Document of The World Bank
Report No: ICR00002307 Public Disclosure Authorized
IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-37280 IDA-H0150 IDA-H0160 TF-51053)
ON
IDA CREDIT (37280) IN THE AMOUNT OF SDR13.1 MILLION (US$ 17.2MILLION EQUIVALENT)
IDA GRANT FOR POOREST COUNTRY (H0150)
Public Disclosure Authorized IN THE AMOUNT OF SDR6 MILLION (US$7.8 MILLION EQUIVALENT
IDA GRANT FOR HIV/AIDS (H0160) IN THE AMOUNT OF SDR1.6 MILLION (US$2 MILLION EQUIVALENT)
AND
DFID TRUST FUND (TF051053) IN THE AMOUNT OF GBP1,198,775 (US$ 1.84 MILLION EQUIVALENT) Public Disclosure Authorized TO THE
KINGDOM OF CAMBODIA
FOR A
HEALTH SECTOR SUPPORT PROJECT
June 19, 2012
Public Disclosure Authorized Human Development Unit East Asia and Pacific Region
CURRENCY EQUIVALENTS (Exchange Rate Effective as of December 31, 2011) Currency Unit = Khmer Riel (KHR) KHR 1.00 = US$ 0.00 US$ 1.00 = KHR 4,029.98
KINGDOM OF CAMBODIA FISCAL YEAR January 1 - December 31
ABBREVIATIONS AND ACRONYMS
AIDS Acquired Immune Deficiency Syndrome AOP Annual Operating Plan AusAID Australian Agency for International Development CDHS Cambodia Demographic and Health Survey CPA Complementary Package of Activities DFID Department for International Development (United Kingdom) DOTS Directly Observed Treatment, Short Course (for TB) GFATM The Global Fund to Fight AIDS, Tuberculosis and Malaria HEF Health Equity Fund HIV Human Immunodeficiency Virus HMIS Health Management Information System HSP1 Health Sector Strategic Plan 2003-2007 HSSP Health Sector Support Project HSSP2 Second Health Sector Support Project IEC Information, Education and Communication IMCI Integrated Management of Childhood Illnesses ISR Implementation Status and Results Report JICA Japan International Cooperation Agency JAPR Joint Annual Performance Review M&E Monitoring and Evaluation MDG Millennium Development Goal MEF Ministry of Economy & Finance MOH Ministry of Health MPA Minimum Package of Activities NGO Non-government Organization OD Operational District PAD Project Appraisal Document PHD Provincial Health Department PMU Project Management Unit SWAp Sector-wide Approach SWiM Sector-Wide Management UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund
Vice President: Pamela Cox Country Director: Annette Dixon Sector Manager: Toomas Palu Task Team Leader: Nareth Ly ICR Lead Authors: Richard Andrew Cornish and Timothy Johnston
CAMBODIA IMPLEMENTATION COMPLETION AND RESULTS REPORT HEALTH SECTOR SUPPORT PROJECT TABLE OF CONTENTS
Data Sheet A. Basic Information ...... i B. Key Dates ...... i C. Ratings Summary ...... i D. Sector and Theme Codes ...... ii E. Bank Staff ...... ii F. Results Framework Analysis ...... iii G. Ratings of Project Performance in ISRs ...... viii H. Restructuring ...... viii I. Disbursement Profile ...... ix
1. Project Context, Development Objectives and Design ...... 1 2. Key Factors Affecting Implementation and Outcomes ...... 3 3. Assessment of Outcomes ...... 9 4. Assessment of Risk to Development Outcome ...... 15 5. Assessment of Bank and Borrower Performance ...... 15 6. Lessons Learned ...... 21 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners ...... 21
Annex 1. Project Costs and Financing ...... 25 Annex 2. Outputs by Component ...... 26 Annex 3. M&E indicators ...... 40 Annex 4. Economic and Financial Analysis ...... 47 Annex 5. Bank Lending and Implementation Support/Supervision Processes ...... 48 Annex 6. Summary of Borrower's ICR and/or Comments on Draft ICR ...... 50 Annex 7. Comments of Cofinanciers and Other Partners/Stakeholders ...... 57 Annex 8. List of Supporting Documents ...... 61
MAP
CAMBODIA IMPLEMENTATION COMPLETION RESULTS REPORT HEALTH SECTOR SUPPORT PROJECT (HSSP) DATA SHEET
A. Basic Information
KH-Health Sector Country: Cambodia Project Name: Support Project IDA-37280,IDA- Project ID: P070542 L/C/TF Number(s): H0150,IDA-H0160,TF- 51053 ICR Date: 06/22/2012 ICR Type: Core ICR KINGDOM OF Lending Instrument: SIM Borrower: CAMBODIA Original Total XDR 20.70M Disbursed Amount: XDR 19.95M Commitment: Revised Amount: XDR 19.95M Environmental Category: B Implementing Agencies: Ministry of Health Cofinanciers and Other External Partners: United Kingdom Department for International Development (DFID)
B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 07/31/2001 Effectiveness: 08/14/2003 08/14/2003 Appraisal: 10/03/2002 Restructuring(s): 12/16/2010 Approval: 12/19/2002 Mid-term Review: 03/01/2006 10/02/2006 Closing: 12/31/2007 12/31/2011
C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Moderate Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Satisfactory
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C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Moderately Satisfactory Implementing Quality of Supervision: Moderately Satisfactory Moderately Satisfactory Agency/Agencies: Overall Bank Overall Borrower Moderately Satisfactory Moderately Satisfactory Performance: Performance:
C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments (if Indicators Rating Performance any) Potential Problem Project Quality at Entry Yes Moderately Satisfactory at any time (Yes/No): (QEA): Problem Project at any time Quality of Supervision No None (Yes/No): (QSA): DO rating before Moderately
Closing/Inactive status: Satisfactory
D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 5 5 Health 80 80 Non-compulsory health finance 10 10 Sub-national government administration 5 5
Theme Code (as % of total Bank financing) Child health 22 22 Health system performance 22 22 Nutrition and food security 22 22 Rural services and infrastructure 11 11 Tuberculosis 23 23
E. Bank Staff Positions At ICR At Approval Vice President: Pamela Cox Jemal-ud-din Kassum Country Director: Annette Dixon Ian C. Porter Sector Manager: Toomas Palu Emmanuel Y. Jimenez Project Team Leader: Nareth Ly Vincent Turbat
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ICR Team Leader: Nareth Ly ICR Primary Author: Richard A. Cornish Timothy A. Johnston
F. Results Framework Analysis
Project Development Objectives (from Project Appraisal Document) The objective of this project is to contribute to the improvement of the health status of the population by: (a) increasing the accessibility and the quality of health services; and (b) assisting the Kingdom of Cambodia to implement its Health Sector Strategic Plan and strengthen the sector's capacity to manage resources efficiently.
Revised Project Development Objectives (as approved by original approving authority) N/A
(a) PDO Indicator(s)
Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years Indicator 1 : Maternal mortality ratio (per 100,000 live births) Target values for CMDG indicators Value (Updated at quantitative or 437 (1997) N/A 206 (2010 CDHS) 2007 MTR): Qualitative) By 2005: 343 By 2010: 243 By 2015: 140 Date achieved 05/22/2007 12/31/2007 12/31/2010 12/31/2010 Comments Exceeded the initial CMDG interim target of maternal mortality ratio of 243/100,000 (incl. % live births by 2010. achievement) Indicator 2 : Fertility rate Target values for CMDG indicators Value (Updated at quantitative or 4.0 (2000 DHS) N/A 3.0 (2010 CDHS) 2007 MTR): Qualitative) By 2005: 3.8 By 2010: 3.4 By 2015: 3.0 Date achieved 12/31/1998 12/31/2007 12/31/2010 12/31/2011 Comments Already achieved 2015 CMDG target.
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(incl. % achievement) Indicator 3 : Malnutrition rate among children under 5 years of age Target values for CMDG indicators (Updated at 2007 MTR): Stunting 35% Stunting 39.90% by 2005, 28% Stunting 45% (2000 DHS) (2010 CDHS) Value by 2010, 22% Wasting 15% (2000 DHS) Wasting 10.9% (2010 quantitative or N/A by 2015 Underweight 45% (2000 CDHS) Qualitative) Wasting 13% DHS) Underweight 28.30% by 2005, 10% (2010 CDHS) by 2010, 9% by 2015 Underweight 36% by 2005, 29% by 2010, 22% by 2015 Date achieved 12/31/2000 12/31/2007 12/31/2010 12/31/2011 Comments (incl. % Off track to achieve CMDG interim target values for 2010 for stunting and wasting. achievement) Indicator 4 : Child mortality rate (under 5 mortality rate) Target values for CMDG indicators Value (Updated at quantitative or 124 (2000 CHS) N/A 54 (2010 CDHS) 2007 MTR): Qualitative) By 2005: 105 By 2010: 85 By 2015: 65 Date achieved 12/31/2002 12/31/2007 12/31/2010 12/31/2011 Comments (incl. % Exceeded CMDG target values for 2010 and 2015. achievement)
(b) Intermediate Outcome Indicator(s)
Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised Target approval Completion or Values documents) Target Years Indicator 1 : HIV prevalence among 15-49 years old Target values Value 2003: 1.9% (NCHADS for CMDG (quantitative N/A 0.7% (JAPR 2011) 2004) indicators or Qualitative) (Updated at
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2007 MTR): By 2005: 2.3% By 2010: 2.0% By 2015: 1.8% Date achieved 12/31/2003 12/31/2007 12/31/2010 02/15/2011 Comments (incl. % Exceeded CMDG target values for 2010 and 2015. achievement) Indicator 2 : Malaria case fatality rate (severe case only) treated in public facilities per 100 patients Target values for CMDG indicators Value (Updated at (quantitative 2002: 10.85% (HMIS) N/A 0.22% (JAPR 2011) 2007 MTR): or Qualitative) By 2005: 0.3% By 2010: 0.25% By 2015: 0.1% Date achieved 12/31/2002 12/31/2007 12/31/2010 12/31/2011 Comments (incl. % Achieved CMDG interim target value for 2010. achievement) Indicator 3 : Incidence of malaria per 1,000 inhabitants in high risk areas Health Strategic Plan 2008- 2015: Value By 2010: 3.34/1,000 (quantitative 2002:8.6 (HMIS) N/A 3.58/1,000 inhabitants (2010 or Qualitative) inhabitants result, JAPR 2011) By 2015: 2.16/1,000 inhabitants Date achieved 12/31/2002 12/31/2007 12/31/2010 12/31/2002 Comments (incl. % Achieved 2010 target of Health Strategic Plan 2008-2015 achievement) Indicator 4 : Percentage of children under 1 year fully immunized Health Strategic Value Plan 2008- (quantitative 39% (2000 DHS) N/A 2015: 73.6% (2010 CDHS) or Qualitative) By 2010: 70% By 2015: 80% Date achieved 12/31/2002 12/31/2007 12/31/2010 12/31/2011 Comments (incl. % Achieved target value of Health Strategic Plan for 2010. achievement) Indicator 5 : Percentage of pregnant women received at least 2 ANC consultation Value Target values 72% (2010 result, (quantitative 2002:29% (HMIS) N/A for CMDG JAPR 2011) or Qualitative) indicators
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(Updated at 2007 MTR): By 2005: 60% By 2010: 75% By 2015: 90% Date achieved 12/31/2002 12/31/2007 12/31/2010 12/31/2011 Comments (incl. % Significant progress, but slightly short of CMDG target value for 2010. achievement) Percentage of married women aged 15-49 years using modern contraceptive in public Indicator 6 : health services Target values for CMDG indicators Value (Updated at (quantitative 2002:17% (HMIS) N/A 35% (2010 CDHS) 2007 MTR): or Qualitative) By 2005: 30% By 2010: 44% By 2015: 60% Date achieved 12/31/2002 12/31/2007 12/31/2010 12/31/2011 Comments (incl. % Off tract to achieve CMDG interim target value for 2010. achievement) Indicator 7 : Percentage of deliveries attended by trained staff Target values for CMDG indicators Value (Updated at 69.6% (2010 result, (quantitative 20% (HMIS) N/A 2007 MTR): JAPR 2011) or Qualitative) By 2005: 60% By 2010: 70% By 2015: 80% Date achieved 12/31/2002 12/31/2007 12/31/2010 12/31/2011 Comments (incl. % Achieved CMDG interim target value for 2010. achievement) Indicator 8 : Improved capacity of health centers (full MPA capacity) 470/965 set for Value 2006 annual (quantitative 294 (HMIS 2003) N/A N/A operational plan or Qualitative) (JAPR 2007) Date achieved 12/31/2003 12/31/2007 12/31/2006 12/31/2010 Comments This indicator was dropped from the monitoring framework of health Strategic Plan (incl. % 2008-2015. achievement) Indicator 9 : Improved capacity of Referral Hospitals (achieved CPA2 & CPA3 levels) Value 47/67 RH set 56/89 Referral (quantitative N/A N/A for 2006 annual Hospitals (JAPR or Qualitative) operational plan 2011)
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(JAPR 2007) Date achieved 03/31/2002 12/31/2007 12/31/2011 12/31/2011 Comments (incl. % Increased from 45/79 Referral Hospitals in JAPR 2010. achievement) Indicator 10 : Disbursement of MOH budget expenditures 102.6% Value (Disbursement of (quantitative N/A N/A N/A national budget, or Qualitative) JAPR 2011) Date achieved 08/31/2003 12/31/2007 12/31/2011 12/31/2011 Comments (incl. % achievement) Pulmonary TB Smear (+) case detection rate Indicator 11 : Pulmonary TB cure rate Target values for CMDG indicators (Updated at 2007 MTR): All estimated new smear- All estimated new positive TB cases smear-positive TB detected under cases detected under DOTS (%): 66% Value Smear (+) case detection DOTS (%):70% by 2005, >70% "Registered smear- (quantitative rate: 57% (2002) Pulmonary N/A by 2010 and positive TB cases or Qualitative) TB cure rate: NA 2015. successfully treated Registered under DOTD (%)": smear-positive 91% TB cases (JAPR 2011) successfully treated under DOTS (%): >85% by 2005, 2010 and 2015. Date achieved 03/31/2002 12/31/2007 12/31/2010 12/31/2011 Achieved target for cure rate. Off track to achieve case detection rate, based on Comments estimated prevalence. A recently completed MOH TB prevalence survey found that TB (incl. % prevalence has declined by 36% from 2002 to 2011 (269/100,000 to 171/100,000 in achievement) 2011) Indicator 12 : Per capita consultation rate in public facilities (new cases) 2006: 0.5 (per Value Annual 0.63 (2010 result, (quantitative 2002: 0.38 (nationwide) N/A Operational JAPR 2011) or Qualitative) Plan 2006) Date achieved 03/31/2002 12/31/2007 12/31/2010 12/31/2011 Comments (incl. % Achieved target of 0.6 for 2010. achievement)
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G. Ratings of Project Performance in ISRs
Date ISR Actual Disbursements No. DO IP Archived (USD millions) 1 06/24/2003 Satisfactory Satisfactory 0.00 2 06/30/2003 Satisfactory Satisfactory 0.00 3 12/18/2003 Satisfactory Satisfactory 3.02 4 05/11/2004 Satisfactory Satisfactory 3.26 5 12/21/2004 Satisfactory Satisfactory 4.70 6 06/06/2005 Moderately Satisfactory Satisfactory 5.82 7 06/23/2005 Moderately Satisfactory Moderately Satisfactory 5.91 8 12/19/2005 Satisfactory Satisfactory 7.24 9 07/20/2006 Satisfactory Satisfactory 9.58 10 06/18/2007 Satisfactory Satisfactory 12.67 11 06/05/2008 Satisfactory Satisfactory 18.95 12 06/26/2009 Satisfactory Moderately Satisfactory 24.05 13 04/30/2010 Moderately Satisfactory Moderately Satisfactory 26.54 14 04/05/2011 Moderately Satisfactory Moderately Satisfactory 28.17 15 03/14/2012 Moderately Satisfactory Moderately Satisfactory 30.30
H. Restructuring (if any)
ISR Ratings at Amount Board Restructuring Restructuring Disbursed at Reason for Restructuring & Key Approved PDO Date(s) Restructuring Changes Made Change DO IP in USD millions Extension of closing date and 12/16/2010 N MS MS 27.67 reallocation of proceeds.
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I. Disbursement Profile
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1. Project Context, Development Objectives and Design 1.1 Context at Appraisal In 2002, Cambodia had the second highest poverty level (36%) in South-East Asia. Health indicators from 1997 were among the worst in the region, with a maternal mortality ratio of 900 per 100,000 live-births, under-five mortality rate of 115 per 1,000 live-births , and a stunting rate of 53% among children under five. Cambodia was assessed as not being on track to achieve most of the health-related Millennium Development Goals (MDGs). The Health Sector Support Project (HSSP) appraisal team identified communicable diseases (particularly tuberculosis, malaria and HIV/AIDS), malnutrition, and maternal and reproductive health issues as the main contributors to the burden of disease in Cambodia.
Key sectoral issues identified at appraisal were: low levels of public spending on health, with 82- 84% of total health expenditure coming from out-of-pocket payments; high dependence on donors and non-government organizations (NGOs); low quality of services by both public and private providers; insufficient access to health services for the poor; 88% of public spending being allocated to administrative and training costs; severe capacity constraints; distortions in geographic distribution of health personnel and facilities; inequitable utilization of services; and problems with drug quality, prescription and dispensing practices.
From the mid-1990s, the Ministry of Health (MOH) with donor support had piloted various models to improve service delivery and quality, increase salaries and protect the poor from the burden of health care costs. While some models were considered successful, their sustainability remained in doubt.
HSSP was designed and financed by the International Development Association (IDA), the Royal Government of Cambodia (RGC), the Asian Development Bank (ADB) and the UK Department for International Development (DFID). After inception they were joined by the United Nations Population Fund (UNFPA). The project had joint review mechanisms and a number of common management arrangements. MOH dubbed this a Sector Wide Management (SWiM) approach, the first step towards a sector-wide approach (SWAp) in Cambodia.
In 2002, MOH had prepared the Health Sector Strategic Plan 2003-2007 (HSP1). This was its first attempt to prepare an overall sector strategy and provided a clear framework for HSSP. HSP1 called for implementing Sector Wide Management (SWiM) to establish a common vision and effective partnership among all stakeholders.. HSSP adopted this policy direction of SWiM throughout its implementation process. Under the HSSP design, the World Bank supported activities in 12 provinces, while the ADB project supported the remaining nine largest provinces. Activity design was the same in all provinces. Both the WB and ADB provided support to MOH at national level. 1.2 Original Project Development Objectives (PDO) (as approved) The objective of HSSP was to contribute to the improvement of the health status of the Cambodian population, particularly the poor and rural population through: (a) increasing the accessibility, quality and affordability of health services; and (b) assisting the Kingdom of
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Cambodia to implement its Health Sector Strategic Plan 2003-2007 and strengthen the sector's capacity to carry out the health sector reform and to manage health sector resources efficiently. 1
The project’s specific objectives were to: (i) develop affordable quality health services with emphasis on primary health care and first referral services in rural areas; (ii) increase the utilization of health services by the poor; (iii) mitigate the effects of infectious disease epidemics and of malnutrition; and (iv) improve the health sector’s capacity and performance.
