76% of women aged between 15-49 years with a

Feasibility live birth in last five years took iron supplements for 90 or Local research and data collection more days during pregnancy, up from 57% in 2010. prior to implementation National policies and treatment (+/-): The proportion of pregnant women and women in Effectiveness guidelines general with anemia dropped from 58% to 45% between 2000- and Coverage 2014, although remaining high. Pilot testing (+) Introduction of National Guidelines for Iron and Folic Acid National policies and treatment Supplementation in 2007; first-ever National Nutrition Strategy Fidelity guidelines introduced in 2009 to combat burden of disease related to

malnutrition and micronutrient deficiency (+/-): Immense improvements in proportion of pregnant women who received iron tablets during pregnancy for both the poorest and wealthiest quintiles. In 2000, only 1% (poorest Equity quintile) and 3% (wealthiest quintile) received iron tablets during pregnancy. By 2014, these had improved to 65% (poorest quintile) and 82% (wealthiest quintile) although equity gaps were seen (Figure 22).

Figure 22. Equity and Coverage Outcome – Iron Supplementation in Pregnancy (2000-2014) (Source: Victora, et al 2018)

Exemplars in U5M: Cambodia Case Study 84 4.7.2 Improving Childbirth Delivery Services, Access, and Uptake 4.7.2.1 Skilled Birth Attendant and Facility-Based Delivery

Table 35. Skilled Birth Attendant Key Implementation Strategies

Implementation Strategies • Collaboration across sectors • Provider training/Human resources strengthening • Culture of learning and adaptation • National policies • Focus on equity • Financial • HRH motivation

EXPLORATION Quality obstetric care during delivery from a trained provider is crucial for reducing maternal and neonatal mortality.7 In 1997, the Safe Motherhood Policy was published to establish standards for maternal health, focusing on family planning, clean labor and delivery practices, and essential obstetric care.17 In Cambodia in 2000, just 10% of births in the previous five years took place in a health facility.8

Beginning in 2000, the government began to focus on increasing access to skilled birth attendants and FBDs. The MOH set a target of at least one primary midwife at each health center, while banning deliveries by unlicensed, untrained traditional birth attendants, and strongly discouraging home births.16 In order to reduce pregnancy- and delivery-related health care costs and promote access to priority public health services among the poor, Cambodia introduced HEFs beginning in 2000. As discussed in the introduction (Health Insurance), HEFs pay public providers on behalf of poor people, and cover prenatal care, delivery, comprehensive postpartum care, and other MNCH services.

PREPARATION By 2005, qualitative research of skilled birth attendants began to demonstrate constraints in the scale-up efforts of the previous five years. Problems included absenteeism of midwives at facilities and “attitude problems,” both of which were at least somewhat associated with low remuneration. The first Midwifery Forum took place that year, where these problems were surfaced and discussed with high-level policymakers. One outcome of this forum was the MOH decision to commission a comprehensive review of midwifery.17 Other concrete recommendations resulting from the forum included increasing the number of midwives at health centers, motivating midwives through increased salaries and performance incentives, improving working and living conditions in rural areas, and supporting midwifery education. In 2007, the Secretary of State established a high- level Midwifery Taskforce to focus on the quantity and quality of midwives and maternal health services.

Exemplars in U5M: Cambodia Case Study 85 IMPLEMENTATION The Government Midwifery Incentive Scheme was introduced in 2007 through a joint initiative of the MOH and the Ministry of Economy and Finance. The scheme increased the government midwife salary scale, provided midwives with cash incentives, and allocated government budget to pay these incentives.17 Skilled birth attendants were to be paid US$15 for each live birth attended in health centers and $10 for those in hospitals. The incentives were shared with other facility health personal in addition to Village Health Support Groups, village chiefs, and traditional birth attendants. This was to encourage communities to refer women to facilities for delivery.

Other policy initiatives included improving supply side barriers and integrating traditional birth attendants into the health care system through trainings and job placements.16 Midwife recruitment was prioritized – and midwives represented more than half of all health personnel recruited between 2005 and 2015. The maximum entry age for midwives was increased from 28 to 30, and the recruitment policy focused on midwife candidates who came from the areas where they intended to work after training. All health centers were to increase staffing levels targeting two primary midwives and a secondary midwife. Technical standards were revised for consistency with international standards, including the development of preservice and in-service training programs that emphasized clinical practice.17

Between 2000 and 2015 there were dramatic changes to the statistics around skilled birth attendance and FBD. Births delivered by skilled providers increased from 44% in 2005 to 71% in 2010, and 89% in 2014.7–9,117 In 2014, 83% of births in the five years preceding the survey took place in a health facility. Only 11% of babies in 2014 were delivered with the assistance of a traditional birth attendant. While the disparity had decreased, births to urban women in 2014 were more likely (98%) to be assisted by a trained health professional than births to rural women (88%), compared to 57% urban and 28% rural in 2000.7,8 Births to women in the highest wealth quintile in 2014 were still more likely (98%) to be assisted by a trained health professional than births to women in the lowest quintile (75%), compared to 90% vs and 21% in 2005 (Figure 23).7,9

By 2013, HEFs had been implemented in 48 health districts, covering 70% of referral hospitals and 45% of health centers. Hospital-based HEFs seemed to effectively address financial barriers to accessing public health services for the poor and reduce out-of-pocket health expenditures.17

ADAPTATION DURING IMPLEMENTATION In 2008, the second Health Strategic Plan (HSP2) 2008-2015 was developed. It declared a “Fast track initiative to reduce maternal and newborn mortality” with a target of midwives in all health centers.146

Exemplars in U5M: Cambodia Case Study 86 Table 36. Skilled Birth Attendant Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcome Provider training/Human resources (+) Births delivered by skilled providers increased from 37.7% strengthening in 2000 to 69.3% in 2005, 89.1% in 2010, and 95.3% in 2014, Acceptability suggesting high acceptability among pregnant women. Culture of learning and adaptation (+) The Government Midwifery Incentive Scheme, developed Multiple implementation strategies by the MOH and Ministry of Economy and Finance, increased including: Provider training/Human the government midwife salary scale, provided midwives with resources strengthening cash incentives, and allocated government budget to pay these Feasibility incentives. Collaboration across sectors (+) HEFs had been implemented in 48 health districts, covering National policies 70% of referral hospitals and 45% of health centers, improving access to FBD for poorer women. (+) Births delivered by skilled providers increased from 37.7% Provider training/Human resources in 2000 to 69.3% in 2005, 89.1% in 2010, and 95.3% in 2014.7– Effectiveness strengthening 9,117 and Coverage (+) In 2014, 83% of births in the five years preceding the survey Collaboration across sectors took place in a health facility. Only 11% of babies in 2014 were delivered with the assistance of a traditional birth attendant. (+) All health centers were to increase staffing levels targeting two primary midwives and a secondary midwife. Technical National policies standards were revised for consistency with international Fidelity standards, including the development of preservice and in- Culture of learning and adaptation service training programs that emphasized clinical practice.

Data on quality of delivery not available. (+/-): Facility-based delivery rates improved immensely for all wealth quintiles in Cambodia from 2% to 69% for the poorest quintile between 2000-2014 and 47% to 96% for the Focus on equity wealthiest in the same time period. However, equity gaps

Equity remained. National policies

(+) HEFs and the national incentive scheme reduced inequities. By 2013, about 16% of the population or 2.2 million people below the poverty line had coverage from HEFs.

SUSTAINMENT The Safe Motherhood Policy was updated/consolidated into the National Reproductive and Sexual Health Strategies (2006-2010, 2013-2016).130

Figure 23. Equity and Coverage Outcome – Institutional (Facility-Based) Delivery in Cambodia (2000-2014) (Source: Victora, et al 2018)

Exemplars in U5M: Cambodia Case Study 87 4.7.2.2 BEmONC and CEmONC

Table 37. BEmONC and CEmONC Key Implementation Strategies

Implementation Strategies • National policies and guidelines • Data use (M&E, international evidence) • Integration of program into existing structures • Stakeholder engagement • Leveraging partners • Provider training/Human resources strengthening • Focus on equity • Engagement of partners in preparation and implementation • Culture of learning and adaptation

EXPLORATION In 1997, national policies and strategies for safe motherhood were developed, based on pillars of family planning, antenatal care, clean labor and delivery, and essential obstetric care. Basic essential obstetric care was to be provided at health center level while comprehensive essential obstetric care was to be provided at the first referral level.

In 2008, UNFPA and AusAid supported the baseline emergency obstetric and neonatal care (EmONC) Needs Assessment to better understand the status of EmONC. It was observed that only 19 facilities (out of 110 facilities needed to fulfill international targets) met the targets for Basic Emergency obstetric and Newborn Care (BEmONC). Twenty-five (two-thirds of the 37 needed to fulfill international targets) hospitals provided Comprehensive Emergency Obstetric and Newborn Care (CEmONC). The majority of health facilities were critically understaffed, and many midwives had only limited expertise and skills to manage complicated deliveries.147 While 88% of the population could reach a health center within one hour, 73% of the population could reach an emergency obstetric facility within one hour.44

In 2009, the National EmONC Study, a nationwide review on the EmONC, reported a shortage in EmONC facilities, at less than two (1.6) per 50,000 women, compared to the UN recommendation of at least five per 50,000 women.148 Further, the review reported shortage in distribution, with majority located around cities and towns, and that five provinces (Kampong Speu, Kandal, Mondul Kiri, Otdar Meanchey and Kampot/Kep) did not have any EmONC services. In an additional eight provinces, services were limited to referral hospitals.

PREPARATION In response to the needs assessment, the MOH developed the 2010-2015 EmONC Improvement Plan, a detailed plan for improving EmONC services through implementing an evidence-based package of interventions focused on human resources, equipment, drugs, infrastructure, and referral systems. 17,44 In addition, the MOH updated

Exemplars in U5M: Cambodia Case Study 88 existing guidelines on eclampsia and newborn asphyxia management to better align with international evidence, while also expanding the number of facilities intended to provide EmONC services.17

IMPLEMENTATION In 2009, the 2010-15 EmONC Improvement Plan and Fast Track Initiative Road Map were introduced to provide training to midwives and doctors. The MOH launched a concerted campaign in 2010 as a 5-year plan in order to increase the availability and utilization of access to emergency obstetric and newborn care, particularly focused on the poor and vulnerable.39 Four training sites were established in Battambang, Kampong Cham, Takeo, and Phnom Penh. Across 24 provinces, these sites provided support to 136 BEmONC facilities and 44 CEmONC facilities.147 Training involved skills for the prevention and management of eclampsia and pre-eclampsia, performing manual vacuum extraction, and dealing with post-partum hemorrhage. In 2014, 35 regional BEmONC trainings were conducted, working with new and experienced midwives. Overall, 898 midwives were trained under this program between 2010-2014.147

In 2012, in collaboration with MOH, the German Federal Ministry for Economic Cooperation and Development (BMZ) launched the Cambodian-German Rights-Based Family Planning and Maternal Health Project (2012-15), to improve quality and utilization of family planning and maternal and child health care services. It was implemented in four provinces: Kampong Thom, Kampong Speu, Kampot, and Kep, and focused on facility-based deliveries in the context of improving EmONC, including abortion-related complications, increasing the use of modern family planning methods, and promoting education campaigns on safe delivery, family planning and neonatal care.149

As part of this project, UNICEF was responsible for procurement of equipment and commodities for obstetric and newborn care health centers and referral hospitals. GFA, an international consulting firm, and RACHA partnered to strengthen diagnostic, therapeutic, and counselling skills of health staff in EmONC facilities.

In 2015 the MOH conducted an EmONC Review to assess the impact and remaining gaps of the EmONC Improvement Plan, assisted by NMCHC, Provincial Health Departments, EmONC facilities and partners including UNFPA, URC, USAID, WHO, and members of the Sub-Technical Working Group for Maternal and Child Health. The 2015 review reported that there was significant progress in the availability, accessibility, quality, and utilization of EmONC. Between 2009 to 2015, the number of BEmONC facilities increased from 19 to 110. The number of CEmONC facilities increased from 25 to 37. While five provinces had no EmONC facilities in 2008, by 2014 only one province, Kep, had none. The proportion of births in all EmONC facilities doubled from 17.8% in 2008 to 35% in 2014. The proportion of functional EmONC facilities with two or more secondary midwives rose from 84% in 2008 to 98% in 2014.150

Exemplars in U5M: Cambodia Case Study 89 Table 38. BEmONC and CEmONC Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcome Integration of program into existing structures (+) The proportion of births in all EmONC facilities doubled Acceptability from 17.8% in 2008 to 35% in 2014. Provider training/Human resources strengthening (+) In 2008, a baseline EmONC Needs Assessment to better Use of multiple strategies understand the status of EmONC in Cambodia.

National policies and guidelines (+) In response to the needs assessment, the MOH developed the 2010-2015 EmONC Improvement Plan, a detailed plan for Feasibility Data use (M&E, international improving EmONC services through implementing an evidence- evidence) based package of interventions.

Culture of learning and adaptation (+) In addition, the MOH updated existing guidelines on Partnership engagement eclampsia and newborn asphyxia management to better align with international evidence. Integration of program into existing (+) Between 2009 to 2015, the number of BEmONC facilities structures increased from 19 to 110. The number of CEmONC facilities increased from 25 to 37. Effectiveness Provider training/Human resources and Coverage strengthening (+) In 2008 five provinces had no EmONC facilities; by 2014 only one province, Kep, had none. Engagement of partners in preparation and implementation (+) Increase in staffing and access National policies and guidelines Fidelity Data use (M&E, international evidence) (-) By 2015 EmONC facilities were still largely concentrated at the hospital level, and in urban areas. C-section rates were very low (1.8% in 2008 growing to 3.9% in 2014), except in Phnom Penh where they were much higher (22.6% in 2014).150

Focus on equity Equity (+\-) As noted above, facility-based delivery was varied by

wealth quintile ranging from 68% among the poorest quintile to 96% among the wealthiest in 2014. That year just 68% of women with no education delivered in a facility, compared to 81% of women with primary education and 93% of women with secondary and higher education.7

ADAPTATION AND SUSTAINMENT At the end of the 2010-15 EmONC Improvement Plan, a number of challenges remained including insufficient facilities provided life-saving EmONC services, inequitable distribution of facilities, some services such as manual vacuum extraction and anticonvulsants were under-utilized, there was continued low proportion of births by cesarean section, and EmONC services were found to be of low quality.

Exemplars in U5M: Cambodia Case Study 90 After the study period, the 2016-20 EmONC Improvement Plan was introduced in order to continue improving the coverage, availability, accessibility, utilization, and quality of EmONC services, and to strengthen the of administrative structures supporting these services. The main objectives of the plan included a target of at least 160 total EmONC facilities, including at least 35 CEmONC and at least 125 BEmONC by 2020; ensuring effective utilization of EmONC services in order to meet at least 90% of need, through improved communications, effective referrals, delivery of quality services, continued reductions in financial barriers, and community participation; strengthening the capacity of administrative structures to plan, manage, monitor, and support EmONC services and ensure high quality of care; and reducing the financial barriers to EmONC services by ensuring all women in reproductive age would have access to full package of key reproductive maternal and newborn health services without financial hardship.150

4.7.3 Improving Postpartum Care

4.7.3.1 Newborn Resuscitation

Table 39. Newborn Resuscitation Key Implementation Strategies

Implementation Strategies • Data use for decision-making • Engagement of partners in preparation and implementation • Donor coordination • Community-based care delivery • Human resources strengthening (training) • National policies and guidelines

EXPLORATION AND PREPARATION The National Strategy for Reproductive and Sexual Health in Cambodia (2006-2010) proposed availability of neonatal resuscitation as a component of neonatal care in the essential service package for reproductive and sexual health.129

IMPLEMENTATION In 2004, the RACHA, a local NGO, collaborated with the NMCHC and the Church of Jesus Christ Latter-Day Saints Charities (LDSC) to launch the Neonatal Resuscitation Program, a national training program for health care professionals which provide theoretical knowledge and practical skills related to neonatal resuscitation.151–153 By October 2006, 1,310 midwives, 129 nurses, and 218 medical doctors and medical assistants had been trained.152,153

Helping Babies Breathe (HBB) was launched nationally in Cambodia with the support of RACHA in 2010.151 RACHA supported the transition from the Neonatal Resuscitation Program to HBB. HBB training materials were translated from English into Khmer to make them accessible to all health professionals in Cambodia, initially training core

Exemplars in U5M: Cambodia Case Study 91 trainers and then scaling the program to all 24 provinces.151 RACHA also collaborated with the LDSC and the RHAC to purchase neonatal resuscitation kits and distribute them across health facilities in the country. Between 2010 and 2012, this program trained 3,689 midwives, 505 doctors, and 153 nurses in Cambodia.151

In 2013, HBB was further implemented by the Lake Clinic Initiative in order to provide newborn resuscitation to remote villages in severely isolated and underserved regions of Tonlé Sap Lake area in central Cambodia.154,155 The clinics used a three year grant focused on HBB to purchase teaching materials, conduct trainings, and provide resuscitation equipment for midwives and village health volunteers.155,156

ADAPTATION DURING IMPLEMENTATION No information found.

SUSTAINMENT The HBB package was incorporated into the Immediate Newborn Care training package, a two-day coaching course for health workers involved in maternal and newborn care at provincial referral hospitals, provided nationally beginning in 2012.151

Table 40. Newborn Resuscitation Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcome (+) The National Strategy for Reproductive and Sexual Health in Cambodia (2006-2010) proposed availability of neonatal Appropriateness National policies and guidelines resuscitation as a component of neonatal care in the essential service package for reproductive and sexual health. Data use for decision-making Engagement of partners in (+) RACHA collaborated with the LDSC and the RHAC to purchase Feasibility preparation and implementation neonatal resuscitation kits and distribute them across health Donor coordination facilities in the country. Community-based care delivery Data use for decision-making Engagement of partners in Effectiveness and preparation and implementation (+) By 2012, the RACHA-led HBB program had trained 3,689 Coverage Community-based care delivery midwives, 505 doctors, and 153 nurses in Cambodia. Human resources strengthening (training) Engagement of partners in (+) The RACHA-led HBB program was conducted nationwide and preparation and implementation trained 3,689 midwives, 505 doctors, and 153 nurses in Reach Donor coordination Cambodia. Community-based care delivery (+) The HBB package was incorporated into the Immediate Sustainability National policies and guidelines Newborn Care training package, provided nationally beginning in 2012

Exemplars in U5M: Cambodia Case Study 92 4.7.3.2 Clean Cord Care

EXPLORATION The National Strategy for Reproductive and Sexual Health in Cambodia (2006-2010) proposed clean cord care as a component of neonatal care in the essential service package for reproductive and sexual health.129

PREPARATION A team of researchers from the National Institute of Public Health and Reproductive Health Association of Cambodia and Tulane University conducted formative research in early 2014 in Takeo Province in the south, on newborn health practices with an aim to identify common newborn care practices. Qualitative data were collected on four observations of newborn care in the home setting and 27 semi-structured interviews with mothers.157 Balms containing camphor and terpenic compounds were found to be available in most households. The authors concluded that parents and caregivers of infants in Cambodia who commonly use camphor- and menthol-containing products must be educated on the risks of these to prevent child morbidity and potential mortality. No record found for implementation, adaptation, or sustainment.