1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification The PDO was not revised during the implementation of this project.
1.4 Main Beneficiaries HSSP aimed to benefit all residents in the 12 provinces where it provided support. The rural poor, including ethnic minorities, were expected to benefit especially from activities in primary health care, infectious disease control, preventive health, and the treatment and prevention of malnutrition. Affordability of health services for the poor would be improved. The PAD did not indicate the expected numbers of beneficiaries in the 12 provinces, however.
1.5 Original Components (as approved) Improved Delivery of Health Services – focused on access, quality and affordability. Support included development of primary health care facilities and referral hospitals (at district and provincial levels) by financing civil works, equipment and maintenance. Project design also planned support for training to improve service quality, establishment of a Quality Improvement/Standards Unit in MOH, and quality assurance activities in three districts of Kampong Thom province. Other activities to be supported were: performance-based contracting for district health services, activities to increase user participation in decision-making, health equity funds (HEFs) to pay for services provided to the poor, and improvement of drug quality and availability.
Improved Programs Addressing Public Health Priorities – focused on infectious disease control, (mainly malaria, tuberculosis, dengue and STI/HIV/AIDS) and nutrition. For malaria, support included the provision of insecticide treated bed-nets, training for better case management, improved surveillance, and information, education and communication (IEC) activities. TB control activities included integration of TB activities at the HC and district hospital levels, increasing case detection and reducing default rates, improving laboratory capacity and strengthening IEC. For dengue control, the activities included strengthening early diagnosis, appropriate treatment and vector control. For STI/HIV/AIDS, the project supported procurement
1 Development Objective as stated in the Financing Agreement. See Data Sheet summary for DO as stated in the PAD. 2
of drugs and 100% condom use among high risk groups. For nutrition, financing included training, information campaigns, and community outreach to support an essential package of preventive and curative services, e.g. exclusive breast-feeding up to 6 months, timely and adequate complementary feeding from 6 to 24 months, appropriate care of sick and malnourished children, micro-nutrient supplementation for women and children, and increased availability of iodized salt.
Strengthened Institutional Capacity – provided support to key functions at central, provincial and district levels. This included oversight of policy, improving the legislative and regulatory framework, better sector planning and program coordination (specifically improving MOH analytical capacity for health financing, planning capacity at provincial and district levels and coordination and monitoring of plan implementation). The component planned to improve sectoral management, including human resource planning and management, improvement of skills and performance, strengthening financial management systems and capacity, and recruitment of procurement consultants. The component sought to improve monitoring and evaluation (M&E) capacity, including surveillance of health service delivery outside the public sector, and the use of data to inform health sector governance and planning (see Annex 1 for component costs).
1.6 Revised Components Project components were not revised.
1.7 Other significant changes The original closing date of the IDA credit financing was June 30, 2007. The project was extended to June 30, 2008, and then to December 31, 2010. Most activities, other than civil works, were completed by early 2009, when the Second Health Sector Support Project (HSSP2) began. In December 2010, the Bank approved a third and final one-year extension of the closing date for HSSP to December 31, 2011, and a reallocation of unspent IDA funds from categories of goods, training and incremental operating costs to the category of civil works. These changes enabled the project to complete construction activities that had been subject to delays.
2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry Background analysis – Preparation of HSSP took account of both the prior experience of the World Bank and other donors in the health sector. Analytic work undertaken during project preparation included analyses of poverty and health; review of mechanisms to improve equity of access to health services; beneficiary and social assessments, including for indigenous peoples. MOH prepared a number of strategic documents, including HSP1, a medium term expenditure framework, and various disease control strategies. The design correctly identified the major disease burdens in the country, weaknesses in health system management and monitoring, issues of accessibility and coverage, and the problem of access for the poor following the introduction of user fees in 1996. Prior donor support was fragmented, and individual projects implemented without regard to overlap or duplication. There was limited cooperation between donors. HSP1
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provided a sector framework for donors to support and HSSP closely aligned with this. At the time donor support to the sector was modest, so HSSP enabled significant expansion of health services and geographic coverage.
Project design – HSSP was prepared in parallel with the preparation of HSP1, which facilitated alignment of project design with MOH strategic priorities. In keeping with the SWIM approach adopted by HSP1, donor partners financing HSSP harmonized among themselves (ADB, DFID, UNFPA and, WB) by joining common management arrangements and agreed to rely on the MOH systems for planning, program implementation, monitoring and reporting. While funds were not pooled among HSSP donor partners, the World Bank managed DfID contributions through a Trust Fund arrangement. The HSP1 monitoring and evaluation (M&E) framework was not finalized when the project was negotiated, however, and some indicators included in the PAD did not have clearly defined baselines, targets, or means to collect data. A clearer hierarchy of objectives and more logical linkage to the components would have led to a better monitoring framework. The project was not expected to have a PMU, but instead to strengthen MOH implementation capacity prior to Credit and Grant effectiveness and during the implementation, with the Planning Department in the MOH responsible for coordinating project activities. The MOH subsequently decided to establish a PMU (HSSP Secretariat) as a transition arrangement, with a team of consultants working under the management of the Project Director (an MOH Under Secretary of State), and a Project Coordinator (a Deputy Director General for Health).
Government commitment – MOH prepared the HSP1 through a participatory process with donors and NGOs, following a sector review to identify key problems. A number of planning and policy documents to support it had been prepared, as well as a health coverage plan for infrastructure development and a health workforce plan. MOH also committed to developing comprehensive annual plans and budgets, linked to three-year rolling plans (3YRPs). Thus the signals in favor of HSSP were strong. The Royal Government of Cambodia (RGC) had also shown strong support for the SWiM approach, through the HSP1 and subsequently through endorsing the 2003 Paris Declaration on Aid Effectiveness.
Risk assessment – the HSSP design identified risks to implementation and to longer term sustainability. The overall risk rating was ‘substantial’. Major risk areas were financial management capacity, political will for reform, planning capacity, commitment to human resource development, low government salaries, slow release of government funds, and weak lateral cooperation within MOH. Specific and overall risk assessments were sound and mitigation strategies were both feasible and appropriate.
Quality at Entry Assessment. In June 2003, the World Bank’s Quality Assurance Group undertook an independent Quality at Entry assessment of HSSP. Quality at Entry was rated as fully satisfactory with respect to strategic relevance and approach; technical, financial, and economic aspects; poverty and social aspects; but rated marginally satisfactory for environment, fiduciary, implementation arrangements, and risk assessment. The overall Quality at Entry rating was marginally satisfactory. The panel praised the relevance and technical quality of the design, but noted that a number of key issues were left to be address during initial implementation (e.g., project staffing and incentive issues; arrangements for DfID cofinancing;
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arrangements for routine monitoring; and an excessive number of project legal covenants), which contributed to delays in project effectiveness.2
2.2 Implementation External factors – two major external factors affected implementation. From 2004, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) began supporting programs in Cambodia, with high levels of funding going to combating TB, malaria and HIV/AIDS. These were three of the four key diseases being addressed by HSSP (dengue being the fourth). The large volume of GFATM money reduced the importance of HSSP support, especially for malaria and HIV. MOH therefore agreed to re-focus HSSP financing on gaps in GFATM support rather than pursue its original scope. HSSP remained the major source of funding for dengue.
In 2006-07, there was a rapid escalation of costs for materials used in civil works, especially cement and steel used for reinforcement. Most construction contracts were fixed price. While some contractors were able to absorb the price increases, others faced losses. Construction of the provincial hospital in Preah Vihear province was most affected, with construction stopping and the contractor taking legal action against MOH. Several other contracts (mostly for HCs) were cancelled prior to contract award, because the proposed contract costs were substantially higher than estimated costs. The contract for this hospital and the canceled contracts had to be repackaged and re-tendered.
Government policy issues – After the detection of irregularities in procurement in ministries other than MOH, the government mandated the use of an Independent Procurement Agent (IPA) for all ministries in WB-funded projects. The first IPA proved unsatisfactory and slow recruitment of a second IPA contributed to further delays in the procurement of goods and civil works. The implementation of the government’s public financial management reform, including procurement reform, has been subject to persistent delays, which undermined efforts to build national capacity to shift toward country systems.
The Ministry of Economics and Finance (MEF) had prepared standard operating procedures for financial management and procurement at the start of HSSP and revised these in 2007. These had a positive impact on project implementation by providing clear guidance and delineating procedures that had previously not been formalized. Release of government funds from the national budget by MEF was sometimes slow, especially in the first quarter of the financial year, causing the timeframe for some activities to shift.
MOH policy support – The preparation of HSP1 and the subsequent Health Strategic Plan 2008- 2015 were crucial in providing a strong and clear framework for donor support and were keys to
2 The QAG panel commented, “…despite an important amount of good work on the project, the project was in many ways not ready for implementation at the time it was taken to the Board….Given the long delay in effectiveness, the critical staffing and incentive issues, and the project development activities still to be undertaken, the panel believes that it will be difficult to implement the project on the timetable that was planned.” With respect to M&E, the panel noted that “…the baseline survey was excellent and the outcome indicators are best practice, although some of the important details of M&E are still to be worked out.” The overall subrating for M&E was satisfactory, however. 5
the success of HSSP. MOH’s decision to establish a Project Management Unit to directly manage project activities, however, meant that HSSP’s aim of integration into MOH systems was only partly successful. MOH’s facilitation of the joint review missions with the WB, ADB, DFID and UNFPA, and development of integrated Annual Operational Plans, helped to strengthen the SWiM approach and to lay the groundwork for the pooled funding and harmonized implementation approach in HSSP2.
Mid-term review – a mid-term review was conducted in October 2006, with participation of MOH, the World Bank, ADB, DFID and UNFPA, and AusAID staff joined the mission as observers. HSSP M&E framework was updated during this MTR to align to the extent possible with the M&E framework of HSP1. The MTR acknowledged weaknesses in the original M&E framework for the project, and updated the key Project indicators, which were aligned with HSP2 indicators and targets and tracked in subsequent ISRs (see Annex 2). The review endorsed a one-year extension of the project to June 2008, but did not recommend formal restructuring: Bank policy at that time did not require restructuring when updating project monitoring frameworks, if key indicators were not included in the legal agreement.
Actions in response to problems – From 2005, the World Bank deployed a Senior Health Specialist and a national staff to work on the Project at country level. This was supported by two more positions (one national, one international) in the transition to HSSP2. This increased country presence had a positive impact on the speed and quality of problem solving and strengthened relationships with both MOH and the partners. In response to procurement challenges across the portfolio, the Bank arranged for a senior procurement specialist to work half-time in Cambodia, supported by a procurement analyst based in Bangkok. This contributed to progress in resolving the procurement difficulties facing the project. Issues of financial management and disbursement of funds were addressed directly and promptly by MEF, MOH and the PMU, but sometimes wider government policies and processes contributed to implementation bottlenecks (e.g. government-wide restrictions on payment of per diems). HSSP linked well to wider World Bank support for public sector financial reform, providing information on specific issues encountered by the project.
Delays in civil works were due to a number of factors, including: price escalation of construction materials, resulting in re-bidding of contracts when contractors abandoned a site or when proposed award prices were substantially higher than estimates; MOH’s decision to move the site of the national drug quality control laboratory to a new location; and a lack of market interest in small value contracts. These issues took time to resolve, leading to three project extensions and the eventual transfer of some civil works to HSSP2.
2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization The M&E design was based on a strong foundation of analytic work and household surveys, but finalization of the framework for routine monitoring was left for initial implementation. The PAD proposed 23 core performance indicators to monitor project performance, of which nine key performance indicators were to be collected annually. Because the overall HSP1 sector monitoring framework still was not finalized, the PAD did not specify baselines or targets for
6 these indicators, and the 23 Core Performance Indicators were not thoroughly checked for matches with available data sources3. Among the nine key performance indicators, two required special surveys (malnutrition and patient satisfaction), and one was difficult to measure (% of population with access to minimum package of activities at health center level – although the number of HCs providing the minimum package of activities was monitored). The classification of the Core Performance Indicators into ‘sector indicators’, ‘outcomes’, ‘outputs’ and ‘inputs’ did not always follow accepted definitions of these terms. The expectation that data could be disaggregated by ethnicity was not based on government policy or available data sources.
M&E implementation – The project monitoring framework was updated periodically, initially following finalization of the results framework for the Health Strategic Plan, and subsequently based on f data from Cambodia DHS 2005; and the Project midterm review and sectorwide Joint Annual Performance Review in 2006. Following the MTR, a consistent set of 16 indicators, four development outcome indicators and other 12 intermediate outcome indicators, were used and updated routinely in ISRs. The Annual updates of Health Strategic Plan 2008-2015 monitoring indicators led to changes of definition of some indicators and adoption of new indicators, but the team sought to maintain consistency in reporting on key Project indicators agreed at MTR. The joint annual sector performance reviews provided an opportunity to review progress on all HSP1 indicators, however.
With respect to evaluation, a range of reviews, evaluations, and surveys were commissioned by the government, WB and by other partners. These included the Cambodia Demographic and Health Surveys (2005 and 2010) and the Cambodia Socioeconomic Survey (2004, 2007, 2009); independent midterm reviews of HSP1, including a SWiM review; a Health Public Expenditure Tracking Survey (2008), impact evaluation and reviews of performance contracting; several evaluations of health equity funds; and various program evaluation (e.g., comprehensive midwifery review). In addition, the MOH commissioned in 2010 an independent final evaluation of HSSP1 (AGEG-Domrei 2010).
M&E utilization –HSSP support to strengthen the Health Management Information System (HMIS) in MOH improved data quality and timeliness, which continued under HSSP2. HMIS data were regularly used in annual planning workshops and annual joint reviews of progress by MOH, donors and NGOs. Use of data by provinces, operational districts and health facilities improved during implementation – for example, health facilities now post monthly progress on key indicators near the entrance of the facility. Data from the CDHS and the Cambodia Socioeconomic Survey were used to assess progress towards the MDGs; analyze health spending and service utilization by the poor, as well as for broader policy development and decision making. The various program reviews and evaluations informed policy decisions and follow up actions by government and partners. 2.4 Safeguard and Fiduciary Compliance HSSP1 design triggered safeguards related to environment, pest management, indigenous peoples, and involuntary resettlement. With respect to environmental safeguards, the MOH adopted a medical waste management plan, which was monitored by a Bank environmental
3 See Annex 2 for data tables covering the KPIs, Core Performance Indicators, and additional indicators tracked in the ISRs. 7
specialist on at least an annual basis. National guidelines on infection control were developed, trainings were conducted for health staff at all levels of health care system, medical waste were properly segregated before disposal, safety boxes were used for collecting sharp waste; and incinerators were constructed as part of facility construction or upgrading. All insecticides financed by the Project were prequalified by WHO. An assessment of environmental and health impact was undertaken prior to the construction of the National Laboratory Quality Control Laboratory. With respect to social safeguards, an indigenous people consultation was done as required by the Project. The Bank and MOH collaborated on a sample verification of compliance with resettlement safeguards, which were found to be satisfactory. Overall safeguards ratings varied between ‘moderately satisfactory’ and ‘satisfactory’. The final overall rating was ‘moderately satisfactory’, with 3 of the 4 safeguards being rated ‘satisfactory’ and one (indigenous peoples) rated ‘moderately satisfactory’ due to modest progress in strengthening the overall MOH indigenous peoples policy framework.
Financial management monitoring was discussed at every Project Joint Review Mission and recorded in aide memoires and ISRs. The financial management rating up to 2004 was ‘satisfactory’ but was downgraded in June 2005 to ‘moderately satisfactory,’ and where it remained to the end of the project. The procurement rating was reduced to ‘moderately satisfactory’ from ‘satisfactory’ in June 2005, then fell to ‘moderately unsatisfactory’ in 2009. It was rated ‘unsatisfactory’ in March 2011 but restored to ‘moderately satisfactory’ in the final ISR, based on successful rebidding of civil works contracts and improved procurement implementation.
2.5 Post-completion Operation/Next Phase In 2007-08, preparations began for HSSP2. This incorporated a number of lessons from HSSP. ADB decided to withdraw from the health sector in Cambodia (except for some regional support). The Bank built a partnership with a number of other donors (including AusAID, DFID, AfD/France, Belgian Technical Cooperation, UNICEF, and UNFPA) to form a stronger sector- wide partnership for the new project. Most HSSP activities ended in December 2008, with the exception of civil works, HEFs, and support for performance-based contracting with district health services. Malaria, TB, and HIV/AIDS programs were subsequently financed by GFATM and other partners, but HSSP2 continued financing for dengue and some neglected tropical diseases. HEFs were transferred to HSSP2 in April 2009. Performance-based service delivery contracts with NGOs ended in March 2009 and NGOs shifted to a capacity building support role under HSSP2, with selected health districts and hospitals performance-based Service Delivery Grants. After two further extensions to complete unfinished civil works, HSSP closed on December 31, 2011. At that point, a small number of civil works remained incomplete and these were all transferred to HSSP2. There was a smooth transition between the two projects.
All of the successful initiatives in HSSP were continued in HSSP2, apart from the Merit Based Pay Initiate scheme, which was designed with support from HSSP1 and other partners, but implemented for only 6 months before being cancelled by government at the end of 2009. Skills and capacities built in MOH and the PMU during HSSP have been used in the implementation of HSSP2, and financial management and operational management systems further improved. The M&E framework has been revised and now closely aligns with MOH’s Second Health Strategic Plan. 8
3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation The objectives of HSSP were highly relevant to the country context, sector priorities and the World Bank’s Country Assistance Strategy. The Bank’s Country Assistance Strategy (2000) called for helping to reduce poverty by increasing affordability of health services through HEFs and making services more accessible by providing new facilities and resources; building built human capital through training and provision of equipment; and promoted good governance by improving the quality and integration of planning and budgeting, including participatory planning involving key stakeholders. The Project objectives remained highly relevant to the priorities of HSP 2008-2015, in term of enhancement sustainable development of the health sector for better health and well-being of all Cambodians, especially of the poor, women and children. The project design was substantially relevant: it addressed the most important health priorities, both in terms of disease burden and health system strengthening; and was well aligned with HSP1 and the subsequent Health Strategic Plan 2008-2015, promoting country ownership and sustainability. The SWiM approach was appropriate to existing capacity and experience in country, and contributed to further alignment of donor financing. Project design relevance had some modest shortcoming, including inadequate specification of the results framework, and the need for a clearer strategy to sequence institutional reforms, in light of experience from other SWAps. Overall relevance is judged to be Substantial.
3.2 Achievement of Project Development Objectives While IDA financed focused on 12 of 24 provinces, the overall HSSP program provided support across the whole of the public health sector and at all levels (with ADB financing similar activities in the other nine largest provinces). The combined funding of HSSP provided a substantial share of public health sector expenditure (over two-thirds in the first two years), even after the entry of GFATM into the country in 2004. Given the size and reach of HSSP alone, it can be plausibly assumed that HSSP contributed to sector-wide outcomes. In a sectorwide framework, however, comparing performance among “project” and “nonproject” provinces is of limited use in assessing project effectiveness4, and rigorous attribution between Project financing and specific sector indicators is not possible. Instead, achievement of specific Project Development Objectives is assessed below against overall progress on sector outcomes and service indicators, followed by a review of evidence regarding plausible linkages between project outputs and progress on intermediate sector indicators.