4.7.3.3 Kangaroo Mother Care

EXPLORATION The National Strategy for Reproductive and Sexual Health in Cambodia (2006-2010) proposed Kangaroo Mother Care for high-risk neonates as a component of neonatal care in the essential service package for reproductive and sexual health.129 Initiation and strengthening of appropriate newborn care practices, including Kangaroo Mother Care (KMC) for low birthweight and preterm babies, was one of the interventions in the Five-Year Action Plan for Newborn Care in Cambodia 2016-2020, after the study period.146 No record found for preparation, implementation, adaptation, or sustainment.

4.7.3.4 Improving Postpartum Visits

Table 41. Postpartum Visits Key Implementation Strategies

Implementation Strategies • Data use for decision-making • Adaptation of existing training and guidelines to reflect local context • Engagement of partners in preparation and implementation • Pilot testing • TOT and cascade to district control and responsibility • Culture of learning and adaptation

Exemplars in U5M: Cambodia Case Study 93 EXPLORATION The WHO recommends utilization of postnatal visits for new mothers and newborns since most maternal and infants deaths occur in the early postnatal period. It provides a strong recommendation of provision of 1) postnatal care for at least 24 hours after facility deliveries, 2) initial postnatal contact as early as possible within 24 hours after home deliveries, 3) additional postnatal contacts for all mothers and their newborns on day three, between days seven and 14, and six weeks after birth, and 4) home visits within the first week after birth.158

The 2000 Demographic and Health Survey reported fairly low utilization of postnatal care in Cambodia. It found that 46% of women who had a live birth in the previous five years did not receive any postnatal care (CDHS began tracking newborn access to postnatal care separately in 2014). Of women who delivered outside a health facility, only 31% received care within the crucial first two days following delivery. Utilization of postnatal care varied greatly by province, ranging from 7% in Prey Veng to 89% in Phnom Penh. Women living in rural areas were more likely (49%) than those in urban areas (28%) to receive no postnatal care.8

PREPARATION The MOH released the National Strategy for Reproductive and Sexual Health in Cambodia 2006-2010 in February 2006, identifying essential and comprehensive neonatal and postnatal care as a service to be expanded or introduced.

In 2007, the National Safe Motherhood Technical Sub-Committee formed a Neonatal Health Sub-Working Group consisting of representatives of the MOH’s National Reproductive Health Program (NRHP), National Maternal and Child Health Center (NMCHC), donors, and other partners. This group was established to examine issues and work needed to improve newborn health in Cambodia. It identified care of newborns and their mothers during the immediate postpartum period as a priority and created an integrated strategy for maternal and newborn care.

The Neonatal Health Sub-Working Group collaborated with the NRHP and several partners (including UNICEF, ACCESS Cambodia, and others) to develop the Integrated Postpartum Care (IPPC) program. It used a WHO manual (Pregnancy, Childbirth, Postpartum, and Newborn Care: A Guide for Essential Practice) as a main resource for development of the program’s technical content and training materials. This manual was revised and adapted to fit both national policies and the Cambodian context. The program’s partners aided development of a package of IPPC materials and tools, including development of a five-day, competency-based IPPC training course intended for midwives working at public health facilities, which was developed by ACCESS Cambodia and partners. The training package aimed to prepare midwives to provide an established package of services to mothers and newborns during three contact visits.

The training package was piloted in two initial training courses held in the Kampong Thom and Koh Kong provinces. These courses were attended by 37 participants, primarily midwives. Following these two initial courses, the IPPC training materials and methodology were modified in preparation for piloting at facilities.

Exemplars in U5M: Cambodia Case Study 94 IMPLEMENTATION In April 2008, IPPC program was piloted in 80 facilities (75 health centers and five referral hospitals) located within seven provinces and 12 operational districts of Cambodia. These pilot facilities made up 45% of all public health facilities within the 12 operational districts. The IPPC pilot started with a five-day training-of-trainers course held in Phnom Penh. This training established 23 trainers from the NMCHC, partner agencies, and maternal and child health staff from participating provincial health departments and operational districts. These trainers then conducted trainings for midwives and other providers in their respective provinces. Overall, 335 midwives were trained in the seven provinces.

The IPPC pilot program was concluded in July 2009 and was followed by a stakeholders’ meeting the following month to share experiences of the program. Program assessment in pilot facilities found that across facilities, utilization of postpartum visits increased from baseline to endline at all three time points (within 24 hours, on day two or three, and within six weeks after delivery). The largest observed percentage change occurred for visits within 24 hours of delivery, which increased from 24% of women and newborns at baseline to 54% at endline.159

The 2014 DHS survey showed great improvement in postnatal care utilization from the 2000 survey. It reported that 91% of women who gave birth within the previous two years received a postnatal check-up, with 90% of all women receiving a check-up in the first two days following delivery. Urban women were more likely to receive a postnatal checkup within two days after birth (98% versus 89% for rural women). There was a moderate gap between women in the lowest wealth quintile who received a postnatal checkup in the first two days (84%) compared to women in the highest wealth quintile (96%) (Figure 24).

Newborns were less likely than their mothers to receive postnatal care in 2014. 80% of newborns received a postnatal check-up and 79% received a check-up within the first two days after birth.7 Newborns in urban areas (84%) were more likely to receive PNC services from a trained health professional than those in rural areas (75%), and newborns in urban areas (84%) were more likely to receive PNC within first two days after delivery than those in rural areas (78%). Again, the gap between care for the lowest wealth quintile (75%) and the highest (84%) was moderate, but the lower coverage levels of newborns to mothers are notable (Figure 25).

ADAPTATION DURING IMPLEMENTATION Beyond the study period.

Table 42. Postpartum Visits Implementation Strategies and Outcomes

Implementation Implementation Strategy Evidence Outcome (-) The 2000 DHS reported fairly low utilization of postnatal care Data use for decision-making in Cambodia. It found that 46% of women who had a live birth in

the previous five years did not receive any postnatal care. Of Appropriateness Adaptation of existing training and women who delivered outside a health facility, only 31% guidelines to reflect local context received care within the crucial first two days following delivery.

Exemplars in U5M: Cambodia Case Study 95 (+) The Neonatal Health Sub-Working Group collaborated with several partners to develop the Integrated Postpartum Care (IPPC) program, using the WHO manual Pregnancy, Childbirth, Postpartum, and Newborn Care: A Guide for Essential Practice as a main resource for development of the program’s technical content and training materials. Engagement of partners in (+) Expansion of PNC service delivery through district and local preparation and implementation Feasibility providers

Pilot testing (+) The IPPC pilot started with a TOT course establishing 23 trainers from the NMCHC, partner agencies, and maternal and TOT and cascade to district Effectiveness child health staff from participating provincial health control and responsibility and Coverage departments and operational districts. These trainers then

conducted trainings for midwives and other providers in their respective provinces. Engagement of partners in preparation and implementation Reach (+) Overall, 335 midwives were trained in the seven provinces. TOT and cascade to district control and responsibility (+/-) Women with a secondary or higher education (93%) were more likely to receive PNC services from a trained health professional than those with either no schooling (71%) or only a Data use for decision-making primary school education (86%). Equity

(+/-) In 2014, newborns in urban areas (84%) were more likely to receive PNC services from a trained health professional than those in rural areas (75%).

SUSTAINMENT Beyond the case study period.

Figure 25. Equity and Coverage Outcome in Wealth Figure 24. Equity and Coverage Outcome in Wealth Quintiles - Postnatal Checkup for the Mother (2000- Quintiles - Postnatal Care for all Babies (2010-2014) 2014) (Source: Victora et al 2018) (Source: Victora et al 2018)

Exemplars in U5M: Cambodia Case Study 96 4.8 Common Implementation Strategies Cambodia was found to have utilized a range of strategies during implementation of EBIs, combining them to address identified contextual factors and key steps needed to achieve implementation outcomes. Many of these implementation strategies were shared across many or most EBIs, while others were specific to individual interventions. While some of these strategies were successful in achieving national scale-up for both coverage – the geographic and population spread of an EBI – and reach – the extent to which an EBI reached everyone intended, others were implemented with some inconsistency or less effectiveness in coverage. For example, some EBIs were piloted and scaled to selected districts and provinces but did not reach national scale, while others were identified as a priority and proposed for implementation, but stalled before being fully implemented.