High-level objective: Contribute to the improvement of the health status of the Cambodian population, particularly the poor and rural population: This objective was substantially achieved – reflecting outstanding progress on maternal and child, but modest progress on nutrition. Cambodia DHS 2010 reported substantial improvement of health status of Cambodian population. Among all four PDO indicators, three (maternal mortality, infant mortality, and under 5 mortality) surpassed 2010 Cambodia MDG targets. After stagnating from 2000 to 2005,
4 A comparison of changes in key outcome indicators in HSSP and non-HSSP provinces is included at the end of Annex 3, using CDHS data. While there are variations among provinces, the average differences between HSSP and non-HSSP provinces are not statistically significant. 9
maternal mortality was reduced by half from 2005 to 2010 (from 472 to 206 per 100,000 live births). Reductions in child mortality have been remarkable, declining at an average annual rate of 8 percent per year in the past decade – among the fastest reductions in the world. Child mortality declined sharply among the poorest, although at a similar rate to the richest quintile.5 With respect to MDG 1 (child nutrition), stunting showed a modest decline (from 50% in 2000 to 40% in 2010), but wasting increased (from 8% in 2005 to 11% in 2010) and underweight showed no change (28.1 in 2005 vs 28.3 in 2010). 6 HIV/AIDS prevalence among 15-29 years olds declined from 2 percent in 1998 to 0.8 percent in 2010.
Increasing the accessibility, quality, and affordability of health services. This objective was also substantially achieved. Among 12 intermediate result indicators reported routinely in ISRs, nine either exceeded or achieved national targets set by various government monitoring frameworks. Indicators exceeding targets included percentage of children under one year fully immunized, and percentage of deliveries attended by trained staff. Indicators achieving targets included: malaria case fatality rate in public facilities per 100 patients, incidence of malaria per 1,000 inhabitants, per capita consultation in public facilities; and percentage of pregnant women received at least 2 ANC consultations. The percentage of women using modern contraceptives doubled during project implementation, but fell short of national targets. No mechanism was established to measure client satisfaction on an annual basis, however, but various client surveys show an overall improvement in satisfaction with public services. Similarly, no methodology was established to estimate the percentage of population with access to minimum package of activities (MPA) at health center level, but the number of health centers reaching full MPA capacity increased from 294 in 2003 to 469 (out of 1,010) in 2010. In addition, household surveys showed increased utilization of public health services by the poor and rural population, and declines in catastrophic spending (see Annex 2). Annex 2 provides a detailed summary of project outputs by component, as well as available data on progress against performance indicators from the PAD and ISRs. Progress on key indicators and project contributions are summarized below according to specific sub-objectives: • Develop affordable quality health services with emphasis on primary healthcare and first referral services in rural areas: Progress on this sub-objective is rated as substantial overall. Key HSSP outputs in the 12 provinces included: renovation of six health centers, and construction of 21 new health centers, five health posts, and five new district referral hospitals; provision of essential medical equipment to 366 health centers, 17 district
5 The child mortality rate the poorest quintile declined from 127 per 1000 in 2005 to 90 per 1000 births in 2010, compared to a decline from 43 to 30 per thousand among the richest quintile. The CDHS reports on average child mortality for the five years preceding the survey; as such, improvements between the 2005 and 2010 survey reflect progress during HSSP implementation. 6 A detailed analysis of these trends goes beyond scope of the ICR, but evidence suggests that rapid declines in child and maternal health have been driven by overall improvements in socioeconomic status; improved access to health services through facility constructions/rehabilitation and improved road networks; high coverage of preventive interventions (immunization, vitamin A); increased utilization and quality of health services, including by the poor; and a dramatic increase in antenatal care and facility deliveries (see details below and in Annex 2). The persistence of child malnutrition appears to be driven by various factors, including inappropriate child feeding practices (despite significant increases in exclusive breastfeeding); limited progress in sanitation and hygiene; and food insecurity for the poorest. 10
hospitals, and eight provincial hospitals; training in child health and integrated management of child illness for nearly 1000 health staff, covering 78% of health centers in target provinces. Assessments of clinical quality (for IMCI, maternal services) showed improvements due to HSSP financing training and supervision, although further improvements in clinical quality are needed. Health center and health post construction was targeted to remote areas, including those with large indigenous populations. The end of project survey concluded that the combination of improved infrastructure, staff training, and staff motivation (through HEFs, contracting, and other incentive programs) contributed to increased utilization, quality improvements, and overall high satisfaction with public services (AGEG/Domrei 2010). A Quality Assurance Office was established in MOH, and various service quality assessment tools were developed and implemented with support from HSSP and other partners. The project supported performance contracting through an NGO to improve services in one remote operational district (Preah Vihear), with ADB and Belgian Technical Cooperation supporting various forms of contracting elsewhere. Impact evaluations of NGO contracting showed significant improvements in utilization of key services, and reduced spending by the poor (Bhushan and others 2007). Monitoring data show that these gains have been maintained with the transition to internal contracting under HSSP2. Planned activities to strengthen community social accountability mechanisms were implemented, however, but have been initiated under HSSP2. Table 1: Selected Project Indicators Indicator Baseline Target (year) Result (year) Achieved (year) 1 HIV prevalence among those 1.9% (2003) 1.8% (2015) 0.7% (2010) 15-49 years old 2 % of children < 1 year fully 39% (2000) 70% (2010) 73.6% (2010) immunized 3 % of pregnant women 29% (2002) 75% (2010) 72% (2010) Within received at least 2 ANC 10% consultations 4 % of married women aged 17% (2002) 44% ( 2010) 35% (2010) No, but 15-49 years using modern more than contraceptives in public double the health services baseline 5 % of deliveries attended by 20% (2002) 70% (2010) 69.6% (2010) trained staff 6 Improved capacity of HCs 294 (2003) 470 of 965 469 of 1,010 Within (full MPA capacity) (2006) (2010) 10% 7 Improved capacity of referral 47/67 (2006) 56/89 (2010) hospitals (achieved CPA2 and CPA3 levels) 8 Disbursement of MOH 102.6% (2010) No target budget expenditures • Increase utilization of health services by the poor. The project targeted investments to underserved rural areas; supported outreach activities; expanded health equity funds (HEFs), which finance user fees for the poor at public health facilities. By 2008, HEF coverage expanded to 50 of 76 operational districts (covering two-thirds of the poor geographically), of which HSSP financed 13. The total number of households for which costs were paid by HEFs increased from 18,500 in 2003 to 227,000 in 2008. HEFs
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initially focused on coverage of inpatient services at hospitals. A number of evaluations and academic studies have been carried out on HEFs, and the independent HSSP evaluation commissioned by MOH undertook a household survey and beneficiary assessments on HEFs (AGEG/Domrei 2010) These concluded that HEFs reduced (but did not eliminate) out-of-pocket and catastrophic spending by the poor on health (Flores and others 2011), increased use of public health service use by the poor. HEF oversight through local NGOs improved responsiveness of public providers to the poor (Annear 2010). While not all the poor yet have access to HEFs, catastrophic spending on health by the poorest quintile declined from 3.6 percent in 2004 to 2.3 percent in 2009.7 • Mitigate the effect of infectious disease epidemics and of malnutrition. In the early years of the Project, HSSP was the major source of financing for malaria, TB, and HIV/AIDs, and remained the major funding source for dengue throughout. Outputs included support to national programs, including for strategy development and program monitoring; training of health workers; distribution of bednets in malaria endemic areas; distribution of condoms and targeted campaigns for groups at high risk for HIV; and support for community case detection and prevention programs (for TB, malaria, etc.). The project contributed to improved case detection and treatment success rates for all these programs, including significant declines in case fatality rates for malaria and dengue (see Annex 2). With respect to nutrition, HSSP and other partners supported a highly successful breastfeeding campaign, which increased exclusive breastfeeding from 11% in 2000 to 68% in 2008. The Project also financed training in child health and nutrition for over 3000 staff. The number of hospitals able to treat severe malnutrition reached 15 (out of 78) in 2008, and increased further to 33 by 2011. The Project supported outreach costs for micronutrient distribution. Coverage of iron folate for pregnant women increased from 18% in 2005 to 40% in 2008; vitamin A coverage for children aged 6-59 months increased from 11% in 2000 to 68% in 2009. Efforts to promote complementary feeding and improve nutrition counseling have been less successful, however, and remain a priority under HSSP2. Assist the Kingdom of Cambodia to implement its Health Sector Strategic Plan 2003-2007 and strengthen the sector’s capacity to carry out health sector reform and to manage health sector resources efficiently. The first part of this objective (support implementation of HSP1) was substantially achieved, but progress on the second part was modest, particularly with respect to improved sector efficiency. Overall efficacy is rated as modest. • As discussed above, the project design and annual review process supported the overall objectives of the HSP1, as well as the specific objective to implement a SWiM approach. The Project aligned financing with priorities articulated in the strategic plan, and made substantial contributions to strengthening of planning and monitoring capacity at central and provincial level. As a result, all provinces now prepare annual operating plans that increasingly integrate government, partners, and NGO financing (but the AOP formats still differ from the MEF requirements budget submissions at province level). Various national programs received support to develop and implement programs, and the policy
7 Based on secondary analysis of CSES 2004 and 2009 data. Catastrophic health expenditure uses WHO definition:
expenditures exceeding 40% of non-subsistence income (e.g., after subtracting expenditure on food consumption). 12
dialogue and evaluation studies by HSSP and partners contributed to progress on key policy reforms (including HEFs, service contracting, etc.). • The project’s contributions to strengthening the sector’s capacity to manage health resources efficiently was modest, however. HSSP provided substantial training in financial management to MOH staff, but continued reliance on the PMU for project implementation, and slow overall progress in public financial management reform reduced the impact of this training on government capacity. The RGC budgetary contribution to health increased substantially in the past decade (exceeding 11% of national budget in 2009), and budget execution rates have been high, but progress in fiscal decentralization and procurement reform was limited. Drug availability improved at facility level (stockout rates of essential drugs are now less than 5%), but planned support for improving efficiency of pharmaceutical procurement and the supply chain was not implemented. Construction of a new National Drug Quality Control Laboratory was initiated under HSSP1, but construction experienced a number of delays, including to ensure that the design was fully compliant with international certification standards. Completion is expected in late 2012, with HSSP2 financing. Overall efficacy in achieving development objectives is rated as substantial. This overall rating reflects a balance between the ratings of specific objectives, weighted by importance: substantial progress toward increasing the accessibility, quality, and affordability of health services (high importance); substantial progress in supporting HSP1 implementation, but modest progress in improving capacity to manage sector efficiently (substantial important); and substantial progress toward improved sector-wide indicators for maternal and child health and nutrition (modest importance). 8 3.3 Efficiency The ICR has not attempted to calculate a final rate of return for the project.9 Efficiency is therefore assessed based on available evidence on the project’s contribution to allocative efficiency in the sector; technical efficiency of health services; and “value for money” from project investments. HSSP support for strengthening the annual planning and performance monitoring process improved resource allocation, particularly for donor financing. Mid-year reviews of the AOPs and quarterly expenditures also contributed to improving efficiency. Limited progress was made in improving the overall efficiency of the national drug procurement and logistics system, and delays in implementing public sector management reforms undermined progress in improving efficiency of RGC budget allocations to the sector (World Bank 2011). The overall contribution to allocative efficiency is rated as modest. With regard to technical
8 When a project has multiple objectives and sub-objectives, the ICR should indicate the relative importance of each objective to arrive at an overall rating (see ICR Guidelines). There is no standard methodology to assign weights to among sub-objectives, so the following was used: (i) progress toward higher-level sector outcomes is given a 20% weight, since in context of SWiM approach, HSSP was represented only a portion of sector financing; (ii) increasing the accessibility, quality, and affordability of health services is assigned 45%, because of the importance of improving services for the poor, and because it represented the major portion of HSSP financing; (iii) the objective to support HSP implementation and improve sector capacity and efficiency is given a weighting of 35%. 9 Annex 4 of the PAD provided a detailed economic analysis of the project including an estimated internal rate of return of 17% and a net present value (minus costs) of US$45 million. However, these figures were highly sensitive to a number of assumptions, so the potential result ranges were very broad. No follow up analysis was conducted by the project, MOH or MEF. 13
efficiency, several sector-wide efficiency indicators improved during project implementation, including bed occupancy rates and the number of consultations per health staff. The project contributed to technical efficiency of health services through provision of infrastructure and equipment, training of staff, and various performance incentive schemes through HEFs and contracting. Independent evaluations studies concluded that support for HEFs and for performance-based contracting with health districts increased service utilization, which in turn contributed to improved equity and technical efficiency of services (Mathonnat and others 2012; Bhushan and others 2007; Annear 2010). Contribution to technical efficiency is therefore rated as substantial. The efficiency of project investments (input/output efficiency) is rated as modest: project delays reduced efficiency, including the rebidding of civil works contracts that necessitated further two-year extension. The rebidding process resulted in 30 percent lower contract prices, however. Overall efficiency is rated as modest.
3.4 Justification of Overall Outcome Rating Rating: Moderately satisfactory
The overall outcome rating of the project is Moderately Satisfactory, based on substantial relevance of project objectives and design, substantial efficacy in achieving development objectives, but only modest efficiency. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development Catastrophic health spending by the poorest 20% of the population dropped by 36.7% between 2004 and 200910. From 2007, there was a substantial increase in the number of HEFs covering health service costs for the poor, and those HEFs were largely funded by HSSP. An impact evaluation concluded that HEFs contributed to a significant reduction in out-of-pocket payments, catastrophic expenditures, and debt by the poor (Flores and others 2011). Expansion of the number of health facilities also meant that people in more remote areas, often the poorest and those with indigenous populations, had increased availability of health care (AGEG-Domrei 2010). There were significant improvements in women’s health, with a dramatic reduction in the maternal mortality ratio, a substantial increase in the number of women attending antenatal care visits, and a doubling of the number of women with access to modern contraceptives. Though men are the majority of MOH employees, of the 6,328 staff trained under HSSP, half were women11.
(b) Institutional Change/Strengthening HSSP used and strengthened MOH’s systems for planning, coordination, and monitoring of sector financing. The introduction of AOPs and 3YRPs gave MOH the capacity to allocate sectoral resources more effectively. Training under HSSP covered all categories of staff and all levels of the system, helping to build overall capacity. JAPR of the sector involved MOH, donors
10 Cambodia Socio-Economic Survey data: Catastrophic expenditures for poorest quintile declined from 3.6% in 2004 to 2.3 % in 2009 -- defined as catastrophic if a household’s out of pocket payments for health exceed 40% of income remaining after subsistence needs have been met (WHO methodology). 11 MOH 2012, Annex 5. 14
and NGOs. The reviews examined available data, promoting evidence-based decisions, and ensured greater participation in planning and policy making. While HSSP retained a PMU for its full duration, MOH staff managed this unit and increased their capacity in contracting, monitoring and the preparation of standard procedures and guidelines. (c) Other Unintended Outcomes and Impacts (positive or negative) None. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops Beneficiary surveys or stakeholder workshops were not conducted for this ICR. Qualitative and quantitative surveys were undertaken, however, for an independent evaluation of HSSP1 contracted by MOH, which included household surveys and focus groups, as well as quality of care surveys (AGEG-Domrei 2010). Beneficiaries reported substantial improvements in the perceived quality and availability of public health services in the previous five years, as a result of construction/upgrading of health facilities, outreach and preventive services, improved motivation and behavior of health staff, improved roads/transport, introduction of HEFs, and reduced unofficial payments to health providers. 4. Assessment of Risk to Development Outcome Rating: Moderate Over the course of HSSP, improved capacity in planning and management, increased service coverage and the training of staff have helped to ensure that MOH has the capacity to prepare and implement effective strategies. The good progress on HSP1 and the preparation of the Health Strategic Plan 2008-2015 bear this out. The planning process is now well embedded and continues to be improved. The quality and timeliness of HMIS data is also making solid progress. The main risks remaining are the ability to finance initiatives such as HEFs and performance- based contracts in the long term, the need to better regulate private sector health providers, respond to challenges of drug resistant TB and malaria, and the rapidly increasing burden of non- communicable diseases such as diabetes and hypertension.
5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Strategic relevance and approach –Implementation experience in the earlier Disease Control and Health Development Project revealed weaknesses in MOH planning and management systems, poor staff motivation and low coverage of health services. HSSP focused on addressing these. The prior ADB-funded Basic Health Services Project had tested different approaches to performance-based management, and HSSP also drew lessons from this. While HSSP was in preparation, MOH drafted HSP1, providing for the first time an overarching policy framework for the sector within which donors could structure their support. HSSP explicitly aligned with this framework, and design was fully aligned with World Bank and RGC strategies. Poverty, gender and social development – Before HSSP began, Cambodia faced widespread poverty, poor infrastructure and major health problems. HIV prevalence was high and diseases like TB, dengue and malaria were endemic. Ill health kept households in poverty or pushed
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marginal households back below the poverty line. Coverage of health facilities was limited. People in remote areas, mainly the poor and ethnic minorities, often had no access to public health services. The introduction of user fees had helped to finance health services, but raised a barrier to access for the poor. Exemptions were granted in an ad hoc manner. Maternal and child mortality rates were some of the highest in the region and pregnancy was high risk for many women, especially the poor, with insufficient health facilities offering safe deliveries. The planning for HSSP took account of all these issues and included support to improve access, affordability, and quality of health services for women and children. Environmental aspects – Because civil works and insecticide spraying would have an environmental impact, appropriate safeguards for both were established. Fiduciary aspects – HSSP used standard operating procedures for externally financed projects developed by MEF. Financial management risks were clearly identified, but the willingness of MOH to integrate project financial management into its systems was over-estimated. HSSP provided sound capacity building support to financial staff in MOH and the PMU. Both internal and independent external financial audits were conducted. Policy, institutional aspects and implementation – HSSP was designed to use MOH systems. While MOH endorsed this approach at the design stage, it resisted full integration during implementation. Policy alignment with MOH’s HSP1 and harmonization with the support of other donors in the sector were strong. Support for the four key national programs and various departments in MOH were consistent with project objectives and MOH priorities. Support for decentralization of planning was consistent with wider government policy. Monitoring and evaluation (M&E) – The M&E framework and indicators did not fully match those in HSP1, nor the framework used by ADB, and targets and means of measurement for some indicators not adequately defined. The feasibility of collecting data on a number of indicators was not sufficiently assessed. Risk assessment – the PAD identified 13 critical risks, one (financial management) which was rated high, and 6 were rated substantial. The risk assessment covered all major problem areas in the health sector and clear mitigation measures for all of these were laid out. World Bank inputs and processes – The World Bank previously provided technical assistance to develop financial management and procurement guidelines. External advisers were recruited in MOH. The Development Credit Agreement was signed on 27 February 2003 and became effective on 14 August 2003, allowing time for MOH to comply with effectiveness conditions. Despite this time lag, most activities got under way quickly from August 2003. Rating: Moderately Satisfactory Project objectives and design were based on solid analysis of sector issues and constraints, and relevant to RGC and World Bank strategies. Project design both supported and aligned with development of the first Strategic Health Plan. The Bank played a key role in encouraging development partners to organize their support around a common framework led by MOH. The major weaknesses in project design were inadequate definition of the M&E framework, and that no provision were made during design to locate national or international staff in the country office to support implementation. This slowed down the startup and initial implementation of the project. Although the PAD called for using country systems for managing the Project, the Bank
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subsequently agreed to MOH’s request to establish a PMU, which may have facilitated implementation but mitigated contributions to capacity building. (b) Quality of Supervision (Implementation Support) Focus on development impact – World Bank oversight maintained a clear focus on accessibility, affordability, coverage and quality of health services and tackling key diseases. The last of these was overshadowed after 2004 by the inflow of GFATM support for TB, malaria and AIDS, but the World Bank responded well by focusing on specific areas in these fields that were overlooked or weakly supported by GFATM. World Bank staff maintained a strong emphasis on maternal and child health and on improving access for the poor. This was bolstered by development of a common position on many of these issues with ADB, DFID and UNFPA in the joint review process. ISRs tracked key issues, with quality improving over the course of the project. The JRMs produced detailed aides memoires with clear recommendations and action plans for all partners and MOH. Participation in annual planning workshops helped to maintain a focus in MOH on using evidence to identify and address priorities.
Fiduciary aspects and safeguards – internal and external audits were regularly conducted and results discussed with MOH in conjunction with other donors. Compliance with safeguards was tracked and assessed regularly in ISRs, specifically those for environmental assessment, pest management, indigenous peoples and involuntary resettlement.
Adequacy of supervision inputs and processes – There were some delays in release and acquittal of funds, procurement, and in resolving issues in the PMU. Much of this was because World Bank supervision up to 2005 was done from headquarters. The placement of a senior health specialist in the country office and recruitment of a local staff helped to reduce delays and solve problems more quickly. Frequent meetings with MOH and the PMU meant issues were identified earlier and mitigation measures agreed in a more timely way. World Bank cooperation with other donors was strong, and promoted a growing harmonization between donors that has continued since. The heavy workload in procurement, complicated by changes in government policy, contributed to delays, however. World Bank procedures were clear and well understood by PMU and key MOH staff and records have been well maintained.
Candor and quality of performance reporting – ISRs and aides memoires from the JRMs clearly identified major issues, with detailed and often critical appraisals of activities, and from 2004, included recommendations and action plans to address problems identified. ISRs routinely rated the project as “satisfactory” for the first three years, until it was downgraded to “moderately satisfactory” in June 2005 after the team-leader moved to Cambodia. More realistic ISR ratings earlier on might have led to more prompt identification and resolution of issues.
Ensuring adequate transition arrangements – Most activities in HSSP ended in December 2008. This overlapped with preparation of HSSP2, which commenced in early 2009. World Bank staff coordinated well with MOH and other donors in the design of HSSP2, which built on lessons from HSSP and aimed for a stronger SWAp, including the pooling of funds. The new project began on schedule. Three extensions for HSSP meant it ran to the end of December 2011, in order to complete delayed civil works. A small number of these were transferred to HSSP2 at the start of 2012, and this transfer was smooth.
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Rating: Moderately Satisfactory While World Bank supervision and support, including policy dialogue and partner coordination were generally satisfactory, a lower rating of “moderately satisfactory” is given due to the absence of in-country management staff in the early years and the slow identification of problems, which if addressed earlier, could have avoided implementation delays. (c) Justification of Rating for Overall Bank Performance Rating: Moderately Satisfactory. World Bank performance is rated “moderately satisfactory” both during preparation and during implementation, so the overall rating is also moderately satisfactory. 5.2 Borrower Performance (a) Government performance Ownership and commitment – Government showed commitment to reforms in public sector financial management, decentralization and localized planning in the lead-up to HSSP. The World Bank provided technical assistance to MEF to develop guidelines for management of donor funds and procurement. MEF was supportive of the internal and external audit process for HSSP. Enabling environment – Government remains strongly committed to the MDGs. Reducing HIV prevalence, maternal and child mortality, and reducing poverty have been given strong emphasis in government policies, and clear interim and final targets were set in these areas. The government established 19 Technical Working Groups across a range of sectors to facilitate dialogue between government and donors, and the Technical Working Group for Health was paralleled by working groups in the provinces. Government supported MOH in the preparation of HSP1, as well as policies on quality improvement and health financing. Government had approved the introduction of user fees and exemptions for the poor. Beneficiary/stakeholder consultations – Government undertook consultations with MOH, WHO and health sector donors in the preparation and implementation of HSSP. It supported the SWiM approach and has increasingly shown interest in SWAps in order to improve donor harmonization and alignment with government systems. More needed to be done in terms of consultations with local government and civil society in the context of decentralization and linkage to other social protection measures. Readiness for implementation – Government had prior experience with World Bank projects, including in the health sector and was familiar with its systems. MEF assigned staff to liaise with and monitor the project. It also oversaw use of the guidelines on financial management and procurement. Timely resolution of implementation issues – MEF staff assigned to cooperate with HSSP were open to discussions and constructive about dealing with issues. MEF took part in joint quarterly portfolio reviews with the World Bank, ADB and JICA and this was useful to identify and address issues quickly. Issues affecting wider government policy were dealt with more slowly. Good relationships between staff in MEF and MOH and the PMU enabled solutions to be found cooperatively, though this process could sometimes be protracted. MEF trained MOH and PMU staff when there were changes in government policies.
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Fiduciary issues – As mentioned above, after the detection of irregularities in procurement in ministries other than MOH, the government took decision to mandate all WB-financed Projects to use services of IPA for procurement. This mandated decision may have helped reduce fiduciary risks related to procurement, but contributed to delays for procurement of civil work of HSSP due to the performance of the first IPA. The use of the IPA meant it was not possible to transfer the procurement function from PMU to the Government system, which was the aim of the Project. In addition, government showed limited commitment to strengthening the national procurement system, and overall public financial management reform implementation was slow. There were delays in release of the national budget, especially in the first quarter of each financial year. This was due to the government budget process and was outside the control of MEF staff. M&E – MEF monitored financial management and procurement issues. It took part in reviews of audits of HSSP and was active in trying to resolve procurement problems. MEF did not conduct any economic evaluation of efficiency or effectiveness in HSSP, but this was consistent with its general policy on donor-funded projects. Relationships and coordination of donors – For HSSP, donor coordination was managed in the joint quarterly portfolio reviews involving MEF, the World Bank, ADB and JICA; and through the Technical Working Group for Health. Transition arrangements – MEF worked closely with the WB and other donors in the preparation of, and transition to, HSSP2, which commenced on schedule. MEF also helped to ensure the two extensions of HSSP were implemented smoothly. Rating: Moderately Satisfactory For all project-related issues within its control, government responded effectively and quickly, and was pro-active in negotiating solutions. While there were delays in disbursement of the national budget , these were due to government system that were to be improved through public financial management reform. Implementation of these reforms have been slow, however, which undermined the project objective to increase overall efficiency of health expenditure. (b) Implementing Agency or Agencies Performance Commitment to development objectives – The health sector was given a high profile with respect to the MDGs, especially maternal and child health and HIV prevalence. MOH was strongly committed to HSSP in part because it offered a way to make progress on these issues. MOH was also keen to extend health service coverage and to improve the quality of services, two core elements in HSSP. While user fees were essential to health financing, MOH was aware of the barrier this posed for the poor and the ad hoc nature of exemptions. MOH saw that HSSP support for HEFs would allow this problem to be confronted in a systematic and sustainable way. Beneficiary/stakeholder consultations – MOH’s most regular interaction with donors and NGOs was through the Technical Working Group for Health, which convened monthly. Consultation and discussion with provincial and OD levels, and NGOs working at these levels, was most active in the annual planning process and mid-year reviews. MOH commissioned client satisfaction surveys in 2007 and 2008, and then introduced consultation on client satisfaction with community representatives through the process of integrated supervision from to HCs.
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More could have been done in terms of consulting with local government in the context of decentralization. Readiness for implementation – MOH set up a steering committee and financial management group, with a Project Director at a sufficiently high level for decision making and political advocacy. Management, procurement and financial management manuals were prepared. Meeting effectiveness conditions took longer than expected, but once HSSP became effective activities began quickly across all components. Timely resolution of implementation issues – The health sector Joint Annual Performance Reviews (JAPRs) provided a regular forum for MOH to interact with HSSP partners, other donors and NGOs to identify issues and to map ways forward. The JRMs produced joint recommendations and action points more regularly to help resolve issues. Performance of the PMU often had room for improvement, with slow disbursement of funds, delays in procurement and regular complaints from provincial and OD levels about the complexity of procedures and the slow responsiveness of PMU staff. Fiduciary issues – regular audits provided monitoring of financial management. While no serious issues were identified, MOH and PMU personnel were often slow to respond to findings, with problems often carrying over from one audit to another. Procurement, especially of goods and civil works, experienced delays. In the case of civil works, delays led to the necessity of three project closing date extensions, and the transfer of unfinished works to HSSP2 at the end of 2011. Adequacy of M&E – A clear M&E framework with indicators and targets was set out in HSP1 and items were monitored regularly by MOH. HMIS data was used in monitoring sector annual progress and annual planning process; data quality and timeliness improved during implementation. HMIS data was supplemented by CDHS and other survey data for some key indicators. HSSP monitoring indicators were updated upon annually from HMIS through JAPR and from CDHS 2005 and 2010. Relationships and coordination with partners – The JAPRs and Technical Working Group for Health were the main forums for discussion and coordination between MOH, donors and NGOs. The Project Director and PMU personnel were readily accessible and willing to discuss issues, as was the Minister of Health. Transition arrangements – MOH was closely involved in the preparation of HSSP2 and in taking further steps towards sector-wide planning. Transition was aided by a new framework in the Health Strategic Plan 2008-2015, strongly focused on the MDGs. Extensions of HSSP from the end of 2008 to accommodate unfinished civil works were adequately managed by MOH, as was the transfer of remaining items to HSSP2. Rating: Moderately Satisfactory The SWiM approach was a new direction for Cambodia, but MOH adapted well for applying to HSSP. Planning was a key strength. However, delays in procurement, disbursements and civil works, mixed progress toward achieving sector efficiency objectives, and the need for three project extensions means that MOH performance is rated moderately satisfactory. (c) Justification of Rating for Overall Borrower Performance Rating: Moderately Satisfactory
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Borrower performance and implementing agency performance eare both rated moderately satisfactory, so the overall rating is ‘moderately satisfactory’. 6. Lessons Learned Establishing clear objectives and M&E frameworks for sector wide programs – Reviews of the SWiM experience concluded that the overall objective of Sector Wide Management encompassed a range of specific objectives, which were not always clearly defined or adequately understood by MOH and donors. In addition, the M&E framework for HSSP1 and the HSP1 were not fully aligned initially, and the results chain among sector and project outputs, intermediate indicators, and outcome indicators could have been better define. In addition – although not a new lesson -- it is important to select indicators that are available, allow timely monitoring of progress, and enable mid-term and final reviews to make meaningful statements about impact.
Political economy analysis – While HSSP preparation focused on health sector issues and addressed them well, problems and delays in implementation often arose because of systemic issues in the partner government that were not fully appreciated or taken into account during the design. It is important that a technical sectoral analysis is matched with a political economy analysis of government systems and structures in order to help clarify risks and select appropriate implementation arrangements and strategies.
Adaptation and innovation – The project introduced direct disbursements from the PMU to provincial accounts, speeding up the process, and also revised financial arrangements to permit second generation accounts. Innovative solutions such as this are often needed, especially in sector-wide operations, to remove bureaucratic bottlenecks. The challenge then is how to convince government to adopt these more efficient methods into existing systems.
In-country management – implementation of HSSP improved markedly when the WB switched to in-country management. Regular meetings to discuss strategy, to resolve problems and to build relationships with government and other stakeholders became feasible and convenient. Assessments of progress were also more realistic because of the day to day involvement. HSSP is a clear example of the benefits of in-country management. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies MOH issues Cost overruns and delays in civil works – MOH acknowledges these were partly due to changes in MOH designs and equipment lists for referral hospitals, but also due to increased costs of materials during the project. All of these were unforeseen at project inception and are good examples of the risk of detailed activity planning and budgeting over an extended timeframe, and the fixation on targets for both outputs and expenditure rates that such planning entails. Good flexibility was shown by the World Bank and MOH in addressing this problem. No formal linkage of HEFs to other demand and supply side strategies – MOH noted that HEFs would have been more effective if better linked to strategies such as community based health insurance or staff incentive schemes. This is true, but was not a known lesson at inception. It only became clear as the rate of HEF expansion rose in the later part of HSSP. The lesson was 21
incorporated into HSSP2, though the development of effective linking strategies remains a challenge. The lack of harmonization between HEFs was also noted as an issue in HSSP, but again this was a later lesson that has informed HSSP2, where standardization is under way. Support for dengue prevention program – MOH felt this program could have benefited from a stronger community-based approach, as in the malaria program, and greater funding. These two issues are linked. HSSP funding for dengue was modest, but at the same time the National Program Dengue Prevention and Control never responded to requests for a clear strategy implementation plan and budget that HSSP could consider for funding. A community-based approach needed to fit into a larger strategy, and the cost (and cost-effectiveness) of this needed to be clear. Given that the positive impact on dengue under HSSP was quite dramatic, especially in case fatality and hospitalization rates, the very high overall budget estimate of $5 million annually appeared disproportionate. Project management unit – MOH saw HSSP project management as ‘integrated into the existing MOH structures’. Its ICR gives little attention to the PMU and the perception of HSSP partners and other donors that retention of the PMU was a barrier to strengthening MOH systems. It is clear that there were continuing difference in perception between MOH and donors regarding the importance and desirability of integrating the PMU into line departments. Private sector linkages and decentralization – the MOH ICR notes that more efforts could have been made in both these areas under HSSP. This is true, but MOH does not provide any reasons or analysis for this. Central government support for decentralization in particular is strong, but MOH has been slow to act on this, and its capacity and willingness to monitor and regulate the private sector remain weak. (b) Cofinanciers ADB issues Civil works – ADB noted that delays and problems in civil works construction could have been addressed more quickly if there had been better planning and oversight by MOH. The quality of construction would have benefited from closer supervision and monitoring by MOH. This reflects the need for a dedicated civil works supervision unit in MOH. Both the World Bank and ADB could perhaps have advocated for this more strongly during HSSP. Reporting – while seeing the SWiM approach as positive, the ADB ICR notes that each donor still retained different reporting requirements and each prepared separate ICRs, despite having conducted JRMs during implementation. While this is true, the ability of any donor, including the WB, to move to common reporting is limited by internal organizational requirements and is not within the control of any individual project to address. Greater harmonization between donors would certainly reduce the reporting burden on MOH. DFID issues In-country presence – Although DFID’s contributions were smaller than either the World Bank or ADB, it found itself playing a significant role in day to day management and coordination of HSSP because the World Bank initially had no strong in-country presence. The World Bank addressed this after late 2005 with the deployment of a Senior Health Specialist and later additional staff, but the size and complexity of HSSP justified such deployment from the outset.
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Policy reversal – DFID put substantial time and resources into developing the MBPI scheme under HSSP. It was cancelled by the government in 2009. While this was a concern in terms of commitment to reform, the decision was taken at a senior government level and took MOH unawares. There was little that either MOH or donors could have done to avoid this outcome. Insufficient donor response to assessments of slow progress – DFID saw this as perhaps the most important issue in HSSP. The identification of issues and setting out actions in response were both well covered by the JRMs and the action plan contained in each aide memoire. But it is true that issues tended to accumulate rather than be resolved. This was due in large part to the fact that the PMU was normally the unit responsible for dealing with problems rather than specific MOH departments. In this sense the PMU was a barrier to MOH ownership of both problems and solutions. (c) Other partners and stakeholders Donor partner issues Delays in procurement – most donors noted the delays in procurement in HSSP. This is a valid observation. While a number of factors were at play, WB responsiveness could have been more timely and resourcing of support in country could have been greater from project inception. UNICEF issues Nutrition – UNICEF felt that support for nutrition needed to be stronger and that there was poor linkage to other sectors involved in nutrition. Both comments are valid. There is a need to heighten the institutional status of the National Nutrition Program in MOH and to build stronger links to NGOs. HSSP2 partners need to advocate on these issues. Weak links between MOH and other ministries relevant to nutrition remains an operating constraint. The government has made some efforts to improve this with the setting up of the Council on Agriculture and Rural Development and preparation of the National Social Protection Strategy, but nutrition has remained peripheral in this process and donors need to advocate for a higher profile. Training – UNICEF would have preferred HSSP to set budget limits for training and to link budgets to comprehensive training plans. HSSP2 has made progress on both of these, but this was not done in HSSP. At project inception in 2003, MOH promised to develop a workforce plan for human resource development, and DFID provided technical support for this. The World Bank and other partners requested integrated training plans but neither a ministry-wide human resource development plan nor annual training plans were forthcoming. Advocacy continues on these issues in HSSP2.
Medicam12 issues Poor linkage with civil society and local government – while Medicam acknowledged the importance of client satisfaction surveys and HSSP support for HC management committees, it felt that engagement with civil society and local government needed to be stronger in order to promote quality assurance in the health system. Part of the problem is that MOH has few institutional tools for such formal engagement. HC management committees and Village Health Support Groups are the only permanent mechanisms. Weak links to local government are a
12 Medicam is the umbrella organization for NGOs working in the health sector in Cambodia. 23
function of slow progress on decentralization of MOH functions. Under HSSP2, HEFs are proving a useful avenue for better engagement with local government,. No engagement with the private sector – engagement with the private sector was reiterated a number of times in the PAD as an aim of HSSP. But apart from the regulation of iodized salt quality and the sale of infant formulas, HSSP made virtually no progress in this area. This reflects the absence of effective mechanisms in MOH for engaging with the private sector and the tendency for MOH to narrowly define the private sector in terms of professional organizations. The private sector remains the largest deliverer of health services in Cambodia, so engaging with it is vital for MOH to achieve a truly SWAp to health services management and quality control, but MOH resources and skills to do this remain limited.
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Annex 1. Project Costs and Financing
(a) Project Cost by Component (in USD Million equivalent) Actual/Latest Appraisal Estimate Percentage of Components Estimate (USD (USD millions) Appraisal millions)
Component 1: Improvement of 14.41 15.70 105%% Health services Component 2: Support to Programs 10.21 12.05 118%% of Public Health Priorities Component 3: Capacity Building for 4.05 6.54 161% Health Sector Reform Total Baseline Cost 28.67 31.76 117%
Physical Contingencies 0.95 0.00 0.00
Price Contingencies 2.22 0.00 0.00 Total Project Costs 31.84 33.76 106%
(b) Financing Appraisal Actual/Latest Type of Percentage of Source of Funds Estimate Estimate Cofinancing Appraisal (USD millions) (USD millions) Borrower 3.00 2.23 74% UK: Department for International 1.84 1.32 72% Development (DFID) International Development Association 17.20 18.99 110% (IDA) IDA GRANT FOR POOREST 7.80 8.96 115% COUNTRY IDA GRANT FOR HIV/AIDS 2.00 2.24 112%
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Annex 2. Outputs by Component
The table below reports actual outputs against planned out at appraisal in Annex 2: Detailed Project Description (pp. 55-63).