Implementation strategies identified across multiple EBIs included: 1. Integration and leveraging of existing systems and programs • Building upon existing systems and programs for implementation of new EBIs, rather than using standalone approaches for implementation. Examples: o FB-IMCI added into pre-service training for doctors, nurses, and other health workers. o CB-IMCI expanded the role of VMWs. o Implementation of the PMTCT program involved training midwives in counseling and performance of a rapid HIV test and point of care testing was incorporated into routine antenatal and maternity services. 2. Local research to produce evidence and data use for decision-making • Utilization of data from many sources throughout implementation of several EBIs, including: o Data use to understand disease burden and ensure appropriateness of EBI, for example: § Introduction of FB-IMCI reflected high burden of targeted diseases such as diarrhea, pneumonia, and measles. Cambodia’s FB-IMCI also focused on hemorrhagic fever given its high burden in the country. § Introduction of CB-IMCI reflected need to integrate care for malaria, ARI, and diarrhea at community level and improve care-seeking overall. § The ORT and Zinc Program was introduced based on evidence of disease burden and policy gaps (though did not reach national scale). § High disease burden and case fatality rate informed PCV introduction. o Data use for prioritization and feasibility, for example: § PCV13 introduced instead of PCV10 because of PCV13’s lower wastage factor. § Decision to implement a PMTCT and ARV for pediatrics program based on spike in new HIV infections among children between 1992-1999 from less than 100 cases in 1992 to over 1,000 in 1999. 3. Community engagement and sensitization • Activities to engage and educate communities in order to improve acceptability and therefore utilization of services. Examples: o For Hib, at the end of the preparation phase, a detailed vaccine introduction plan included training, IEC, community engagement, and surveillance components.

Exemplars in U5M: Cambodia Case Study 97 o IFA supplementation activities focused on community engagement as a primary mechanism for increasing uptake. o The campaign to promote increased ANC participation used mass media, including national television and radio messages repeated several times a day, to communicate to women to make their first ANC visit within one month of missing their period. Mobile ring tones, posters, banners, and leaflets also communicated this message. The message was reinforced at the community level by trained interpersonal communicators. o Skilled birth attendant/FBD services were promoted through community participation and reimbursements to VHSG members who encouraged women to deliver at health facilities. 4. Adaptation of interventions to local setting • Most EBI implementation components were adapted, including training and protocols. o Examples: TB, IFA supplementation, PCV, the Maternal and Neonatal Tetanus Elimination initiative, PNC. 5. Training for health workers • Training (in-service and pre-service) to strengthen skills of providers for many key EBIs. • Large-scale national trainings utilizing a cascaded approach beginning with training-of-trainers to increase feasibility of training across the country. • Integration of key intervention areas into pre-service training. o Examples: FBD, IMCI for VMWs, PNC: IPPC program. 6. Engagement and coordination of implementing partners and donors and leveraging resources and expertise • Bringing donors and implementing partners together with MOH officials, staff, and researchers to review published evidence and explore feasibility before implementing new EBIs. Examples: o In 2007, the National Safe Motherhood Technical Sub-Committee formed a Neonatal Health Sub-Working Group consisting of representatives of the MOH’s NRHP, NMCHC, donors, and other partners, to examine issues and work needed to improve newborn health in Cambodia. The program’s partners aided development of a package of IPPC materials and tools, including development of a five-day, competency-based IPPC training course intended for midwives working at public health facilities. o Nutrition: In 2010, the Government of Cambodia collaborated with partners such as the US CDC, WHO, WFP, USAID, RHAC, RACHA, World Vision Cambodia, Hellen Keller International, International Relief and Development, and UNICEF to develop the first national interim guidelines for the management of SAM (including CMAM using RUTF), introduced in 2011. • Coordination of development assistance through Sector-Wide Management. o Example: The SWiM mechanism aligns and directs the contribution and activities of the development partners in achieving objectives set by the MOH. The Technical Working Group for Health and other sub-technical working groups and task forces help with coordination and development of technical content, which is co-chaired by Secretary of State for Health and WHO. • Engaging implementing partners for support during planning and implementation of most EBIs.

Exemplars in U5M: Cambodia Case Study 98 o Examples: Hib adoption and roll-out; Preparations for rolling out a PMTCT and ARV for pediatrics program involved the establishment of a technical working group coordinated by NCHADS with donors, civil society, and partners, to develop national guidelines and policy; JICA/WHO involvement in move to C-DOTs for TB. 7. Pilot testing and rapid scale • Use of small-scale implementation and pilot studies (often implemented with partners) to inform large-scale implementation, followed by rapid national expansion for some EBIs. Examples: o Preparations for introducing LLINs in 2004 included small-scale testing of the VMW program to deliver the nets in areas with high risk of malaria transmission. o Pilot testing for ORT/Zinc for diarrhea. o In September 2005, Cambodia’s HIV program received funding support from the Global Fund which accelerated the process of scaling up PMTCT services with the number of treatment facilities for PMTCT increasing from 24 in 2005 to 69 in 2007. o The MOH adopted a demonstration program, Linked Response to support PMTCT interventions, in two areas to strengthen existing reproductive health services and increase access to comprehensive testing and treatment through decentralizing HIV counseling and testing services. In 2010 following a successful demonstration, this program was rolled out nationally, leading to 92% of all health facilities in Cambodia (921) offering antenatal care services along with HIV counseling and testing to pregnant women. o PNC: IPPC program. 8. National leadership and accountability; setting clear goals and priorities and planning for sustainability • High-level recognition, acceptance, and commitment to international targets and initiatives combined with a willingness to be held to global standards. o Examples: Introduction of National Guidelines for Iron and Folic Acid Supplementation in 2007; first-ever National Nutrition Strategy introduced in 2009 to combat burden of disease related to malnutrition and micronutrient deficiency. • Incorporation of EBIs into national policy and planning documents as areas of prioritization. o Examples: Early recognition and prioritization of NMR; Strong Reproductive, Maternal, Newborn and Child Health (RMNCH) programming and ongoing support through cross- ministry actions like The Government Midwifery Incentive Scheme. 9. Integration of equity focus into policy and implementation • Work has increasingly included a focus on underserved groups and communities. o Examples: Health Equity Funds to encourage access and use of ANC, FBD, and PNC services; ITNs targeted high-risk areas; measles SIAs targeted remote border and densely populated areas. o Strategies to reduce financial barriers.

Exemplars in U5M: Cambodia Case Study 99 5 Cross-Cutting Contextual Factors Facilitating Under-5 Mortality Reduction

We identified a number of contextual factors at the global, national, subnational, community, and implementing partner levels that were critical to successes or represented challenges in implementing the targeted EBIs in Cambodia and others which influenced other causes of U5M. These also influenced the relative role of the three pathways in the TOC to reduce amenable U5M to varying degrees (health status and resilience, prevention, and access and quality of care). The facilitating contextual factors were critical in creating the environment and providing the support that contributed to the country’s success, directly or indirectly, some of which Cambodia leveraged to implement the EBI. The challenging contextual factors which primarily represented barriers to success in achieving equitable and quality coverage are discussed in the Cross-Cutting and Remaining Challenges section, below. Some of the key contextual factors in Cambodia which facilitated implementation and reduction in U5M are discussed briefly below. Others include donor resources and partnerships, the MDGs which provided broader targets, as well as new developments in EBIs (such as vaccines as well as improvements such as new antibiotics and HBB).

Table 43. Global, National, MOH, Community, and Individual Contextual Factors

Effective Leadership and Accountability: Setting Clear Goals and Priorities Culture and Process of Donor and Implementing Partner Coordination and Donor Resources Economic Growth and Poverty Reduction Other Public Health Initiatives with Impact on U5M Reduction Including WASH Community Health System and Structure National, MOH and Global Health Systems Structure and Strengthening Level Contextual Factors Data Availability and Culture of Use Existence of In-Country Research Capacity and Prioritization of Local Research Expanding Private Health Sector End of Conflict Resources: Urban/Rural Divide Health Insurance Nutrition-Targeted Interventions Individual and Community Women’s Empowerment/Education Level Contextual Factors Reproductive Health

5.1 Effective Leadership and Accountability: Setting Clear Goals and Priorities (Facilitator) Effective leadership and associated accountability to both the citizens and the international community was a key facilitating factor of U5M reduction between 2000-2015. The leadership was most active and effective nationally as reflected in the ability to develop and implement key national goals and priorities reflecting global goals and priorities (e.g. MDGs). For example, • The 2000-2015 MDGs informed much of the child and newborn reduction targets set as part of national Sector-Wide Management (SWiP) which helped in outlining the Health Strategic Plans for 2003-2007 and

Exemplars in U5M: Cambodia Case Study 100 2008-2015.39,160 In addition, strong M&E and mechanisms of performance-based financing (e.g. Special Operating Agency) helped to inform health policy decisions related to child health.39 • The Government Midwifery Incentive Scheme was introduced in 2007 through a joint initiative of the MOH and the Ministry of Economy and Finance. The scheme increased the government midwife salary scale, provided midwives with cash incentives, and allocated government budget to pay these incentives.17 Skilled birth attendants were to be paid US$15 for each live birth attended in health centers and $10 for those in hospitals. The incentives were shared with other facility health personal in addition to VHSGs, village chiefs, and TBAs. This was to encourage communities to refer women to facilities for delivery. Births delivered by skilled providers increased from 69.3% in 2005 to 95.3% in 2014.7,9 In 2014, 83% of births in the five years preceding the survey took place in a health facility, and only 11% of babies in 2014 were delivered with the assistance of a TBA.