Table of Outputs by Component
Component Planned outputs at Actual outputs at Comments appraisal ICR 1. Improved Delivery of Health Services (for the benefit of the poor and rural population) 1.1 Accessibility Infrastructure – rehabilitation Infrastructure – 6 HCs Infrastructure – the scope and Quality of and extension of 16 district or were renovated and 21 new of civil works was Health Services provincial hospitals; HCs built. 5 new Health modified early in the construction of 24 new HCs; Posts to serve remote project to align with the rehabilitation and extension of communities were Health Coverage Plan and 46 existing HCs; construction of constructed. 5 new district to avoid overlap with the 6 district health offices; referral hospitals were built works of other donors. construction of 10 drug stores. and 2 national program Civil works were delayed buildings had extensions due to a number of factors. added to allow more In the first four years of training and storage. The the project, all construction of 12 HCs and procurement (goods, 1 provincial referral services and civil works) hospital and the was done by the national construction of the consultants of the PMU National Drug Quality with an international Control Laboratory have adviser, but the workload been moved to HSSP2 due was overwhelming. There to delays in finalizing was no World Bank works. support in country and concerns about procurement in other ministries led to a change in government policy requiring all projects to use an IPA, which took some time to recruit. In the latter half of the project, cost escalations and a contractual dispute prevented some works being completed on time.
Equipment – provided to all Equipment – MPA kits Equipment – CPA2 kits constructed and repaired were supplied to 366 HCs were for secondary facilities.(including MPA kits). (the full complement in the referral hospitals doing 12 project provinces in minor surgery and offering 2008). CPA1 & 2 kits a basic range of services. 26
Component Planned outputs at Actual outputs at Comments appraisal ICR were provided to 17 CPA3 kits were for district hospitals, and provincial hospitals doing CPA3 kits to 8 provincial routine surgery and hospitals. offering a diverse range of services.
Maintenance – 6 Maintenance Maintenance – no Maintenance – the MOH, Units established (including Maintenance Units were and government agencies facilities, equipment and established. more generally, remain training). unwilling to commit funds and staff for maintenance. No maintenance (routine, repair or preventive) plans are produced and the End of Project Assessment 2010 (pp. 54-55) found a high proportion of equipment was out of order.
Quality of care – improved Quality of care – exit Quality of care – while quality of care at health facilities interviews at HCs during quality of care improved, (including quality standards and the project found some problems persisted indicators). A Quality significantly increased in health facilities, Improvement/ Standards Unit in client satisfaction, with including insufficient MOH. Improved training and 64% very satisfied and water and electricity supervision for health providers. 35% satisfied. Nearly 90% supplies, over- felt waiting time was prescription, poor hygiene acceptable and almost all practices and outdated saw that the cleanliness of examination techniques. facilities had improved. Training outcomes, in The behavior of health terms of pre- and post- staff was said to be more testing, were very good professional where but follow up and facilities had been supervision were upgraded or given more constrained by lack of equipment and supplies. transport, staff Staff attendance improved unwillingness to travel and use of public health without financial facilities rose. Substantial incentives, and sometimes training was provided for weak integration in health staff, including for supervision. Training supervisors. The MOH tended to be fragmented prepared a Quality and poorly coordinated, Improvement Master Plan with no link to workforce in early 2009, with planning or an overall implementation to be staff development plan. overseen by the Hospital Methods were outdated, Services Department and though training focused policy direction provided well on priority issues. by the Quality The sex ratio of staff Improvement Working trained was relatively Group in MOH. even, and staff at all levels
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Component Planned outputs at Actual outputs at Comments appraisal ICR and in all categories received training.
Child health – training in MPA3 Child health – training in Child health – a WHO (child health & Integrated MPA Module 3 (child survey in 2006 found Management of Childhood health and IMCI),981 staff significant improvements Illnesses-IMCI). were trained, and 81 staff in the examination of undertook the training of children at facilities with trainers course. By 2009, IMCI-trained staff. 92% of ODs and 78% of Follow up and supervision HCs had staff trained in however were weak, IMCI. This compares with leading to concerns in <3% of Operational MOH that skills would Districts (ODs) in 2003. dilute over time. IMCI Pre- and post-testing tended to be better in comparisons showed an facilities where staff were improvement of receiving financial knowledge on IMCI and incentives. The figure for child health from 20% to new cases of children <5 80% overall. years rose from 0.17 in 2000 to 1.1 in 2008, showing significantly greater use of HCs for child health problems.
Drug procurement – a National Drug procurement – Drug procurement – Drug Quality Control HSSP did not provide drug procurement remains Laboratory upgraded to kits as MOH indicated it under the management of international standard. Study on could finance these by the Minister for Health the establishment of a central itself. Offers of technical and there have been drug procurement unit. Drug assistance for drug limited opportunities for kits supplied to HCs and first procurement and logistics technical assistance. and secondary Referral were not taken up by the Stock-out data for Hospitals to fit the needs of MOH. No drug warehouse essential drugs is MPA and CPA. Technical refurbishment was done, monitored regularly and assistance on drug procurement but stock-outs of essential rates have fallen. The and logistics. Rehabilitation and drugs and logistics of drug construction of the drug construction of drug distribution were quality control laboratory warehouses. Study on drug monitored by the project. was delayed due to financing. Annual reviews of Design for an international relocation of the site drugs situation and financing standard drug quality (which required a design needs. control laboratory was revision), and the failure initiated, and some to incorporate key design construction began. recommendations before construction got under way. The construction has now been moved to HSSP2 and design issues appear close to resolution.
1.2 Improving the Utilization – increased use of Utilization – use of public Utilization – while the use
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Component Planned outputs at Actual outputs at Comments appraisal ICR Affordability of quality services. health facilities increased of public facilities Health Services greatly over the course of increased, so did the use the project, aided by new of private health facilities. infrastructure and the About two-thirds of health introduction of HEFs for visits take place in the poor patients. Longer private sector, though poor opening hours and better and rural populations are staff availability, increasingly using public particularly midwives at health centers (IFAPER, every HC, and improved World Bank 2011, pp. 41, staff attendance also 44). contributed to greater utilization. Average distance for the poorest quintile to travel to a HC fell by 36% between 2004 and 2007.
Health Equity Funds (HEFs) - Health Equity Funds – by Health Equity Funds – equity in use of enhanced the end of 2008 there were with increased HEF services. Contracting of HEFs HEFs in 50 of 76 ODs. Of coverage there has been a in 6 districts of Kampong Thom these, HSSP financed 13. tendency for providers to and Kampong Speu provinces. HEFs covered 51 referral raise user fees, increasing hospitals (74% of the total) the costs for HEFs MOH and 120 HCs (13% of the is working on a long-term total). HEFs covered over financial sustainability two-thirds of the poor. A strategy for HEFs under government-operated HSSP2. Schemes are subsidy scheme, similar to managed by NGOs and a HEF, operated in the 6 have different packages national hospitals. 58% of and procedures but there funds spent on HEFs are moves towards provided direct benefits to standardization. In 2008, the poor, while 42% was a third party manager for spent on training, HEFs was contracted and management and advisory has taken on the costs. MOH conducted monitoring role. MOH detailed monitoring of prepared a master plan for HEFs in 2007 and 2008. social health protection in By 2008, provincial 2009 and this was hospitals with HEFs followed by an inter- sourced 25% of their ministry National Social income from the funds. Protection Strategy in 2010. The future administration of HEFs will be guided by these documents. Government spending on Government spending on Government spending on health – increased proportion of health – this increased health – rises in operational costs supported from from less than $50 million government spending domestic funding sources. in 2003 to about $110 were paralleled by
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Component Planned outputs at Actual outputs at Comments appraisal ICR million in 2008. The increases in development upward trend increased assistance over the same more rapidly from 2006 period. About 70% of the onwards. government budget is managed at central level, with limited progress thus far toward fiscal decentralization. Non- program spending accounted for 63% of the MOH budget in 2009. About 60% of public health spending is financed by bilateral and multilateral donors.
Stronger local management – Stronger local Stronger local performance-based contract for management – a management – there was health services in Preah Vihear performance-based no participation from province. contract with an NGO was provincial health implemented in Preah department during Vihear province (one OD contracting health services and one provincial referral with NGOs. This posed hospital). The model had no capacity building and strong support from MOH caused challenges on and led to the choice of monitoring contracting contracting-in (as opposed health services when the to contracting-out, which schemes were switched to had also been tried) with contracting within the the setting up in 2009 of 15 MOH system in HSSP2. Special Operating Though MOH formalized Agencies (10 ODs, 5 a monitoring group in hospitals) using 2010. Long term performance based government commitment contracts between PHDs to SOAs will depend on and Special Operating the development of a Agency (SOA) heads, and sustainable financing between SOA heads and strategy. staff. 15 additional SOAs were established in 2010.
2. Improved Programs Addressing Public Health Priorities 2.1 Infectious Malaria – support to the Malaria Malaria – $2.47m in Malaria – while HSSP Diseases Control Strategic & Operational Master support to the national made important Program Plan (2001). Case detection malaria program. From contributions to the strengthened. Improved 2003-08, malaria fell from prevention and treatment rd surveillance. IEC for behavior the 3 most common of malaria, it was
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Component Planned outputs at Actual outputs at Comments appraisal ICR change. Raised demand for bed- reason for outpatient visits overshadowed by the entry nets. Improved case to 8th position, the of GFATM support to management. percentage of inpatient Cambodia from 2004. treatments for malaria fell While HSSP spent from 4.2% to 1.8%, and $2.47m, in the same the death rate in hospitals period GFATM spent fell from 9.5% to 3.4%. $17m. HSSP’s key The case mortality rate was contributions were support 3.6 per 100,000 in 2003, to Village Health and fell to 1.46 by 2008. Volunteers to increase Severe case mortality fell community awareness from 8.8% to 7.1%. about treatment and use of Village Health Volunteers insecticide treated bed were trained and played an nets, and support for important role in raising training to improve case awareness about treatment detection and and bed net use. Bed net management. coverage met national targets in all but 2 years of the project, the exceptions due to slow procurement.
Tuberculosis – implementation Tuberculosis – $2.59m in Tuberculosis – TB was a of directly observed treatment- support to the national TB major problem at project short course (DOTS) strategy program. Between 2003- inception, infecting an and decentralization to HCs and 08, the number of new estimated 64% of the communities. Integration of TB smear positive cases rose population. The entry of services into health care delivery from 18,923 to 19,294, GFATM support from services. Improved case while the smear positive 2004 impacted on the TB detection and management. detection rate rose from program, but to a much Improved supervision and 59% to 69%. The cure rate lesser extent than for rose from 80% to 91% and malaria, as GFATM training. Increased compliance has remained around that funding was about double with DOTS. level since. DOTS the level of that from coverage rose from 75% to HSSP. GFATM support 100% and the number of was stronger on HCs and hospitals infrastructure, equipment implementing DOTS rose and drugs, while HSSP from 704 to 943. In 2003, focused on staff training, no ODs were integrating the expansion of DOTS TB and HIV treatment. By coverage and the linkage 2008, 68 of 76 ODs were of TB and HIV treatment. doing this.
Dengue – transmission rate Dengue – HSSP provided Dengue – GFATM does reduced. Early detection and $690,000 in support from not provide support for case management improved. 2003-08, focused strongly dengue, which is endemic Epidemic monitoring improved. on vector control and in Cambodia, so HSSP community outreach. inputs were crucial. HSSP also provided just Environmental factors are over $1m to WHO for important, but largely technical support to the outside the control of the national program, which national program or
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Component Planned outputs at Actual outputs at Comments appraisal ICR included training, donors. Issues remained supervision of monitoring, with the high turnover of and operational research. staff in the national The case fatality rate in program, insufficient staff, 1993 was 4% and this had and weak coordination of fallen to 0.7% in 2008. rapid response teams Hospitalization of cases during severe outbreaks. fell from 5.2% in 2003 to WHO is of the view that 1.8% in 2008 as cases were funding for the dengue detected and treated program remains earlier. HSSP supported insufficient, though Abate insecticide spraying greater support is unlikely for vector control. to be forthcoming until the national program produces a fully costed strategic plan. Insecticide spraying for vector control has continued in HSSP2, supplemented by research on other approaches.
STIs/HIV/AIDS – 100% STIs/HIV/AIDS – HSSP STIs/HIV/AIDS – HSSP condom use strategy provided $2.25m in support was insignificant implemented in 16 provinces, support of this program. in money terms compared targeting high risk groups. STI The condom use strategy with funding from drugs supplied to 12 provinces was supported in GFATM. However, for 5 years. cooperation with separate HSSP support was vital in funding from DFID. HSSP the purchase of STI drugs, supported the purchase of and in combination with drugs, but this tapered off DFID, HSSP became the towards the end of the major supplier of free project as funding from condoms in health GFATM increased rapidly. facilities and during HIV prevalence among outreach work to those those aged 15-49 years was groups most at risk. 2% in 1998 and had fallen to 0.8% by 2010. Towards the end of HSSP, voluntary HIV testing was introduced for pregnant women in antenatal visits, and by 2011, 83% of women opted for the test.
2.2 Nutrition Feeding – promotion of Feeding – exclusive Feeding – growth exclusive breastfeeding for breastfeeding for infants 0- monitoring was stopped infants 0-6 months. Promotion 6months rose from 11% in by MOH early during of appropriate complementary 2000 to 68% in 2008. A HSSP, making tracking of feeding for infants 6 months to 2 complementary feeding nutrition problems more years. campaign was planned by difficult. An the National Nutrition anthropometric survey by Program in 2007, but was UNICEF in 2008 noted not implemented until some worrying trends and
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Component Planned outputs at Actual outputs at Comments appraisal ICR 2011. In 2008, 15% of the 2010 Cambodia DHS infants aged 7 months were has shown no not given appropriate improvement in child complementary feeding. nutrition. While HSSP supported the complementary feeding regulation of infant did improve, the quality formula and baby food and regularity of feeding marketing in Cambodia. remained key problems. Nutrition has been given a stronger profile in HSSP2.
Care and treatment – Care and treatment – Care and treatment – as appropriate care for HSSP supported training in with other training, follow malnourished children and MPA Module 10 (child up and supervision of rehabilitation of severely health and nutrition). trainees was insufficient. malnourished children. 3,052 health staff were Concerns remain that only trained, covering 71% of a small number of severe HCs. Management of cases are being referred up severe malnutrition was the system for appropriate added to training in 2007. treatment. While the By the end of 2008, 15 of focus of HSSP support 78 hospitals were able to was on children, the treat such cases, and this proportion of women with has risen to 33 in 2011, a low body mass index with continued support (<18.5) fell from 21% in from HSSP2. HSSP 2000 to 16% in 2008, the supported training for 202 period when HSSP was staff and re-training of 85 supporting community staff on the treatment of promotion of nutrition. severe malnutrition.
Iron folate – supplements Iron folate – distribution Iron folate – the causes of supplied to pregnant women and to pregnant women rose anemia in Cambodian girls children 6-24 months. from 18% in 2005 to 40% and women are still not in 2008. The rate for post- fully understood. HSSP partum women rose from research showed that iron 12% to 33% in the same folate supplements are period. A pilot study with only part of the answer. schoolgirls in 2008 showed There is no consistent no overall decrease in monitoring of anemia in anemia. girls and women. There were occasional problems with supplies of tablets, but overall this intervention worked well.
Vitamin A – supplied to women Vitamin A – coverage of Vitamin A – this support (to 60 days after delivery) and children aged 6-59 months continues under HSSP2. children (6-monthly for those rose from 29% in 2000 to aged 6-59 months). 89% in 2009. Coverage of post-partum women rose from 11% in 2000 to 68% in 2009. The number of 33
Component Planned outputs at Actual outputs at Comments appraisal ICR delivery agents was reduced, improving efficiency.
Iodized salt – provided to all Iodized salt – HSSP Iodized salt – HSSP household members. supported testing of support was confined to iodized salt being sold in quality control measures. the markets and Supply and marketing supervision visits to private were in the hands of the sector producers of iodized private sector. The 2008 salt. By 2008, 74% of survey showed a high rate households were using of uptake and awareness, iodized salt. so HSSP’s contribution was to ensure that this uptake was underpinned by a good quality product.
Outreach and promotion – Outreach and promotion – Outreach and promotion improved nutrition protocols and HSSP supported an update – HSSP support focused messages. Relevant health of the national policy on strongly on detection and services reaching 80% of the feeding in 2008 and treatment, but there was a rural population. Stronger regulation of private sector need for more community- national and provincial capacity marketing of infant and based approaches. to supervise and monitor baby foods. New IEC Nutrition interventions nutrition activities. materials were developed need to link to water and and some operational sanitation, food security, research undertaken by the hygiene, gender and National Nutrition poverty issues, but this is Program. Coverage and constrained by poor monitoring of nutrition cooperation between services both improved. government agencies in Cambodia. The project built good links between support for nutrition and IMCI. MOH’s discontinuation of growth monitoring and strong reliance on 5-year CDHS cycles and ad hoc research for information makes strategic and policy decisions less timely and responsive.
3. Strengthened Budget and financial Budget and financial Budget and financial Institutional management – use of medium- management – HSSP management – it became Capacity term economic framework to set provided substantial clear during HSSP that indicative spending limits. training for the Financial MOH (and government) Consolidation of all funding Management Group in would not move to sources (investment and MOH. However, the integration with its recurrent) into a single budget. integration into MOH’s financial management or Stronger capacity to analyze systems envisaged in the procurement systems. PAD was not achieved and MEF developed separate 34
Component Planned outputs at Actual outputs at Comments appraisal ICR health sector financing. the PMU continued to play Standard Operating Additional financial a strong role in managing Procedures for the management staff recruited and project finances. MOH financial management of trained at central, provincial and adopted a medium-term donor funds and district levels. Internal audit economic framework and government funds, though function in MOH. capacity in using this for there was substantial budgeting improved over commonality between the course of the project. them. The PMU generally Indicative spending limits performed well in terms of became clearer with the financial management, but shift to the Health Strategic this meant that an Plan 2008-2015. The opportunity for more consolidation of all capacity building in the funding sources into a Department of Budget and single budget was not fully Finance in MOH was lost. achieved, but substantial There was good linkage of progress was made. MOH the MTEF and budgeting capacity to analyze health to the development of sector financing increased, AOPs and 3YRPs, but and this was demonstrated budget allocations were by financial sustainability not always strongly linked analyses of HEFs and to strategic priorities. SOAs. Financial There were problems with management staffing at slow release and central level was increased disbursement of funds by but this was not always both MOH and MEF, done at lower levels. though revision of the MOH established an Standard Operating internal audit function Procedures in 2007 helped during HSSP. to alleviate these. Shortage of funds at the start of the financial year continues to be a problem. While there was increased decentralization of planning to lower levels, budgeting decisions remained very centralized. MOH’s internal audit function remained weak, and greater reliance was put on external audits of project support. While no serious financial management concerns were raised in audits, both MOH and the PMU were generally slow to respond to recommendations.