5.2 Culture and Process of Donor and Implementing Partner Coordination and Donor Resources (Facilitator) Cambodia benefitted from early direct assistance for reconstruction provided by development partners. Since the end of conflict in the 1990s, the government has largely relied on official development assistance provided through various multilateral and bilateral donors channeled through international NGOs. Direction is set at the highest level by establishing clear development goals using the Sector Wide Management (SWiM) mechanism for health, a modified SWAp. The SWiM mechanism aligns and directs the contribution and activities of the development partners in achieving objectives set by the MOH. A government-development partner coordination committee composed of representatives from various agencies (usually technical working groups), ministries, and development partners. The committee held regular meetings to discuss alignment and harmonization of priority 161,162 indicators and allocation of funds. For example, the Technical Working Group for Health in the MOH technically supported health policy development with input from development partners and coordinated subgroups in charge of working on specific areas such as child and maternal health, which were funded by the Partnership for Maternal, Newborn and Child Health and implemented by National Maternal and Child Health Center.17,163

5.3 Economic Growth and Poverty Reduction (Facilitator) Cambodia experienced improvements in its economy with GDP per capita rising from US$431 in 2000 to US$613 in 2005, US$786 in 2010, and US$1,025 in 2015. Despite these increases, in 2015, Cambodia’s GDP per capita remained below the South Asian average of US$1,603, as well as below that of its regional neighbors Laos (US$1,539), Vietnam (US$1,667), and Thailand (US$5,741).164 The proportion of the population living below the national poverty line showed major declines from 50.2% in 2003 to 34% in 2008, and 17.7% in 2012.165 This factor gave the MOH resources to leverage to increase EBI coverage as well as contributing to reductions in U5M.

Exemplars in U5M: Cambodia Case Study 101 5.4 Other Public Health Initiatives with Impact on U5M Reduction Including WASH (Facilitator and Barrier) The MOH’s efforts to improve U5M between 2000-2015 were complemented by corresponding efforts which addressed broader public health issues beyond amenable causes of U5M including WASH programs. Between 2000-2015, Cambodia invested in WASH initiatives focused on improving access to clean water and improving sanitation facilities. By 2015, 76% of Cambodia’s population had access to clean water and 42% had access to improved sanitation facilities, compared to 23% and 3% in 1990, respectively. Although Cambodia improved access to clean water and sanitation facilities, open defecation and unsafe water continued to be a challenge particularly in rural areas.166 In 2014, access to an improved water source was substantially higher in urban (95% of households) than in rural areas (60%). Likewise, access to an improved toilet facility was far higher in urban (83% of households) than in rural areas (40%).7 Food security and nutrition policies have helped to decrease anemia among children under 5 from 63.4% in 2000 to 55% in 2010, and among pregnant women from 66.4% in 2000 to 52.7% in 2010.17

5.5 Community Health System and Structure (Facilitator) The existence of a community health system and CHWs facilitated the U5M reduction work through community engagement activities and direct service delivery. During the study period, Cambodia strengthened its community health system, introducing VMWs and CHWs selected from village health support groups responsible for facilitating the work of the CHWs. CHWs were responsible for providing basic primary care and linking community to health centers through the curative and preventive activities.167 Outcomes which were facilitated included reach and acceptability as Cambodia used this system to extend care and community sensitization and engagement.

5.6 Health Systems Structure and Strengthening (Facilitator and Barrier) The MOH had a strong record on planning and policymaking dating back to the 1980s, which has been critical to achieving major improvements to infrastructure, staffing, and financing of the health system broadly. Cambodia decentralized the health system structure from the MOH to community level. Within the MOH, the Directorate General of Health was in charge of service delivery oversight at provincial health departments and health operational districts. Each operational district supervised a secondary level referral hospital and health centers in its catchment area. This factor – the commitment to improving health systems and through the joint efforts of the government and development partners, facilitated the work in Cambodia to increase the coverage of and access to essential care, especially maternal and child health services, and contributed to the decrease in incidence of major communicable diseases such as lower respiratory infections, diarrheal disease, and measles.104 The efforts also were core to the NMR work with substantially increasing the number of health facilities providing EmONC services from 44 (25 BEmONC and 19 CEmONC) in 2009 to 132 (96 BEmONC and 36 CEmONC) in 2013.17 However the factor was also a barrier where work is still needed in increasing the human resources for health, and ensuring equitable access and coverage across regions.

Exemplars in U5M: Cambodia Case Study 102 5.7 Data Availability and Culture of Use (Facilitator) In Cambodia there was a culture of collecting and using data to evaluate progress and make program decisions at the highest level by national consensus. Cambodia had a long history of ensuring data availability both through HMIS and surveys. The country has been conducting standard DHS since 1998. Other surveys such as Cambodia Socio-Economic Survey and Cambodian Intercensal Population Survey were implemented beginning in 1993 and 2003, respectively.168,169 Since the country was using health databases and information systems beginning in 1994, the stored data were used for prioritization, decision-making, planning, implementation, monitoring and evaluation, and research before and during the study period.52

5.8 Existence of In-Country Research Capacity and Prioritization of Local Research (Facilitator) Cambodia had a culture of leveraging local evidence which was one of the factors facilitating success of the EBIs. For example, the Pasteur Institute in Cambodia produces locally-sound evidence (e.g. pneumonia) to effectiveness of the interventions for the local population.170 Another example is Human Development Research Cambodia which worked with National Maternal and Child Health Center to produce local evidence on effective management of premature birth.171 The ability to have local institutions to conduct research allowed for country prioritization and production of evidence needed for decision-making around the EBIs.

5.9 Expanding Private Health Sector (Facilitator and Barrier) In the 1990s, traditional medicine dominated the private health sector. After 2000, the government began regulating the sector in an effort to promote expansion of the formal private health sector dominating curative health care services while preventive services were more common in public health facilities.23 Private pediatric hospitals play an important role in ensuring preventive and curative care is available free of charge for children – at least those able to access the largely urban-focused facilities.69 However, much of the care from private providers particularly at the community level is not evidence-based, not in line with national strategies, and lacking quality guarantees.69 Given high ongoing private sector usage rates, the public seem to prefer continued opportunities to access private sector providers. A challenge the Government of Cambodia faces in the coming years is to harness the private sector, determining how to work in closer cooperation with it so that public and private health services are all working towards the same ends of preventive and curative health care provision through evidence-based care.

5.10 End of Conflict (Facilitator) Between 1953 and the 1990s Cambodia experienced persistent political unrest and conflict. Cambodia’s health systems, particularly the infrastructure, organization, and human resources, were destroyed during the Khmer Rouge regime.132 Most of those who perished were highly educated and only 45 medical doctors, 26 pharmacists, 28 dentists, and 728 medical students survived the conflict.69 In 1993, Cambodia began to emerge from its civil unrest and has experience sustained peace since the late 1990s. After this period, the health system underwent rapid development including a series of health financing and human resource reforms facilitated by the relative

Exemplars in U5M: Cambodia Case Study 103 stability.132 Cambodia has made great gains rebuilding its infrastructure and human resources, a market economy, and multi-party democracy. Since the end of conflict, development partners including bilateral and multilateral donors and NGOs have partnered with the government to help shape policy, which has made a substantial impact on the public health system and economic development more broadly.39

5.11 Health Insurance (Facilitator) There was no compulsory health insurance or social health insurance coverage during the study period, though many financing mechanisms, including health equity funds and direct tax-funded health services plus user fees for the non-poor and exemptions for the poor, were developed for promoting access to effective and affordable health care for the population, especially the poor and vulnerable. After undergoing reforms, Cambodia’s health financing system had made progress in providing financial risk protection for the poor through measures such as the HEFs, community-based health insurance, performance-based contracting for services, and voucher schemes.172

5.12 Nutrition-Targeted Interventions (Facilitator and Barrier) Work to reduce stunting and improve nutritional status was a contributor, helping to improve resiliency, although gaps in equity persisted. In 2000, 44% of children were stunted, dropping to 32% in 2014 according to DHS. In 2000 nearly half (46%) of children in rural areas were stunted, compared to 38% in urban areas, dropping to 34% (rural) and 24% (urban) in 2014. Economic growth and declining poverty, improving female education, and other factors such as increased breastfeeding and improved feeding were associated with these reductions.173

In 2014, although the prevalence of stunting had dropped, equity gaps remained with 42% of the poorest still stunted compared to only 18% of the wealthiest. A similar pattern was seen for underweight and wasting with drop in prevalence among both groups but persisting equity gaps (Figures 26, 27, and 28). For wasting, the gaps also remained but overall prevalence remained the lowest of the 3 indicators (18% and 19% for the poorest and wealthiest in 2000 and dropping to 11% and 7% respectively in 2014).

Exemplars in U5M: Cambodia Case Study 104 Figure 27. Equity and Coverage Outcome: Percentage Figure 26. Equity and Coverage Outcome: Percentage of of Wasted Children in Cambodia across all Wealth Underweight Children in Cambodia across all Wealth Quintiles (Source: Victora, et al 2018) Quintiles (Source: Victora, et al 2018)

Figure 28. Equity and Coverage Outcome: Percentage of Stunted Children in Cambodia across all Wealth Quintiles (Source: Victora, et al 2018) 5.13 Women’s Empowerment/Education (Facilitator and Barrier) Women’s literacy rate in Cambodia improved from 42% in 2000 to 76% in 2014 with high wealth-based inequity (93% in the richest and 55% in the poorest groups) between the highest and lowest wealth quintiles. Women’s employment also improved from 23.6% in 2000 to 71% in 2014. Among all the employed women, the percentage of those who were employed in professional or technical or management positions, clerical, sales and services, and manual skilled jobs increased from 30% in 2000 to 53% in 2014 with significant inequity from 19.3% in the poorest population to 88.6% in the richest population.7,8 However, the World Economic Forum’s 2012 Global Gender Gap Report, an assessment of women’s parity with men in economic opportunity, educational attainment, and political empowerment, ranked the country 103 out of 135 in gender equity, and Cambodia was the lowest-ranked country in its region.62 Girls’ net enrolment in primary education increased from 76% in 1997 to 97% in 2012, though the proportion of women reporting some primary education was only 48% in 2014.7

Exemplars in U5M: Cambodia Case Study 105 5.14 Reproductive Health (Facilitator) The fertility rate declined from 4.0 births per woman in 2000 to 2.7 in 2014 according to DHS estimates, although gaps existed. For example, the fertility rate for women in the poorest quintile in 2014 was 3.8 compared to 2.2 for women in the wealthiest quintile, a difference of 1.6 births. It was higher among rural women as well, 2.9 versus 2.1 for urban women, though the gap had declined somewhat from 2000 when total fertility was 4.1 for rural women and 3.1 for urban women.

Exemplars in U5M: Cambodia Case Study 106 6 Cross-Cutting and Remaining Challenges

A number of challenges remained despite some of the successes.

6.1 Quality of Care Similar to the other Exemplar Countries, there were missing data on quality of care delivered whether facility- or CHW-delivered. When found, gaps in work to ensure quality as well as actual quality delivered were seen. Some of this was due to implementation challenges while others were broader. For example, community health workers did not receive regular mentorship and supervision. Client dissatisfaction has been noted in areas including health facility staff attentiveness, availability of staff during off-hours, facility cleanliness, and communication around diagnosis and prevention of illness, which will continue to be a barrier to acceptability and reach.39

6.2 Ongoing Health Inequity While health status has improved substantially since 1993, with a number of indicators such as mortality rates dropping significantly, particularly infant mortality rate and maternal mortality ratio, and life expectancy at birth reported a 1.6-fold increase between 1980 to 2010, inequities persisted. This included by rural-urban and socioeconomic status. For example, children in the poorest quintile had a three-fold greater risk of death before their fifth birthday than those in the richest quintile; and stunting was more than twice as common among children in the poorest quintile than in the richest, making them less resilient to communicable disease.39 There were many underlying reasons for this such as geography, health system strength, economic resources, and delayed full coverage and reach of a number of EBIs.

6.3 Out-of-Pocket Spending Out-of-pocket spending in Cambodia remained unacceptably high and peaked at 84% of total health expenditure in the later 1990s – in light of the legalization of private health care delivery, imposition of use fees at government facilities, and widespread informal charging at government health care facilities and reduced to approximately 60% of total health expenditure by 2014.39 During the study period, the out-of-pocket spending proportion varied from 64.4% of total health expenditure in 2000 to 63% in 2015.109 This also represented a barrier and could have contributed to the inequities noted.

6.4 Neonatal Mortality Although Cambodia decreased neonatal mortality, more work is needed to address mortality caused by prematurity, lower respiratory infection, and birth asphyxia. In addition, work to build the capacity needed to manage the low birth weight and premature infants through ongoing health system strengthening, quality, and financial access.

Exemplars in U5M: Cambodia Case Study 107 6.5 Government Funding for Health While Cambodia prioritized funding for EBIs, all-cause government expenditure as a percentage of overall health expenditure remained low and decreased between 2000-2015, from 22.4% in 2000 to 19% in 2005, 19.5% in 2010, and 21.6% in 2015.109 Health spending was just 1.4% of GDP in 2015.39 This also could have slowed work needed to increase coverage as well as address the high OOP.

6.6 Air Pollution Air pollution, especially indoor air pollution, continues to be an important factor impacting health outcomes. Air pollution-related deaths among children U5 have steadily declined since 2000 (from 306 deaths per 100,000 in 2000 to 75 per 100,000 in 2015), but contributing factors such as cooking fuels and secondhand smoke are continuing challenges.109

6.7 Lack of Qualified Midwives and Physicians While progress has been made, particularly in training more midwives, Cambodia still needs to double the size of its midwifery workforce to reach international standards, and increase the physician workforce by tenfold. Equally important is ensuring the workforce is equitably distribution across the country.

Exemplars in U5M: Cambodia Case Study 108 7 Transferable Knowledge for Other Countries

There were a number of implementation strategies from Cambodia that have the potential to be adapted and adopted by other countries looking to learn from Cambodia’s successes and challenges to accelerate their own declines in U5M. Broadly, that multiple implementation strategies are often needed which should be informed by gap analysis and needs assessment for which contextual factors can be leveraged, which need to be addressed by implementation strategies for the EBI, and which require direct address through interventions beyond the health system EBIs.

Cambodia took a broad and holistic approach, working to strengthen and build on existing health system capacity through integrating new initiatives rather than developing vertical systems. Priority was placed on creating laws, policies, and regulations, and enforcing them to ensure quality and delivery. Leaders used evidence-based decision-making and created policies and strategies based on global and local scientific evidence and feasibility, valuing the local generation of research and evidence. There has been strong coordination of donor and implementing partner activities, and the country has engaged meaningfully with stakeholders and leveraged expertise across sectors and levels, including MOH, donors, implementing partners, and community members. In addition, national health leaders have engaged in multisectoral collaboration to address health and health-related determinants. Cambodia also planned for equity from the start of EBI implementation, prioritizing pro-poor policies. Like a number of other Exemplar countries, addressing other factors related to U5M was important. For example, economic development, infrastructure investments, and identifying and addressing other public health issues such as WASH activities.

1. Build on existing health system capacity and strengthen primary health care systems. Integration of new initiatives into existing structures and previous initiatives was an important approach to reduce risk for vertical projects and duplication of work while providing resources to increase overall capacity. This approach was in contrast to focusing on vertical programs which other countries had done. This was particularly important given the work needed to rebuild the overall health system. Notable examples of this include: • CB-IMCI was integrated into the existing community health system involving an existing cadre of community health workers, village malaria workers. • New vaccines were introduced leveraging existing systems such as supply chain and HMIS.

2. National (health and more broadly) leadership to create laws, policies, and regulations, to support implementation of the EBIs and enforce them to ensure quality, delivery, and sustainability. Cambodia formulated national policies and legal frameworks to better define and implement its vision for health. With national policy documents, such as the Child Survival Strategy and the Health Sector Strategic Plans, Cambodia outlined its national priorities and made ministries accountable to these. These policy documents also made it easier to hold implementing partners to the national vision they established. Health workforce policy development has prioritized improving numbers, capacity, and geographic distribution of health providers, and particularly midwives. Reproductive, maternal, newborn, and child health-focused policies have centered women and children in the health care system, supported by laws, standards and guidelines, and delivery strategies.17 These included:

Exemplars in U5M: Cambodia Case Study 109 • 2003-2008 Health Strategic Plans • 2006-2015 Child Survival Strategy • 2006 Comprehensive Midwifery Review • 2006-2010, 2013-2016 National Reproductive and Sexual Health Strategies • 2007 Midwife salary scale increased and Prakas – Government delivery incentive Scheme • 2008-2015 Health Strategic Plans • 2010-2015 Fast Track Initiative Road Map for Reducing Maternal and Newborn Mortality

3. Engage meaningfully with stakeholders and leverage expertise across sectors and levels, including MOH, donors, academics, implementing partners, and community members starting at Exploration and through Sustainment. This approach helped to ensure leveraging of existing available expertise, alignment around a national plan, better acceptability, and potential for scale. This occurred through broad engagement at the start and leveraging of available technical knowledge and resources. This was typically done through high-level consultations and workshops, technical working groups, and identification of technical experts to lead pilot testing (which was often done through local research institutions). For example, the Technical Working Group scope included review of published evidence, exploration of feasibility before implementing new EBIs, design of pilot tests, and adaptation of existing EBI programs. One example of a practical success is the Child Survival Strategy: • In 2004, data analysis showed slow progress in child mortality reductions. The findings were summarized in a benchmark report presented at the High-Level Consultation on Millennium Development Goal 4, noting that pneumonia, diarrhea, neonatal causes, and undernutrition had not received adequate attention or resources. • This consultation brought together representatives from all major child survival partners in Cambodia and was followed by an NGO consultative workshop. • The MOH subsequently established a Child Survival Steering Committee and a Child Survival Management Committee in order to better coordinate planning and resources. These committees developed a national child survival strategy that was finalized at a national workshop in 2006 and disseminated the following year. • This Child Survival Strategy outlined approaches to improving child health, along with interventions and methods of delivery.17 • Policy implementation partners included Cambodia’s MOH, USAID, UNICEF, WHO, inter-ministerial links to the Ministry of Planning, Ministry of Economics and Finance, Ministry of Education, Youth and Sports, and Ministry of Rural Development, the National Pediatric Hospital and other teaching hospitals, provincial health departments, Medical, Nursing, and Pharmacy Associations and multilateral and bilateral agencies and NGOs including the University of Melbourne, PATH, PSI, and village health workers and VHSGs.69

4. Strong coordination of donor and implementing partner activities with national leadership. Cambodia has been able to leverage financial and technical resources to engage donors and implementing partners to work towards national goals and policies. The use of logic, a strong evidence base, arguments for sustainability, and legal frameworks, can be adopted by governments in effectively coordinating donor and NGO activities nationwide. Direction is set at the highest level by establishing clear development goals using the Sector