Planning – three-year rolling Planning – HSSP Planning – improvements plans incorporating an annual commencement coincided in the quality of planning, plan. Planning roles and with, and was closely more comprehensive
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Component Planned outputs at Actual outputs at Comments appraisal ICR capabilities developed at central linked to, the HSP1. This plans, and a more and local levels. Capacity for was MOH’s first sectoral participatory mode of evidence based policies and plan and contained clear planning were major programs increased. strategies and targets that achievements under donors could align with. HSSP, and all have been HSSP supported the continued to improve development of AOPs, under HSSP2. Target prepared at local level and setting in AOPs was consolidated into a central sometimes poorly plan, then linked to a coordinated and guidelines 3YRP. The were unclear, and these comprehensiveness of the challenges continue to be AOPs and 3YRPs addressed in HSSP2. A improved over the course major gap, and one that of the project. Annual remains, is incorporation planning workshops of private sector oversight brought together a wide and regulation into AOPs, range of stakeholders, and linkage of private including civil society, and sector service delivery to had strong representation MOH’s strategic priorities. from OD and PHD levels. In the latter part of HSSP, 4 task forces were set up in MOH to oversee quality control of planning in the four major program areas set out in the Health Strategic Plan 2008-2015. The annual planning workshops and task force reviews have increasingly focused on evidence-based planning and resource allocation, using data from MOH’s health information system.
Project Semi Annual Review Project Semi Annual Project Semi Annual Review - all donors in Review – the joint HSSP, including parallel reviews under HSSP were donors ADB and UNFPA, a major achievement in agreed to adopt a common terms of harmonization set of management and between donors and review systems, dubbed as improving links between a SWiM approach by donors and MOH. MOH MOH. Joint annual sector appreciated the greater reviews involving MOH harmonization of systems and 80% of donors (by and joint reviews reduced volume of funding) took transaction costs for place in 2002 and 2003. MOH, which otherwise From 2004, these reviews would have been doing took place six-monthly. reviews with each donor Joint aide memoires were individually. HSSP2
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Component Planned outputs at Actual outputs at Comments appraisal ICR released after each review, sought to build on the setting out agreed findings success of this process. and recommendations for action. This cooperation also laid the foundation for a more harmonized approach among donors under HSSP2.
Resource and service Resource and service Resource and service management – sector-wide management – management – improvements in managing procurement was done by performance based resources, delivering services MOH until 2007, with management focused and improving health status support from an exclusively on financial monitored by an information international adviser. A incentives and early system. change of government monitoring put insufficient policy meant that emphasis on quality subsequent procurement improvement. Linkage to was managed by an IPA. demand side initiatives Delays were common, was not strong, except especially in procurement where SOAs and HEFs of goods and civil works. coincided. Procurement Performance based delays stemmed from management approaches MOH’s lack of familiarity were introduced and with procedures and developed in HEFs, having no WB support in midwifery, incentive-based country. MOH staff and contracts with ODs, SOAs, the international adviser and staff salary supplement were overloaded with too schemes (Priority Mission many different kinds of Group-PMG). Facilities procurement to manage, using such approaches so staff capacity building performed better in client took a back seat. satisfaction surveys. The Problems in other introduction of SOAs saw ministries led to quick expansion and government mandating the positive support from staff, use of an IPA, and slow though monitoring of recruitment, followed by a performance and service change in IPA, had a quality were slower to take negative impact on project hold. progress. Substantial technical advice and financial support was provided for the development of MBPI, so government cancellation of this in late 2009 was a major setback. Government policy on staff salary supplements remains unclear. On the other hand, the performance based
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Component Planned outputs at Actual outputs at Comments appraisal ICR contracting system, formalized in SOAs and building on lessons from projects prior to HSSP, has been maintained and MOH has progressively taken a stronger role in quality monitoring and assessment. Performance based management in HEFs has worked well, with oversight of this being done by an organization under contract to MOH. Monitoring, evaluation and Monitoring, evaluation Monitoring, evaluation information management – and information and information comprehensive review of M&E management – a management – the paper and HMIS undertaken. comprehensive review was based nature of data undertaken. 19 core collection at lower levels indicators were agreed meant some delays in data with MOH for HSSP. being available for These and their targets planning at central and were linked to the HSP1. provincial levels. This Some changes were made continues to be addressed later in HSSP to align with in HSSP2, with the Health Strategic Plan computerization of the 2008-2015. Data process increasingly disaggregation by sex and common. There were age was done for some issues with definitions of indicators, but indicators, especially in disaggregation by ethnicity the early years of the (envisaged in the PAD) project, but these have was not done. HSSP now generally been supported a review of the aligned with international HMIS, provided a practice, and participation technical adviser for M&E, in the CDHS in 2005 and assisted the preparation of 2010 assisted this. Data HMIS guidelines and disaggregation by training, and supported ethnicity is not done by sectoral workshops and any government agency participation of MOH staff and it is not clear why the in the CDHS 2005. PAD envisaged this would Support was also given to be feasible. Data quality prepare a monitoring checking has improved system for HEFs. Data significantly and this has collection at lower levels made MOH and donors during HSSP remained more willing to use HMIS paper based, with manual data in annual planning aggregation and workshops and mid-year submission to central level, reviews in order to but plans were developed allocate or re-allocate to progressively resources. Support to
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Component Planned outputs at Actual outputs at Comments appraisal ICR computerize this process. improve this continues under HSSP2. Because ODs and government administrative districts are not always congruent, some issues remain in matching service and population data. However, resolution of this is probably outside the scope of donor assistance.
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Annex3: M&E indicators
This annex presents three tables: (1) key performance indicators from the PAD, which were to be monitored annually; (2) Core Performance Indicators from the PAD; and (3) ISR indicators collected in addition to the previous PAD data sets. As noted in the main text, the M&E framework was to be finalized during the first year or so of implementation. • None of the indicators in the PAD had targets, and several monitoring indicators were subsequently modified. Once the HSP1 M&E framework was finalized, baseline figures and targets were aligned with those in the HSP1 and for the MDGs (where appropriate). Baseline figures are for 2003 unless otherwise indicated, and targets were set for 2007 unless otherwise indicated, with CMDG indicators having intermediate targets for 2010 as well as final targets for 2015. . All annual figures are from MOH’s HMIS unless otherwise indicated. Because most HSSP activities relevant to HMIS indicators ceased at the end of 2008 or early 2009 and were taken up by HSSP2, HMIS indicators are only reported below through 2008, but are available through 2011. The HMIS system has continued to improve and is now fully web-based, but reporting from the private sector remains problematic, and official HMIS data cover only the public sector. For some indicators, household surveys may capture the whole of the health sector (public and private). . For key outcome indicators, the CDHS 2010 is used. . Abbreviations: BTC - Belgian Technical Cooperation CAS – Cambodia Anthropometric Survey CDHS – Cambodia Demographic and Health Survey CSES – Cambodia Socio-Economic Survey
Key Performance Indicators (PAD, p. 3)
PAD Key Performance Indicator Baseline 2004 2005 2006 2007 Target 2008 1 MOH recurrent (salary excluded) budget as a 9.5% 11.0% 11.0% 11.1% 11.5% 11.9% 11.2% proportion of the total government recurrent (salary excluded) budget 2 % of the population with access to HCs providing ------MPA services (as defined by MOH) 3 Per capita new consultations (or visit rate) for 0.39 0.47 0.48 0.60 0.56 - 0.54 curative care in public facilities, especially by the
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PAD Key Performance Indicator Baseline 2004 2005 2006 2007 Target 2008 poor [HMIS did not disaggregate by income level] 4 % of patients satisfied with services received in - - Poorest = - - - Satisfaction public health facilities. [No consistent 95% at public methodology was adopted to measure client Better off = facilities satisfaction. The HSSP end of project survey 89% rated 8.4/10 undertook focus groups and satisfaction surveys Source: BTC in 2010 (end for sample villages in HSSP1 provinces. HEFs survey of HSSP regularly conducted exit interviews with clients, survey) which generally found 90%+ of poor clients reporting they were satisfied with services. 5a % of PHDs producing annual health plans (as - 100% 100% 100% 100% 100% 100% specified in the MOH manual) 5b % of ODs producing annual health plans (as - 100% 100% 100% 100% 100% 100% specified in the MOH manual) 6a Incidence of malaria per 100,000 inhabitants in 10.3 7.5 5.5 7.2 4.2 7.21 4.1 areas of risk [figure is per 1,000 as per HMIS; figures are from annual reports of the National Malaria Program] 6b Malaria case fatality rate in public facilities per 8.8 9.1 10.4 7.9 8.3 6.16 7.1 100 patients [figure is for severe cases as per HMIS; figures are from annual reports of the National Malaria Program] 7a Pulmonary TB smear (+) case detection rate 62% 62% 68% 62% - 70% 69% [data from TB national program database] 7b Pulmonary TB smear (+) cure rate 93% 92% 93% 85% 90% >85% 91% [data from TB national program database] 8 HIV sero-prevalence rate among women 1.9% (2002) 1.7% (2003) - 0.7% - - 0.4% (2010) attending ANC [Data from sentinel sites. Voluntary HIV testing for women in ANC visits was not introduced until late 2008. Cf. indicator1 in ISR table. ] 9a Malnutrition (weight for age) in children <2 6-59 months - 29% - - 6-59 months 6-59 months = 45% Source: = 31% = 28.3% Year: 2000 CDHS Year: 2010 Source: Source:
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PAD Key Performance Indicator Baseline 2004 2005 2006 2007 Target 2008 CDHS CDHS 9b Malnutrition (weight for age) in children 2-5 6-59 months - 24-59 months - - 6-59 months 6-59 months = 45% = 40% = 31% = 28.3% Year: 2000 Source: Year: 2010 Source: CDHS Source: CDHS CDHS
Core Performance Indicators (PAD, pp. 53-54) PAD Core Performance Indicator Baseline 2004 2005 2006 2007 Target 2008 1 MOH recurrent (salary excluded) budget as a 9.5% 11.0% 11.0% 11.1% 11.5% 11.9% 11.2% proportion of the total government recurrent (salary excluded) budget 2 % of actual MOH salary and non-salary ------expenditures [cf. indicator 8 in ISR table below]
3 % of actual recurrent expenditures disbursed by ------ODs [cf. indicator 8 in ISR table below] 4a % of PHDs producing annual health plans (as - 100% 100% 100% 100% 100% 100% specified in the MOH manual) 4b % of ODs producing annual health plans (as - 100% 100% 100% 100% 100% 100% specified in the MOH manual) 5 % of the population with access to HCs providing ------MPA services (as defined by MOH) [cf. indicator 6 in ISR table below] 6a % of RHs meeting essential obstetric care ------standards [cf. indicator 6 in ISR table below] 6b % of HCs meeting essential obstetric care ------standards 7 % of out-of-pocket expenditures on health care by - 3,988 riel - - 3,821 riel - 9,538 riel income 3.6% 3.1% 2.3% [Figures are (i) nominal expenditures in riel; and Source: Source: Source: (ii) catastrophic expenditures on health, by the CSES 2004 CSES 2007 CSES 2009
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PAD Core Performance Indicator Baseline 2004 2005 2006 2007 Target 2008 poorest quintile.] 8 Numbers of exempted/non-exempted households 18,591 34,512 99,801 73,000 NA - 227,457 for which costs have been paid (fully/partially) by (JAPR 2004 (JAPR 2005 (JAPR 2006 (JAPR 2007 (JAPR 2007 equity funds reported for reported for reported for reported for reported for year 2003) year 2004) year 2005) year 2006) year 2006) 9a % of RHs meeting minimum staffing levels ------9b % of HCs meeting minimum staffing levels ------10 % of facilities without stock-outs of essential ------drugs (using tracer drugs) 11 Per capita new consultations (or visit rate) for 0.39 0.47 0.48 0.60 0.56 0.51 0.54 curative care in public facilities
12 % of deliveries attended by a primary or 70% 58 22 33 41 39 46 secondary midwife or a doctor Year: 2010 [HMIS figure – includes deliveries by trained staff Source: at home or in health facility] Cambodia
MDG interim
target 13 % of children <1 year fully immunized 39% - - - - 70% 73.6% [HMIS only tracks immunization for measles on Year: 2000 Year: 2010 Year: 2010 an annual basis] Source: Source: Source: CDHS 2000 MDG interim CDHS 2010 target 14 % of ODs with annual plans indicating ------stakeholder/consumer involvement (e.g. joint approval, budget line for meetings, etc.). 15a % of patients satisfied with services received in - - Poorest = - - - Satisfaction public health facilities 95% at public Better off = facilities 89% rated 8.4/10 Source: BTC in 2010 (end survey of HSSP survey) 16a Incidence of malaria per 100,000 inhabitants in 10.3 7.5 5.5 7.2 4.2 7.21 4.1
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PAD Core Performance Indicator Baseline 2004 2005 2006 2007 Target 2008 areas of risk [figure is per 1,000 as per HMIS] 16b Malaria case fatality rate in public facilities per 8.8 9.1 10.4 7.9 8.3 6.16 7.1 100 patients [figure is for severe cases as per HMIS] 17a Pulmonary TB smear (+) case detection rate 62% 62% 68% 62% - 70% 69% [data from TB national program database] 17b Pulmonary TB smear (+) cure rate 93% 92% 93% 85% 90% >85% 91% [data from TB national program database] 18 CPR/modern methods for all women 15-49 years 17% - - - - 44% 35% Year: 2002 Year: 2010 Year: 2010 Source: Source: Source: HMIS MDG interim CDHS target 19a Malnutrition (weight for age) in children <2 6-59 months - 29% - - 6-59 months 6-59 months = 45% = 31% = 28.3% Year: 2000 Year: 2010 Source: Source: CDHS CDHS 19b Malnutrition (weight for age) in children 2-5 6-59 months - 24-59 months - - 6-59 months 6-59 months = 45% = 40% = 31% = 28.3% Year: 2000 Source: Year: 2010 Source: CDHS Source: CDHS CDHS 20 HIV sero-prevalence rate among women 1.9% (2002) 1.7% (2003) - 0.7% - - 0.4% (2010) attending ANC [voluntary testing for women in ANC visits was not introduced until late 2008; cf. indicator 1 in ISR table. Data are from sentinel ANC sites] 21 Infant mortality rate per 1,000 live births 95 - 66 - - 60 45 Year: 2000 Source: Source: Year: 2010 Source: CDHS MDG interim Source: CDHS target 2010 CDHS 22 Under five mortality rate per 1,000 124 - 83 - - 75 54 Year: 2000 Source: Source: Year: 2010
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PAD Core Performance Indicator Baseline 2004 2005 2006 2007 Target 2008 Source: CDHS MDG interim Source: CDHS target 2010 CDHS
23 Maternal mortality ratio 437 - 472 - - 402 206 Year: 2000 Source: Year: 2010 Source: CDHS Source: CDHS CDHS
Additional indicators monitored in ISR reports Indicator Baseline Target Achieved 1 HIV prevalence among those 1.9% 1.8% 0.7% 15-49 years old Year: 2003 Year: 2015 Year: 2010 Source: NCHADS Source: Cambodia MDG Source: Annual Performance Report 2010 2 % of children < 1 year fully 39% 70% 73.6% immunized Year: 2000 Year: 2010 Year: 2010 Source: CDHS 2000 Source: Cambodia MDG interim target Source: CDHS 2010 3 % of pregnant women 29% 75% 72% received at least 2 ANC Year: 2002 Year: 2010 Year: 2010 consultations Source: HMIS Source: Cambodia MDG interim target Source: Joint Performance Review 2011 4 % of married women aged 17% 44% 35% 15-49 years using modern Year: 2002 Year: 2010 Year: 2010 contraceptives in public Source: HMIS Source: Cambodia MDG interim target Source: CDHS 2010 health services 5 % of deliveries attended by 20% 70% 69.6% trained staff Year: 2002 Year: 2010 Year: 2010 Source: HMIS Source: Cambodia MDG interim target Source: Joint Performance Review 2011 6 Improved capacity of HCs 294 470/965 469/1,010 (full MPA capacity) Year: 2003 Year: 2006 Year: 2010 Source: HMIS Source: Joint Performance Review Source: Joint Performance Review 2007 2011 7 Improved capacity of referral - 47/67 56/89 hospitals (achieved CPA2 and Year: 2006 Year: 2010
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CPA3 levels) Source: Joint Performance Review Source: Joint Performance Review 2007 2011 8 Disbursement of MOH - - 102.6% of national budget budget expenditures Year: 2010 Source: JPR 2011
Changes key indicators in HSSP and Non-HSSP Provinces based on 2005 and 2010 CDHS Neonatal U5 % % ANC Skilled % Skilled Birth % Use Modern % Vitamin A Mortality Mortality % Stunted Underweigh DPT3 Provider Attendance Contraceptives Postpartum Banteay Meanchey -8 -20 -0.7 -10.5 7.5 21.7 35.9 10.4 14.9 Kampong Speu -2 -49 5.5 3.7 -1.7 30.9 45.5 18.7 35.5 Kampong Thom -9 -39 8.8 -3 9.6 26.2 23.2 9 4.2 Kratie 10 -30 -29.5 -4.8 7.7 13.3 15.8 3.8 9.3 Pursat 2 -49 -16.8 -18.1 2.2 1.4 42.2 7.5 -7.8 Oddar Meanchey 1 -63 -7.7 -8.7 8.5 35 49.2 8.8 18.6 Battambang/ Pailin -1 -62 -9.7 -7.5 -3.2 9.5 18.8 6.7 18.1 Kampot/ Kep 7 -10 15.2 -1.1 13.1 17 25.5 4.6 25.7 Preah Vihear/ Stung Treng -5 -28 14.4 -11.3 20.2 28.6 15.3 7.3 19.2 Kampong Cham -2 -53 9.7 -1.8 6.3 30.4 22 5.6 4.3 Kampong Chhnang 9 -4 3 -3.2 -3.8 5 22.6 5.5 35 Kandal 4 -32 8.1 -10.3 -3.8 11.1 13.5 9.1 17.6 Phnom Penh -16 -34 2.7 -2.7 4.5 14 12.8 -2.3 16.4 Prey Veng -18 -69 -3.7 -15.8 -1.7 31.1 31.2 16.8 0.9 Siemreap -6 -34 -3 -12.6 35.5 23.6 44.1 12.8 28.8 Svay Rieng -2 -17 -4.2 -7.9 4.8 1.6 60.7 4.7 29 Takeo -15 -18 2.8 -6.7 3.9 12.2 23.3 3.6 26.3 Sihanoukville/ Koh Kong -17 -41 5 -15.5 7 30.5 22.1 4.2 17.6 Mondul Kiri/ Ratanak Kiri -26 -59 0.9 -17.9 0.4 33.6 24.7 13.4 2.9 HSSP1 Provinces -0.6 -38.9 -2.3 -6.8 7.1 20.4 30.2 8.5 15.3 Other Provinces -8.9 -36.1 2.1 -9.4 5.3 19.3 27.7 7.3 17.9 Notes: HSSP1 provinces are shaded. Data on key outcome indicators in the CDHS (including child and neonatal mortality; skilled birth attendance) represent averages for the five years prior to the survey. Comparison of 2005 and 2010 CHDS therefore reflects changes during HSSP implementation. Averages for HSSP and non-HSSP provinces are unweighted. The table shows significant variations among provinces, and some difference between HSSP and non-HSSP provinces, but differences are not statistically significant.