Exemplars in U5M: Cambodia Case Study 110 Wide Management (SWiM) mechanism for health, a modified SWAp. The SWiM mechanism aligns and directs the contribution and activities of the development partners in achieving objectives set by the MOH. The Technical Working Group for Health and other sub-technical working groups and task forces help with coordination and development of technical content, and there is an NGO support organization, MEDiCAM, which helps facilitate collaboration between government activities and activities at the grassroots level. There are structures in place to support partnerships under the SWiM, which could be replicated by other countries: • A Technical Working Group for Health, chaired by the Secretary of State and co-chaired by WHO, is the main forum for consultations between government and development partners. Its membership includes government, NGOs, bilateral donors, and development agencies. • A number of sub-technical working groups are responsible for developing guidelines, planning, and tracking progress in specific areas. • At the provincial level the Provincial Technical Working Group for Health brings together key players from provincial government, development partners, and NGOs. • During the MDG era, an RMNCH task force was responsible for tracking progress towards the MDGs. • Annual Joint Annual Performance Reviews are conducted in conjunction with the National Health Congress, and attended by institutions at all levels, other relevant ministries, health partners, provincial authorities, community councils, members of the community, professional associations, NGOs, for-profit private organizations, and other stakeholders.17

5. Multisectoral collaboration to address health and health-related determinants. Through engagement of multisectoral work, a number of interventions have supported addressing other determinants of U5M whether increasing access and quality, prevention of disease, or improving resilience. These included WASH, women’s empowerment, education, and other work. Cambodia’s RMNCH program is a multisectoral collaboration, with responsibilities shared between national programs and departments which support provincial and health districts, with the MOH supporting district facility-based outreach activities and routine supervision. Community-based structures have been built through NGO collaborations, using community- based distributers of family planning methods, village health volunteers, and other available community resources. The Cambodian MOH leverages links with other ministries, including the Ministry of Education, Youth and Sport, and the Ministry of Women’s Affairs, to promote health through other sectors. For example, the Ministry of Women’s Affairs works with commune councils to promote women’s access to education, family planning in rural and poor communities, nutrition practices, and gender equality.17

Cambodia made significant improvements in infrastructure not related directly to health, which likely contributed to successes in U5M. These included: • Broader infrastructural investment, combined with Cambodia’s steady economic growth, have contributed to the successes seen in the health sector. • Addressing underlying causes, such as improved access to safe water and sanitation. • An equity agenda, including education and reproductive rights which included the educational sector and Ministry of Women’s Affairs. • Sectors outside of health have been central to mortality declines and improvements in health. Cambodia has seen improvements in education (primary school enrolment, time spent in school, literacy), nutrition

Exemplars in U5M: Cambodia Case Study 111 and access to improved water and sanitation. A 60% reduction in poverty was seen across all population groups between 2004 and 2011.17

6. Focus on equity from the beginning – including strategies to address identified gaps not just for wealth but geographic differences. This case study has explored Cambodia’s efforts to improve differences in geographic and socioeconomic equity including through pro-poor policies. One approach that has been expanded due to its success has been through health equity funds and reproductive health vouchers. • In 2000, the HEF was introduced which paid public health providers on behalf of poor people. The HEF pays for prenatal care, delivery, comprehensive postpartum care, and other MNCH services. HEF-funded patients are provided care, with costs for their care, transport to the facility, and reimbursement to the facility by an inspection authority in Phnom Penh, which repays the facilities. The HEF scheme led to a reduction in OOP health expenditure among the poor (Cambodia Socio-Economic Survey 2004–2009), increased utilization of government services, and reduced debt and asset sales for health care.39 By 2013, about 16% of the population or 2.2 million people below the poverty line had coverage from HEFs. • In 2007 reproductive health vouchers were piloted in three rural health districts as an expansion of HEFs targeting pregnant women for safe motherhood services (ANC, FBD, PNC). The pilot was eventually scaled up to 27 health districts by 2013, with studies indicating the vouchers were effective at improving access and coverage among poor pregnant women.17

7. Use evidence-based decision-making and create policies and strategies based on global and local scientific evidence and feasibility, valuing the local generation of research and evidence. Cambodia had a strong practice of exploring globally emerging EBIs and then conducting local pilot testing to determine need or impact of potential EBIs before adoption, often through implementing partners. • Cambodia has a long track record for collection and use of data to evaluate progress and make program decisions at the highest level by national consensus. This approach has facilitated the identification and acceptance of problems, and has resulted in the establishment of important program initiatives including the development of the Child Survival Strategy as well as the 2006 midwifery review that led to actions to improve the availability of midwives including the Government Midwifery Incentive Scheme. • Regular collection and use of survey data: In Cambodia, national population-based surveys have continued to be the primary approach for collecting representative data on key demographic, impact, and coverage measures. Demographic and Health Surveys have been conducted in 2000, 2005, 2010, and 2014. Analysis of data is conducted to identify high-risk populations, factors associated with poor outcomes, and to track progress in RMNCH.17

8. Strengthen health systems to support EBI implementation. Cambodia made the decision to focus on lowering neonatal mortality fairly early in the study period,69 focusing not only on targeted EBIs but importantly on needed health system strengthening efforts needed in order to successfully implement programs such as expanding EmONC nationwide. • In 2009, the National EmONC Study, a nationwide review on the EmONC, reported a shortage in EmONC facilities, at 1.6 per 50,000 women, compared to the UN recommendation of at least five per 50,000 women.148 The review reported shortages in EmONC distribution; the majority were located around cities

Exemplars in U5M: Cambodia Case Study 112 and towns, and five provinces (Kampong Speu, Kandal, Mondul Kiri, Otdar Meanchey and Kampot/Kep) did not have any EmONC services. • In response, the MOH developed the 2010-2015 EmONC Improvement Plan, a detailed plan for improving EmONC services through implementing an evidence-based package of interventions, updating existing guidelines on eclampsia and newborn asphyxia management to better align with international evidence, and expanding facility EmONC service delivery. • Between 2009 to 2015, the number of BEmONC facilities increased from 19 to 110. The number of CEmONC facilities increased from 25 to 37. The proportion of births in all EmONC facilities doubled from 17.8% in 2008 to 35% in 2014. The proportion of functional EmONC facilities with two or more secondary midwives rose from 84% in 2008 to 98% in 2014.150

8 Conclusions Cambodia has achieved remarkable drops in U5M and neonatal mortality despite challenges in regional access and coverage. The increase in coverage of EBIs has been more variable overall for some groups based on rural or urban geography and wealth. Improvements outside the health system and a strong commitment to other initiatives, which impacted social determinants, including economic growth, female empowerment, reduction in stunting, poverty reduction, and WASH, were identified as key factors influencing U5M addressing reduction in disease and improving overall health status and resiliency. Strong national leadership and health system strengthening efforts as well a strategic leveraging of donor and partner resources (financial, expertise, implementation) were credited with many of the successes. Challenges remain in areas including quality, continued improvements to equity in access and coverage, components of neonatal health, and continuing to grow and strengthen human resources for health.

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Exemplars in U5M: Cambodia Case Study 123 APPENDIX A EXEMPLARS IN UNDER-5 MORTALITY METHODOLOGY AND FRAMEWORK

The University of Global Health Equity collaborated with Gates Ventures to explore approaches to better understand the successes of countries in reducing under-5 mortality (U5M). This work was initially designed with two aims: 1. Developing and testing an implementation framework and mixed methods approach to understand the success of these countries, and 2. Extracting actionable knowledge focused on implementation strategies and key contextual factors to inform other countries working towards the same goal. The scope of mortality was limited to amenable causes of death – those which are potentially preventable with a stronger and higher quality health care system. The work was divided into a number of activities. These included: 1. identifying evidence- based interventions (EBIs) in use in LMICs; and 2. understanding how the EBIs implemented by a country were able to achieve success beyond their regional neighbors and other comparable countries. The analysis and conclusions were designed to be data-driven and rigorous, but also to create knowledge that is transferable and accessible and has the potential to be used across a range of key stakeholders. Therefore, the content developed by the Exemplars project is intended primarily for an audience of national policymakers, implementers, and funders – people with the potential to significantly impact global health policy and implementation at scale. The work was guided by the development of a framework which was informed by a number of existing frameworks in use for U5M (e.g. Countdown 2015, WHO) and from existing implementation science frameworks (see below).

Identifying evidence-based interventions to reduce U5M in LMICs The initial work included identifying EBIs found to directly reduce U5M, dividing the work between those targeting the neonatal period (birth to 28 days) and the infant and child period (28 days to 4 years). This work included literature review, discussions with experts in the area, and revisions with them as the work progressed. We focused on those interventions that were relevant to resource-constrained settings, those that were directly related to preventing potential life-threatening conditions (e.g. vaccinations, safe birth practices, insecticide- treated nets), and those treating illness or other complications (e.g. antibiotics, , neonatal resuscitation). We included interventions that were at the individual process level (e.g. administering the right antibiotic and the right time) as well as those targeting inputs (e.g. development of neonatal intensive care units) and systems needed to deliver the EBIs meeting the definitions of quality including effectiveness, safety, timeliness, and equity (e.g. CHWs). For neonatal mortality we also expanded to a limited set of prenatal and intrapartum interventions proven to reduce neonatal death. We did not focus on those interventions that resulted in reductions in stillbirths, as those are not included in the assessment of U5M rates. This was driven in part by the changing epidemiology of neonatal causes of death seen in some countries, with low birth weight (LBW) and prematurity increasing in importance in causes of mortality.174

Exemplars in U5M: Cambodia Case Study 124 Appendix Table 44. Infant and Child Under-5 Mortality Evidence-Based Interventions

Cause of Death EBI Antibiotic treatment Vaccination: PCV Lower respiratory Vaccination: Hib infections Community-based management Facility-based management Oral rehydration therapy Zinc supplementation Diarrheal diseases Vaccination: Rotavirus Community-based management Facility-based management Antimalarial combination therapy Rapid diagnostic testing Insecticide-treated nets Malaria Indoor residual spray Intermittent preventative therapy for high-risk groups Community-based management Facility-based management Vaccination: Measles Measles Vitamin A supplementation (prior to vaccination) Exclusive breastfeeding for six months Continued breastfeeding and complementary feeding after six months Malnutrition Vitamin A supplementation Management of severe acute malnutrition (ready-to-use food, rehydration, antibiotics) ARV treatment for infants and children HIV testing of children born to HIV+ mothers Prevention of Early diagnosis of pregnant women (or pre-pregnancy) mother-to-child PMTCT treatment for mothers* and post-partum to exposed infants HIV transmission Elective C-section for untreated HIV+ mothers**; replacement feeding** ARV treatment for mother for life as prevention (started in 2012)

Exclusive breast feeding Vaccination: PCV meningococcal Vaccination: Hib Meningitis Vaccination: Meningococcal Antibiotic treatment Chemoprophylaxis during acute outbreaks Vaccination: Tetanus Other vaccine Vaccination: Diphtheria preventable Vaccination: Pertussis diseases Vaccination: Polio

* No longer recommended (PMTCT versus ART for life) **No longer recommended for women on ART with suppressed viral load

Exemplars in U5M: Cambodia Case Study 125 Appendix Table 45. Neonatal Mortality Evidence-Based Interventions

Period of Risk EBI Preconception Folic acid supplementation Tetanus vaccination Intermittent presumptive treatment Malaria prevention and treatment ITNs Iodine supplementation (in endemic iodine deficient settings) 4 or more antenatal visits (ANC4) Antenatal Calcium supplementation* Low-dose aspirin for high-risk women* Prevention and treatment of Antihypertensive treatment for severe hypertension preeclampsia and eclampsia Magnesium sulfate Early delivery Antibiotics for PPROM Corticosteroids for preterm labor C-section for breech or obstructed labor Active management of delivery (including partograph) Clean delivery practices (incl. clean cord-cutting) Intrapartum Trained birth attendant Facility-based delivery Basic emergency obstetric and newborn care (BEmONC) Comprehensive emergency obstetric and newborn care (CEmONC) Timely transport for higher level care for mother Newborn resuscitation Immediate breastfeeding Immediate drying and wrapping Prevention and management of Delayed bathing hypothermia Skin-to-skin Baby warming Postnatal Kangaroo care for LBW/prematurity Timely transport for higher level care for mother Post-partum visits to identify danger signs and provide active referral Antibiotics for suspected or confirmed infection Surfactant therapy for respiratory distress syndrome and prematurity Neonatal intensive care units (equipped, trained staff, standards and protocols established and followed) * Further assessment needed in literature review

Exemplars in U5M: Cambodia Case Study 126 Both the desk review and the primary research are informed by an implementation science framework that incorporates a number of existing frameworks and is designed specifically for this project. While we are often able to identify policies and EBIs chosen by a country to reduce U5M, the key lessons in how these were chosen, adapted, implemented, and sustained are often missing from available published or gray literature. Because the same policies and interventions brought different results in different countries, implementation science offers important tools for analyzing and understanding how to think more holistically about how and why countries were able to reduce U5M and from where lessons in replication can be drawn. To guide the overall work, we developed a framework to understand the contribution of contextual factors and the different levels of actors involved: global, national, ministry, subnational, facility, and community.

We reviewed existing implementation science frameworks and have combined a number of commonly applied ones as well as insights from work underway by Dr. Binagwaho to guide how we interpret existing evidence and to design tools for primary research.

The primary frameworks and implementation science resources we drew from include:

Appendix Figure 1: EPIS model of implementation (Source: Aarons, et al)

Exemplars in U5M: Cambodia Case Study 127 1. Exploration, Preparation, Implementation, and Sustainment (EPIS):175 This framework walks through four key steps of the implementation process needed to achieve long-term change-starting. Within each phase there are important contextual factors which may influence success (Appendix Figure 1).

2. Re-AIM:176 This evaluation framework breaks down implementation outcomes into Reach (coverage), Effectiveness, Adoption (range and proportion of individuals and organizations willing to participate), Implementation (fidelity, time, cost, and adaptations made) and Maintenance (institutionalization into routine care and policies, and long-term impact). It is designed to better understand the range of factors that influence success or failure at the individual and broader levels.

3. Consolidated Framework for Implementation Research (CFIR):177 This framework serves as a guide to understand the contextual factors that influenced the success or failure of implementation of a specific intervention. These include the outer context, the inner (organizational) context, the characteristics of the intervention, the implementation approach, and the individual actors responsible for implementation.

4. Implementation Outcomes (Proctor et al):178 This approach distinguishes implementation outcomes from the more traditionally measured intervention and system outcomes. It identifies and defines key areas that are critical to achieving overall effectiveness, core goals of initiatives targeting U5 mortality. Outcomes include acceptability, adoption, appropriateness, costs, fidelity, feasibility, penetration (reach), Appendix Figure 2: Types of outcomes in and sustainability (Appendix Figure 2). implementation research (Source: Proctor, et al)

5. The implementation principles for managing all levels of a health sector as described in the book in progress by Dr. Binagwaho: This book is written to share her experiences on what was successful, what failed, why, and how, when she served in technical and political positions in the health sector in Rwanda between 1996 and 2016.

None of the frameworks alone were felt to cover the complexity the implementation strategies and steps undertaken at the national, subnational, and care-delivery levels. By combining them we have developed a framework that will be used to guide how we prioritize areas for primary research, interpret the secondary research, and form the themes for synthesis of the entirety of our work (Appendix Figure 3).

Exemplars in U5M: Cambodia Case Study 128

Appendix Figure 3: Framework for understanding interventions to reduce under-5 mortality (copyright UGHE)

Exemplars in U5M: Cambodia Case Study 129 Desk Review: (Led by EvaluServe with in-depth support from UGHE and Gates Ventures)

The team undertook an extensive review of available information and published data on the rates and progress of U5M, policies, strategies, specific EBIs available to potential Exemplar countries, and the uptake and implementation of these EBIs in five Exemplar countries defined as countries which have reduced U5M beyond expectations based on regional or resource comparators. Initial secondary research was performed through MEDLINE (PubMed) and Google Scholar, using the search terms “child mortality” or “under-5 mortality” and the country’s name. Further searches included specific EBIs, causes of death, or contextual factors as search terms (e.g. “insecticide-treated nets,” “malaria,” or “community health workers”). Initial desk research was synthesized and then reviewed by the UGHE team for accuracy and completeness. The desk review is an iterative process, with ongoing additions occurring throughout the primary research process. As noted, the initial review was limited to causes of death felt to be “amenable” with effective interventions and targeted all U5M, from neonatal through infancy and early childhood. While maternal health is a critical determinant of child survival, given the extensive work already underway and the limited resources and time of the contract, we did not include an exhaustive review of these EBIs but focused on those more directly related to the childbirth period or primary data analysis. This will be supplemented by selected maternal interventions. We purposely did not include in- depth reviews of important broad interventions that contributed to U5M reduction including education, poverty reduction, water and sanitation, and programs designed to improve nutritional status. These will be captured as important contextual factors in the country case studies.

Human Subjects Review Not needed.

Analysis and Synthesis The UGHE team used a mixed methods explanatory approach, applying the framework to understand the progress (or lack thereof) for each cause of death and coverage of chosen EBIs, as well as facilitators and barriers at the local, national, and global levels. This approach was designed to understand what, how, and why the Government of Cambodia was able to achieve success in decreasing U5M and what the challenges were. The analyses were also informed by work completed by other initiatives, including Countdown 2015, equity plots from the International Center for Equity in Health (C Victora and team), and geospatial mapping from the Institute for Health Metrics and Evaluation (S Hays and team), amongst others.

Final Products The work done by UGHE and Gates Ventures will result in new knowledge examining the implementation strategies for developing needed policies and identifying, adapting, and scaling EBIs, supporting and obstructing contextual factors from countries successful in reducing U5M using an implementation science approach. The final products will include (1) the generally-applicable implementation science framework shown here, (2) in-depth case studies of four Exemplar countries using primary and secondary research, (3) case studies of three Exemplar countries based on desk research and buttressed with light- touch primary research, and (4) a cross-country synthesis of insights from all seven Exemplar countries.

Exemplars in U5M: Cambodia Case Study 130 Although all countries deserve deeper research on and analysis of their successes in U5M reduction, limitations in resources and time bound the scope of this project. The work done related to these seven Exemplar countries will serve as a proof of principle of the added value of applying implementation science to the research of U5M interventions and successes. The products from this work will be disseminated through a larger online platform created by Gates Ventures to highlight actionable lessons from Exemplar countries on a variety of health topics.

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