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Annex 4. Economic and Financial Analysis Annex 4 of the PAD included an economic analysis of the proposed project which covered consistency with government and World Bank strategies, benefits and allocative efficiency of the project activities, risks, rationale for public sector investment in the project activities, a poverty assessment and an assessment of fiscal impact and sustainability. The analysis included a calculation of net present value which showed that project outcomes were highly sensitive to good implementation. It also included an estimated internal rate of return. A likely poverty impact assessment was disaggregated by wealth quintiles.
No subsequent economic analysis was conducted during the project or on completion, nor was data collected in a systematic way with a view to doing such an analysis.
MEF did not carry out an economic analysis of the project or any calculation of the rate of return. There is no RGC policy which mandates this.
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Annex 5. Bank Lending and Implementation Support/Supervision Processes
(a) Task Team members Responsibility/ Names Title Unit Specialty Lending Task Team Vincent Turbat Senior Economist (Health) AFTHE Leader Darren Dorkin Operations Analyst, EASHH Lingzhi Xu Senior Procurement Specialist ECSH1 Rosario Aristorenas Senior Program Assistant AFTED Hoi-Chan Nguyen Senior Counsel LEGEA Legal Enis Baris Senior Public Health Specialist MNSHD Rae Galloway Nutrition Specialist HDNHE Senior Financial Management Financial Wijaya Wickrema Specialist management Christopher D. Walker Lead Specialist (Peer Review) Peer Review Salim J. Habayeb Lead Public Health Specialist AFTHD Slaheddine Ben-Halima Sr. Procurement Specialist AFTPR Peer Review Bernhard H. Liese Public Health Specialist IEGCC Peer review Mead A. Over Senior Economist Peer Review Financial Nipa Siribuddhamas Financial Management Specialist EAPFM management Jean-Pierre Manshande Senior Health Specialist Supervision/ICR Rajiv Aggarwal Consultant SASED Civil Works Simeth Beng Senior Operations Officer EASHE Ms. Loraine Hawkins Consultant MNSHD D&D Noel Sta. Ines Senior Procurement Specialist EAPPR Procurement Helene Sr. Gender Specialist EASER Social Safeguard Carlsson Rex Bunlong Leng Environmental Specialist EASTS Environment Chandra Chakravarthi Program Assistant EASHD Ravan Chieap Program Assistant EACSF Financial Seida Heng Consultant EAPFM Management Timothy A. Johnston Senior Health Specialist EASHH Cornelis P. Kostermans Lead Public Health Specialist SASHN Pema Lhazom Senior Operations Officer EASHH Da Lin Program Assistant EACSF Task Team Nareth Ly Operations Officer EASHH Leader Oithip Mongkolsawat Senior Procurement Specialist EAPPR Procurement
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Donald Herrings Sr. Financial Management AFTFM Mphande Specialist Toomas Palu Sector Manager EASHH Nipa Siribuddhamas Financial Management Specialist EAPFM Sirirat Sirijaratwong Procurement Analyst EAPPR Procurement Sreypov Tep Program Assistant ECSHD Jennifer K. Thomson Manager, Financial Management SARFM Hope C. Phillips Volker Senior Operations Officer EASHH A. Juliana Williams Operations Assistant EASHD
(b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) USD Thousands Stage of Project Cycle No. of staff weeks (including travel and consultant costs) Lending FY00 1.66 FY01 21 158.34 FY02 33 187.55 FY03 35 210.68 FY04 2 34.89 FY05 0.15 FY06 0.20 FY07 0.00 FY08 0.00
Total: 91 593.47 Supervision/ICR FY00 0.00 FY01 0.00 FY02 0.00 FY03 2 46.05 FY04 21 144.29 FY05 30 109.29 FY06 35 100.04 FY07 32 101.99 FY08 12 57.84 FY09 1 0.00
Total: 133 559.50
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Annex 6. Summary of Borrower's ICR and/or Comments on Draft ICR 1. Executive summary of Borrower’s ICR, February 2012 The Ministry of Health developed its first five year Health Sector Strategic Plan (HSP1) for the 2003-07 period in 2002 through consultations with a variety of stakeholders including other ministries and government agencies, local authorities, health development partners, civil society members, and local and international NGOs. The overall goal of HSP1 was to improve health status and contribute to poverty reduction through eight strategies in six priority areas: health service delivery, behavior change, quality improvement, human resource development, health financing, and institutional development. To achieve the Plan, the Health Sector Support Project (HSSP) was developed and implemented by the MOH and its partners. The project was financed by the Royal Government of Cambodia (RGC) through loans from the Asian Development Bank (ADB), The World Bank (WB) and by a grant from the Department for International Development (DFID) of the United Kingdom, with additional funding from the UN Population Fund (UNFPA). The executive agency (EA) for the Project was the Ministry of Health of the Royal Government of Cambodia.
The goal of the project was to improve the health status of the people of Cambodia, especially women, children and the poor in targeted regions. The project’s specific objectives were to: (i) Increase the institutional capacity to plan, finance, and manage the health sector in line with the HSP1, 2003-07 (ii) Develop affordable, quality, basic curative and preventive health services for the population, especially for women, the poor and the disadvantaged (iii) Increase the utilization of health services, especially by the women and the poor, and (iv) Control and mitigate the effects of infectious epidemics and of malnutrition with emphasis on the poor and disadvantaged. WB/IDA financing covered 12 provinces, national level communicable disease control, and other selected MOH activities. A DFID grant also covered national level capacity building, monitoring and evaluation, safe motherhood activities, and contracting of health services to NGOs. A significant portion of DFID funds were channeled through ADB or WB/IDA. The project’s components consisted of the following: (i) improved delivery of health services (ii) support to programs addressing public health priorities and (iii) strengthening institutional capacity.
At the time of design, the MMR was reported as 437 per 100,000 live births based on the findings of the CDHS 2000. Subsequently, the CDHS 2005 reported an MMR of 472, which was within the previous estimate’s margin of error, suggesting that there was no decline. In the CDHS 2010 the MMR estimate is reported at 206 suggesting that a secular decline has occurred. Similarly, the total fertility rate declined from 4.0 in 2000 to 3.0 in 2010. Both under 5 mortality and the IMR in contrast to the MMR showed remarkable declines over the period from 2000 to 2010. Under 5 mortality declined from 124 in 2000 to 83 in 2005 and 66 in 2010, per the CDHS. IMR declined from 95 per 1,000 live births in 2000 to 66 in 2005 per the CDHS and then to 45 in the 2010 CDHS. Both these indicators therefore, have shown a decline that is more than double that anticipated at project design, and HSSP interventions and activities funded by World Bank, among other donors, contributed directly and indirectly to this achievement.
Although the interventions proposed in the initial design directly addressed the challenges and problems facing the health sector, one of the key weaknesses that emerged in the process of implementation was the serious underestimation of cost estimates for civil works, and contracting of health services of NGOs. Civil works overruns reflected the adoption of new MOH approved designs and guidelines for referral hospitals that were not anticipated in the project design. The revised CPA equipment list reflected an increased number of items and quantities and therefore exceeded the original cost estimates. Similarly, the bid prices for NGO contractors for delivering health services in the 10 ADB funded ODs were also severely underestimated, although
50 subsequent DFID funds covered the shortfall. Also, at design a sum of $90,000 was allocated to start up kits for drugs and supplies; however, after project launch it was determined that sufficient drugs and supplies were available through CMS for start-up supply, as well as further routine supply, and therefore this amount was reallocated for other line items.
The project had three outputs: improved delivery of health services, especially those targeting the poor and women; support for priority public health programs; and strengthening of institutional capacity for management and human resources. Most of the targets specified under these outputs were achieved. At the end of the project, the overall physical completion rate was 95%. In general, Project implementation was delayed by a year due to delays in the civil works construction and rehabilitation program and consequent delays in procurement and supply of biomedical equipment. Contracts with NGOs for management of service delivery at Operational District levels were also extended to facilitate the transition to Internal Contracting arrangements comprising of Special Operating Agencies and Service Delivery Grants in line with the Royal Government’s Policy on Public Service Delivery which came into effect in 2006.
The civil works component was a crucial element of the overall project approach and was successful with regard to reaching project objectives. Client appreciation of the modern facilities in combination with improved quality of care brought about increased utilization rates, in particular in child care. A detailed list of civil works under the WB component is at Annex 1. MPA Kits were distributed to 901 HCs. CPA kits were supplied to 38 CPA2 RH and to 18 CPA3 RH. Health facility staff who were interviewed as part of the final evaluation survey stated that they were satisfied or very satisfied with the supply of medical equipment.
Training was a prominent part of HSSP1 activities and involved all categories of health workers and health managers at all levels of the system. Annex provides a list of the total number of staff by category and sex who were trained under HSSP1 auspices.
The affordability strategy to improve quality and make services affordable at the same time included contracting of OD and of NGO and the extension of several schemes of health equity funds. Support for Community Based Health Insurances was not part of HSSP1 financing. HEFs have shown better effectiveness in improving access when combined with other demand-side strategies, such as CBHI and voucher schemes for maternal health services, and with supply-side strategies such as contracting and the national targeted program of incentives for midwives.
The number of ODs with HEFs increased sharply under the review period, especially in 2007 and 2008. By 31 December 2008, 50 of the 76 OD of the country were operating an HEF, of which 9 were under the MoH subsidy scheme (1 with co-funding in Kampong Chhnang) and 41 with Health Partners’ funding (29 under HSSP co-funding, and 13 under bilateral funding). In addition, the MoH subsidy covered 6 national hospitals, 5 since September 2007. By December 2008, HEFs were implemented in 51 referral hospitals and 120 HCs. Implementation of HEFs at HCs was still relatively limited at Project end, and depended on facilities’ accreditation to the minimum standards set by the MoH. At the end of 2008, HEF coverage at RH level was 74% and 13% at HC level.
HEF benefit packages were relatively similar in their overall scope but there was a lack of common arrangements: there was room for harmonization and review of some targeting strategies. Although Reproductive Health was not included in the original project design, it gained momentum with UNFPA becoming a partner in HSSP1. Interventions that were supported by HSSP1/UNFPA for reproductive health included national level support through national programs and departments of the Ministry of Health, and through health service delivery support.
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At the Human Resource Department at the Ministry of Health, support was provided for a range of activities including human resource planning, development of standards for training and accreditation, extension of human resource data bases, strengthening of continuing education systems (regional meetings), revision of training curricula and curriculum development and review, implementation of training programs (CPA surgery, midwifery), and implementation of primary nurse midwifery training programs in the north east of the country. Training formed a significant part of the reproductive health investment. Training was conducted through Regional Training Centers and covered areas such as use of the partograph, IUD insertions, life-saving skills, management of the third stage of labor, maternal death audits, refresher training for midwives, and community based distribution of essential reproductive health commodities. Aside from government health staff, training was also provided for CBD agents in birth spacing. RH outcome indicators have improved considerably. ANC2 coverage climbed from 29% in 2002 to 81% in 2009. Deliveries in health facilities have increased by a factor of 3.6 in a 5 year period to 39% in 2009. The distribution of MPA kits to 901 HCs and of 56 CPA2/3 kits to referral hospitals has greatly contributed to this success. All these interventions and activities have contributed to the decline of the MMR as noted earlier.
Over the last decade there has consistently been an estimated 2 million Cambodians at risk of malaria with 75% of these people living within 1 km of high transmission areas (forest). HSSP1 activities were funded to strengthen malaria services in health facilities, particularly in high-risk geographical areas, mainly through monitoring and supervisory visit activities, but also limited civil works and equipment procurement. In addition, funding was dedicated to further integrate malaria activities within health service delivery. Support for institutional strengthening was focused mainly on a series of training programs, as well as monitoring and supervisory field visits. During the Project period, there were major improvements in malaria outcomes. In 2008, malaria dropped from being the third most common cause of outpatient attendance to being the eighth, and 0.7% of all outpatient attendance. This significant decline is mirrored by the change in percent of inpatient hospitalizations due to malaria, dropping more than two-fold to 1.8%. The once leading cause of mortality in hospitals in 2003 dropped three times to 3.4% of all deaths, or the sixth leading cause. Improved case management and the utilization of ITNs both supported by the Project were the driving forces. The percent population at risk who are living in Malaria endemic areas and received ITNs increased substantially between 2003 and 2008, rising from 49% in 2003 to 76% in 2008. This positive development was strongly facilitated by the involvement of Village Health Volunteers and multiple training and supervision activities at all levels.
Like the malaria village health volunteer program, Dengue could have benefited from a community-based approach to monitoring the disease. However, the program was limited to epidemiological surveillance. The importance of other surveillance such as entomological surveillance and environmental surveillance was recognized but the program was under-funded. In particular vector control needed to be intensified, but also health workers needed to be better prepared for diagnostics and treatment, especially of dengue hemorrhagic fever. HSSP1 financed supervision, training, technical assistance, minor civil works, as well as supporting activities to control the spread of TB in AIDS patients and providing better care to the TB/HIV positive patients. Along with the HSSP1 inputs, there was also financial support from other development partners for TB prevention and control activities including from JICA, the Canadian International Development Agency, WHO and later support from the Global Fund (Round 2 and Round 5). From 2003 to 2008, all TB related indicators have improved: the number of TB cases detected increased from 28,386 to 35,466, the case detection rate from 59% to 69%, the cure rate from 89% to 91%, the DOTS coverage from 75% to 100%, the number of health facilities implementing DOTS from 704 to 943. In addition to the various IEC materials
52 developed and disseminated, a substantial community village health volunteer network was also established, with key informant interviews indicating that the village health volunteer network was a significant factor in achieving CDC outcomes. The TB control program is one of the best integrated vertical programs. This promotes program success as well as strengthening the entire PHC system.
IMCI was steadily scaled up over the past decade and covered most HCs and hospitals in the country. In 2009, IMCI was implemented in all municipalities and 24 provinces and covered 70 ODs (92%) and 751 HCs (78%). Training of health workers was the core activity of IMCI. HSSP1 supported basic training courses for HC/HP, RH, OD and PHD level (11 days) and for TOT (5 days). About 80% of all HCs now had at least two health workers trained in IMCI by Project end, and an estimated two thirds of them practiced IMCI regularly. Observation and interviews confirmed that real and perceived quality improvements were significant, even if there were still quality challenges. Health workers in all visited HCs during final evaluation confirmed that the utilization of child health services had greatly increased with the introduction of IMCI and because of it. The attendance of under-five children in health services has risen from 0.17 to 1.1 new cases per year. Similarly, hospital staff have reported increasing occupancy rates in pediatric wards due to more rational referrals from HCs. Intense supportive supervision and re- training were essential for maintaining the required quality levels.
The HSSP1 nutrition component supported 6 key areas: (i) Infant and Young Child Feeding, (ii) Vitamin A, (iii) Iron, (iv) Iodine, (v) Growth Monitoring, and (vi) Management of severe malnutrition. One essential contribution of HSSP1 in support of the NNP was consistent and continued training of health workers in the MPA 10 Training Module which focuses on nutrition. By the end of 2008, 3,052 health workers at PHD, OD and HC level were trained on the MPA 10, and 71% of HCs had staff trained in the MPA 10. Vitamin A coverage for children doubled, and 69% are reported to having received it in 2008. Distribution coverage to women of reproductive age had increased from 11% to 68% in 2009. About two thirds of pregnant and of post partum women received regular iron/folic acid tablets. In 2008, 74% of households were using iodized salt, and urinary iodine excretion levels were satisfactory. Since 2003, 287 health staff have been trained in the management of severe malnutrition.
Planning was one of the most successful activities implemented in the framework of HSSP1 and more specifically in the framework of the National HSP1 2003 – 2007. Planning was organized at all levels of the chain of command. With project funding, the MoH introduced a rolling medium-term (3-4 years) planning process and redefined the planning roles of the central, provincial, and district levels. The project supported the progressive decentralization of the planning process and the integration of planning and budgeting activities. HSSP1 contributed to the organization of annual sector reviews, which were carried out by an independent organization, with oversight from a suitable institution within MoH responsible for contracting and managing the reviews, disseminating the findings, and incorporating them into MoH policy-making and planning processes. The establishment of the annual health sector review and planning process (to be followed by HSSP review of allocations to specific project activities) was beneficial for this new and evolving sub-component. The national HIS has been collecting data on routine health service activities and public health priorities at all levels from health facility, to operational district to provincial hospital. Disaggregated data by age group, sex, and geographical distribution were available for a limited number of indicators. The HIS did not cover administrative, financial or vital statistics.
During the design stage it was envisaged that a separate M&E unit would be set up in DPHI. However, in 2003, the HIS Bureau was nominated as the M&E unit for the project with the
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Deputy Director in charge nominated as the M&E team leader. Two local consultants were recruited as health management monitors to monitor ADB and WB/IDA operations respectively, reporting to the unit chiefs and they along with the international M&E specialist who came on board in May 2004 assisted the HIS Bureau with HSSP monitoring. NGO contractors performance was monitored separately by the Monitoring Group under the DDG with staff from DPHI, DBF, HRD, DP, and DPM as members along with senior staff from the PHDs. The HSSP contracting specialist served as the secretary to the group. Capacity building was conducted at various levels during the project. In 2006, 202 staff from all 24 provinces comprising PHDs and ODs, and national hospitals were trained in the use of HIS database software and similarly, 201 staff from the same units were trained in GIS use and the preparation of choropleth maps for monitoring. In addition, in 2006, 42 participants from national hospitals, PHDs and DPHI underwent a TOT in M&E and data use and analysis. Subsequently, a total of 111 staff from PHDs, ODs, RHs, and HCs attended 3 day workshops on M&E and data use and analysis conducted by trainers from DPHI, NHs, and PHDs. The HSSP M&E unit has also provided both classroom and hands on training to PHD and OD staff in Koh Kong province and NGO contracting staff from CARE in conducting Lot Quality Assurance Sampling Surveys in 2007. The PHD and ODs have subsequently institutionalized the training by conducting LQAS small sample surveys in 2009 as well. Evidence of the impact of capacity building on data use is witnessed through the presentations made by PHD management teams in rotation at the monthly Technical Working Group-Health meeting consisting of key stakeholders in the sector including DPs, where trend graphs of key indicators are routinely presented and analyzed. Similarly, there is greater use of data at the AOP quarterly and annual reviews conducted at PHD and OD levels. Finally, presentations at the Joint Annual Performance Reviews conducted by the MOH also show clear evidence of more in depth analysis of sector trends in key indicators; this is mirrored in the JAPR/NHC reports through the project period. Since 2008, provincial league tables for core indicators also are a routine feature at such national review events such as the JAPR and JAPA. During the project period, JAPRs were conducted each year with wide participation of stakeholders, including MOH managers, representatives of other relevant ministries, members of the communities and local authorities, NGOs, and DPs. The format of the JAPR has now evolved to include 4 task forces each of which is assigned one program area for review. Task force reviews and presentations then form the basis for the sector review and the delineation of sector priorities and interventions for the next year.
Monitoring of utilization of services by the poor is conducted through the health equity funds monitoring by the Bureau of Health Economics and Financing and covers about 75% of the total population of the country through the establishment of 50 health equity fund schemes. In addition, data from the annual CSES and the five yearly CDHS are routinely analyzed to determine utilization patterns by the poor. In 2008, after a major revision of the HIS forms, classification by sex for all illness conditions at health facility level was introduced, thus enabling monitoring of differential utilization rates by males and females.
The M&E unit within the HSSP secretariat was responsible for monitoring the project's implementation progress. HSSP1 contributed to the preparation of the following: (a) joint annual review of the health sector (JAPR); (b) detailed budget and expenditure reports; (c) semi-annual project reports; (d) Health Management Agreements (HMAs); (e) annual questionnaire surveys and beneficiary assessments; (f) mid-term evaluation report; (g) final evaluation survey; and (h) final evaluation report. As the HSSP M&E unit was located in the DPHI, it has had a pivotal role in instituting progress of M&E practices at central level. The first comprehensive assessment of the HIS was conducted in 2007 and recommendations used for future planning purposes. Cambodia has a number of effective tools and structures in place to ensure harmonization and alignment in the health sector. The most important is the SWiM process which is gradually being
54 developed into a future SWAp. Milestones include the elaboration of regular MTEF, joint annual reviews, close cooperation of MoH with international partners in the elaboration of the HSP and other policy papers, harmonization through annual operational plans (AOP). In the future, the MoH will further strengthen the dialogue with partners and work towards increased harmonization and alignment regarding health sector strengthening, including partners like GAVI and GFATM.
Project management was integrated into the existing MoH structures at central and provincial levels. The overall direction and guidance for the project was provided by a Steering Committee, comprising senior staff from the MoH and representatives from the MEF and other key ministries as needed. Project management structure included a Director, a Deputy Director, a Coordinator, a Senior Management Group (SMG), and an HSSP Implementation Working Group (HIWG). The Planning Department had responsibility for project coordination, while the Budget and Finance Department was responsible for project procurement and financial management. At provincial and district levels, project management primarily involved the Technical and Account and Finance bureaus. In order to clearly define the expectations and responsibilities of both the MoH and the provincial authorities under the Project, Health Management Agreements (HMA) between the MoH and the Provincial Health Departments (PHDs) were implemented for each of the twelve provinces under WB-HSSP and nine provinces under ADB-HSSP. HSSP1 inputs are a mix of institutional, financial and social sustainability strategies, but with a weighting towards the expansion of a supply driven model of public health service provision, with built in mechanisms for strengthening demand for health services, especially for specific vulnerable population groups.
HSSP1 gains in institutional sustainability include the Health Planning and M&E system, the SWiM process, experience of health contracting, and the extension of HEFs. Further effort is required in terms of private sector partnerships and decentralization and de-concentration processes.
Findings from the final evaluation’s HEF survey 13 , qualitative survey 14 and health facility survey15 are provide evidence of improvements in quality and utilization of public health services in Cambodia:
There is a perception by the communities and respondents that health services are now more affordable. Only 1.2% of respondents in the health facility survey considered that health services were “too expensive.” This was reinforced by the qualitative surveys which demonstrated that one of the attractions of the public sector was that it was not as expensive as the private sector. The impression of respondents in the qualitative survey that facilities are cleaner and more hygienic, was reinforced in the facility survey from both a provider and client perspective. In the qualitative surveys, although some respondents reported poor behavior of providers, most were reporting that in recent years the attitudes of public health providers had improved. This finding is reinforced by the findings of the facility survey. 80% of client respondents in the facility survey reported that the politeness of health workers was good (the highest ranked response).
13 Health Equity Funds Survey, Domrei 2010 14 Qualitative Sample Survey on Accessibility, Quality, Affordability and Coverage, Domrei 2010 15 Health Facility Assessment, Domrei 2010 55
Although the facility survey demonstrated that the clinical care and observations for maternal health and ante-natal care showed many shortcomings, results for clinical checklists indicated significantly better results than for adult health. This was also reinforced by the qualitative survey in several ways.
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Annex 7. Comments of Cofinanciers and Other Partners/Stakeholders Meetings were held with health sector donors and key stakeholders both individually and as a group. The comments below are sourced from these meetings, as well as HSSP completion reports prepared by DFID and ADB. General comments For all donors HSSP was a new way of working in the sector. Three major financiers (the World Bank, ADB and DFID) began work in parallel and UNFPA joined from 2004. All made use of the same PMU in MOH, and worked under the common framework of the HSP1. HSSP can thus be seen as a set of projects under a single umbrella – what MOH dubbed a SWIM approach. The advantages included joint planning between donors, MOH and NGOs, and the centralization of monitoring and administration in the PMU, which was located in MOH. The Technical Working Group for Health, co-chaired by MOH and WHO, and the Health Partners Group, chaired by WHO, were important forums for keeping other donors informed and for engaging in wider policy and strategic discussions. Several donors felt that procurement procedures in HSSP were too slow and cumbersome. However, despite the difficulties and delays in the civil works program, most donors approved of MOH’s Health Coverage Plan and HSSP’s large infrastructure component to support this. Some donors thought that the role of HEF operators needed to be strengthened in order to counterbalance the power and influence of service providers. Early in HSSP there were significant advances, with MOH developing its AOPs and 3YRPs. The PMU functions, however, were not integrated into MOH, raising questions about the Ministry’s vision and commitment to sector-wide thinking, and donors’ expectations of MOH. There was a consensus among donors that HSSP successfully balanced supply and demand interventions and this was a considerable achievement. It led to an improvement in services and user attitudes towards them. ADB The ADB completion report in 2010 rated its parallel HSSP successful overall, based on criteria of relevance, effectiveness, efficiency and sustainability. The project was seen as successful in supporting the health sector, achieving improvements in health outcomes, and initiating policy reforms necessary for long-term sector development. Its focus on expanding access and increasing affordability of health services while putting in place measures to improve quality were seen as highly relevant to the needs of the country. The project achieved most of the targets set at appraisal for health outcome indicators. In expansion of health facility coverage, the project made impressive gains. The ADB project constructed or renovated 50 HCs, established 7 emergency units at referral hospitals, and built 15 health posts. Of the 95 MPA medical equipment and supply kits planned to be provided at appraisal, the project provided 93. NGO contracting of health services in 10 ODs substantially increased access, utilization, and coverage of all key reproductive, maternal, newborn, and child health indicators. In two of the ODs, project
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interventions targeted ethnic minorities. As a result of strengthened provision of primary health care, the project achieved its objectives by: (i) improving access to, and quality of, health services; and (ii) establishing a foundation for increasing efficiency and sustainability through user fees and HEFs. The earlier success of trials in contracting of health services under ADB funding provided the foundation for MOH’s introduction of internal contracting arrangements based on the government’s Policy on Public Service Delivery (2006) and adoption of MOH’s procedures and guidelines on contracting. Many innovative features first developed under NGO contracting were adopted for internal contracting, including performance incentive schemes, monitoring indicators, M&E approaches and tools, and supervision arrangements. Internal contracting included performance agreements between the MOH and PHDs, and service delivery contracts between the PHDs and ODs or referral hospitals. Building on lessons from the earlier ADB-funded Basic Health Services Project, the ADB Health Sector Support Project gave greater emphasis to close monitoring and supervision by MOH to ensure that civil works were coordinated with the supply of equipment and drugs under MPA and CPA guidelines. More efficient planning and closer oversight by MOH would have allowed timely completion of civil works and avoided cost overruns. To improve the quality of civil works, implementation arrangements should have incorporated closer supervision and monitoring at all levels. In support of MOH’s sector-wide management strategy, ADB participated in a joint monitoring and management approach along with other partners which proved the benefits of close collaboration between health partners. While HSSP was co-financed by different donors and implemented through a single PMU under the SWIM approach, the project was administered by each donor agency with different implementation schedules. ADB funded activities were closed in 2009 while the World Bank portion of HSSP was extended to complete the construction of health facilities. This resulted in different reporting arrangements including project completion reports. The SWIM approach significantly helped MOH to improve planning and coordination in project implementation, avoided duplication, and provided the basis for a broader SWAp. However, the process of harmonization and coordination of various activities between the partners challenged and slowed implementation progress. Considerable time and effort was spent on the harmonization process. UNFPA UNFPA’s decision to join HSSP in 2004 was the result of a global UNFPA policy to join in-country sector programs wherever these were being established. This proved to be a difficult decision as MOH was keen for UNFPA to continue providing its assistance using a project arrangement. UNFPA favored the SWIM approach because it would help to strengthen health systems, leverage resources and decrease the risk of fraud through joint auditing processes and improved governance. However, UNFPA continued to manage its activities and procurement separately.
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DFID DFID saw previous health sector support as being led by WHO, with World Bank and ADB activities running as separate and weakly coordinated projects. The SWIM approach required some adjustment on all sides. Some donors outside HSSP occasionally felt excluded from discussions with MOH (e.g., during semi-annual review missions), but over time, communication and trust improved and paved the way for a much wider donor grouping in HSSP2. Until late 2005, when the World Bank deployed a Senior Health Specialist, DFID was the only HSSP donor with a specialist adviser in country. This meant that DFID played a significant day to day role in getting the management and coordination arrangements of HSSP working well. ADB was withdrawing from the health sector in Cambodia at the end of HSSP (apart from some regional support). DFID noted that during the preparations for HSSP2, ADB therefore paid less attention to government progress, decreasing the effectiveness of joint donor advocacy. DFID considered that ADB had weaker supervision systems than the World Bank for civil works contracts and that its construction was of lower quality as a result. DFID’s Reducing Maternal Mortality Project could not be managed through HSSP because of its large safe abortion component. It was therefore run as a separate project, even though its objectives were closely linked to those of HSSP. In its 2010 completion report on HSSP, DFID noted that there had been significant government reforms, but also a lack of government energy in tackling politically difficult sector reforms, and that there had been significant reversals in reforms agreed with donors, such as the abrupt cancellation of the MBPI and PMG schemes in 2009. This shook the confidence of donors in the government’s commitment to health sector reforms. An independent review of DFID’s role in HSSP found that there had been an insufficient donor response to assessments of HSSP performance as slow and that this could have been addressed more successfully with MOH and government. The review found this to be ‘perhaps the single most important lesson to be learned from HSSP1’. UNICEF UNICEF felt that the SWIM approach in HSSP was a useful counterbalance to the role of WHO in the sector. It allowed a more diverse range of views and technical advice to be delivered to MOH. UNICEF felt that the National Nutrition Program, funded by HSSP, was never able to fulfill its objectives related to nutrition because of MOH’s decision not to contract activities to NGOs. There were also poor linkages to other sectors such as agriculture and water and sanitation. UNICEF felt that to tackle malnutrition in a more holistic way, HSSP was ‘the wrong instrument in the wrong ministry’. UNICEF was also of the view that there had been a failure to rationalize and limit budgets for training in HSSP, allowing staff to use training as a means to generate extra income through per diems and allowances rather than focusing on technical skills development.
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USAID USAID felt that HSSP complemented its own health program well. It saw the growth of HEFs and progressively greater funding from government for HEFs under HSSP, as a very positive shift. USAID cooperation with HSSP2 is closer as a result of its assessment of HSSP. The shift from earlier contracting of NGOs for health service delivery to internal contracting in MOH under HSSP was a slow and difficult one, but USAID saw this as a move in the right direction. There had been many pilots and experiments in the health sector prior to HSSP, and the project helped to solidify a clear direction and strategy in line with the HSP1. There was good cooperation between donors in the preparation phases for both HSSP and HSSP2. The role and performance of the PMU was not conducive to improving systems in MOH. MEDICAM Medicam is the umbrella organization for NGOs working in the health sector in Cambodia. It felt that HSSP’s alignment with the HSP1 was an important progressive step for donor involvement in the sector. It also acknowledged the difficulties in moving towards use of MOH systems in the Cambodian context. HSSP had a positive impact on health outcomes, but needed to engage more closely with civil society and local government and to focus on the accountability of health services to communities and local government. HSSP support to Health Center Management Committees was insufficient to ensure their sustainability. Civil society and local government involvement in the health system at referral hospital and PHD remained weak during HSSP and the project did not address this. Such involvement is important in driving demand to improve the quality of care. The government is shifting more strongly towards promoting program approaches, and the success of HSSP was a factor in this. HSSP needed more emphasis on promoting good governance and building a better enabling environment. There was no linkage to the private sector.
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Annex 8. List of Supporting Documents • AGEG-Domrei (2010). Health Sector Support Project 1 (HSSP1) End of Project Assessment Final Report No. CAKH525, Phnom Penh, Cambodia. • Annear, Peter Leselie. 2010. “A comprehensive review of the literature on Health Equity Funds in Cambodia: 2001-2010,” Nossal Institute for Global Health, Phnom Penh. • Annear, Peter Leslie,Maryam Bigdeli, Ros Chhun Eang and Bart Jacobs. 2008. “Providing access to health services for the poor: Health equity in Cambodia,” ITM series Studies in Health Service Organisation and Policy, the Institute of Tropical Medicine (ITM), Antwerp. • Asian Development Bank (2010). Completion Report Cambodia: Health Sector Support Project Project Number 32430. • Bhushan, Indu, Erik Bloom, David Clingingsmith, Rathavuth Hong, Elizabeth King, Michael Kremer, Benjamin Loevinsohn, and J. Brad Schwartz. 2007. “Contracting for Health: Evidence from Cambodia.” Brookings Institute, Washington, D.C.. Unpublished manuscript. • Department for International Development (2010). Project Completion Report, Health Sector Support, DFID, United Kingdom. • Flores, Gabriela, Por Ir, Chean Men, Owen O'Donnell & Eddy van Doorslaer, 2011. "Financial Protection of Patients through Compensation of Providers: The Impact of Health Equity Funds in Cambodia," Tinbergen Institute Discussion Papers 11-169/3, Tinbergen Institute. • Ministry of Health (2002). Health Sector Strategic Plan 2003-2007 2 vols., Phnom Penh, Cambodia. • Ministry of Health (2008). Health Strategic Plan 2008-2015 Phnom Penh, Cambodia. • Ministry of Health (2012). Implementation Completion Report, Health Sector Support Project, 2003-08 Department of Planning & Health Information, Phnom Penh, Cambodia. • Mathonnat, Jacky, Aurore Pelissier, and Virginie Melloux. 2012. “Cambodia: Financing health care in Takeo province: HEF, CBHI and the Activities, Financing and Efficiency of Health Facilities,” CERDI, University of Auvergne, France. • Noirhomme, Mathieu, Bruno Meessen, Fred Griffiths, and others. 2007. “Improving access to hospital care for the poor: comparative analysis of four health equity funds in Cambodia,” Health Policy and Planning. 2007;22:246–262. • SBK Research and Development. 2009. “Contracting of health services in Operational Districts: Final evaluation of contractor performance,” Phnom Penh. • Schwartz , J. Brad and Indu Bhushan. 2005. “Cambodia: Using Contracting to Reduce Inequity in Primary Health Care Delivery,” in Davidson Gwatkin, Adam Wagstaff, and Abdo Yazbek, in Reaching the Poor with Health, Population, and Nutrition Services: What Works, What Doesn’t, and Why. The World Bank, Washington D.C.
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• USAID/BASICS. 2009. Costs and Revenue Comparisons for a sample of contracted and non-contracted health centers: Ministry of Health, Cambodia. Phnom Penh. • World Bank (2002). Project Appraisal Document on a Proposed Credit to the Kingdom of Cambodia for a Health Sector Support Project Report No. 24220- KH, Human Development Sector Unit, East Asia and Pacific Region. • World Bank (2008). Cambodia – Reaching the People: Public Expenditure Tracking Survey in Health, Budget Years 2002-2004, Phnom Penh. • World Bank (2011). Cambodia More Efficient Government Spending for Strong and Inclusive Growth, Integrated Fiduciary Assessment and Public Expenditure Review (IFAPER) Poverty Reduction and Economic Management Unit, East Asia and Pacific Region.
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CAMBODIA: HEALTH SECTOR SUPPORT PROJECT
Oddar Meanchey "J Ñ Ñ Siempang Kampong Srorlao
Ñ Preah Vihear Poy Char Kou Len H Sla Kram Ñ Ñ"J Rattanak Kiri Ñ Provincial Hospital "J Mkak Bos Sbov Sophy Ñ Ñ Kdak Ñ H Ñ Kampong Svay Tuek Chuor Ñ Ñ O Chrov Ñ Ñ Sre Veal Ñ Referral Hospital Ñ"J Thnal Koang Chrach Ñ Ñ Russei Kroak Ta Bos Ñ Sras RusseiStung Treng Tuol Pongro Tek Thla Ñ Ñ Ñ"JH Banteay Meanchey Provincial Hospital Siemreap Chak Krei Ñ Boeng Pring "J Ñ Bang Korn Bansay Traeng Ta Poung Ñ Ñ Ñ Ñ Kheang Meas Battambang "JÑ Ou Dambang I Ñ Ou Dambang II
Ñ Reang Kesei Pailin "J Koh Kralor Ñ Kampong Thom Ou Ta Poung "J Ñ Trapaing Chorng Ñ Ñ Pursat Snam Preah Ñ"JH Kratie Provincial Hospital Mondul Kiri "J "J Kampong Chhnang "J 1 Malaria: $2.47 mill. Ñ Kampong Cham Trapaing Sre - Incidence of malaria per 100,000: 4.1% "J - Malaria Case Fatality Rate: 7.1%
2 TB: $2.59 mill. - TB Case Detection Rate: 69% Koh Kong - TB Cure Rate: 91% "J Phnom Penh "J H H Kandal Prey Veng Kampong Speu ÑÑ 3 Dengue: $690,000 + $1 mill. to WHO J" "J "J Rokar KohÑ Dengue Case Fatality Rate: 0.7% (2010) Prey Nheat Ñ Ñ Provincial Capital Veal Ang Popel "J 4 HIV/AIDs: $2.25 million PhongÑ Based Pou WB Province Ñ Mreal HIV Prevalence (15-49): 0.7% Svay Rieng "J Takeo ÑH National Aids Auth. "J 5 Nutrition: - Exclusive Breastfeeding: 68% ÑH Malaria Center - 3,052 staff trained in MPA Module 10 - 202 staff trained in severe malnutrition H Provincial Hospital Krong Preah SihanoukKampot Ñ treatment and 85 staff retrained "J Ñ"JH Provincial Hospital - Iron Folate supplements: 40% Krong Keb Ñ Health Center - Vitamin A supplements: 89% "J - Post-partum Vitamin A: 68% Ñ Health Post - Iodized Salt: 74%