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WHO country cooperation strategy for Cambodia 2009-2015

31 décembre 2009 Organisation mondiale de la santé

Texte intégral

WHO Country Cooperation Strategy yuT§sa®sþénkic©shRbtibtiþkarRbcaMRbeTs rbs;GgÁkarsuxPaBBiPBelak CAMBODIA 2009-2015

October 2009 1

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The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce WHO publications, in part or in whole, or to translate them - whether for sale or for non-commercial distribution - should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: publications@wpro.who.int

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eTBþa[sux RbesIrsYsIþ ElgTukEç lgP½y […] . Gje)ayehAcb; RBlwgR)MabYndNþb; mUlmkRKb;ehIy \tTuk\tP½y céRgeboteLIy jatiepAGñkeGIy mUlmkkuHkr . (k,ÜnehARBlwgGñkCm¶W )

“May the tevoda grant us good health and prosperity, freeing us from suffering and fear. […] I am finishing my call, o nineteen pralung, come back all together now. There is no more suffering, no more fear, no more misfortune. O my dears, your relatives are gathered together in great number.” (Treatise for Calling the Souls of the Sick)

Scene of Assisted Birth Delivery at Health Center, South West Outside Gallery of Bayon Temple, Angkor Wat

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Table of Contents Foreword.................................................................................................................. 7 Executive Summary............................................................................................... 11

esckþIepIþm.................................................................................................................15 Section 1 Introduction............................................................................................................ 21 Section 2 Cambodia’s Health and Development Challenges............................................. 22 Section 3 Development Assistance and Partnerships: Aid Flows, Instruments and Coordination.......................................................... 28 Section 4 Current WHO Cooperation with the Government and People of Cambodia................................................................ 32 Section 5 WHO Policy Framework: Global and Regional Directions, Strategic Agenda and Priorities................... 36 Section 6 Expected Evolution of WHO Presence in Cambodia......................................... 46 Conclusion............................................................................................................. 49 References............................................................................................................. 50 Annex 1................................................................................................................... 54

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Foreword The Royal Government of Cambodia and the World Health Organization have enjoyed a long and productive collaboration in advancing the health agenda in Cambodia. Since the re-opening of the WHO office in Phnom Penh in 1991, WHO staff and counterparts at the Ministry of Health have worked closely together to address health concerns of highest priority in the country. The health sector benefits substantially from the stewardship of the Ministry of Health and from the technical and financial contributions from Development Partners in Health. WHO remains committed to supporting the Ministry of Health in improving the health of all Cambodians. Cambodia has achieved many successes during this time, including reductions in HIV prevalence, in tuberculosis and malaria mortality, and in infant and child mortality. We have seen substantial expansion and strengthening of the health system, and improved access to health services. Yet many challenges remain. Maternal mortality remains high. The old scourges of tuberculosis, malaria, dengue, and HIV surely stand ready to re-emerge or worsen should efforts slacken. Cambodia’s epidemiologic transition means that non-communicable diseases and injuries take an ever-increasing toll. Stable and sustainable health care financing and social safety nets to address the needs of the poor are priorities with substantial financial implications. Dedicated and skilled health workers need to be retained, and quality services assured, through capacity-building, appropriate compensation, and good working conditions. A healthy population means assuring a safe water supply and adequate sanitation, and safeguarding a healthy environment. Cambodia is developing rapidly. Priorities, needs, and resources for health are continually changing. The Royal Government of Cambodia and the World Health Organization recognize the importance of periodically reassessing approaches and inputs. This is reflected in the second Ministry of Health Strategic Plan 2008 – 2015 (HSP2). WHO, in its commitment to align with Ministry and Government priorities, has reassessed and reaffirmed its own collaborative support in this second Country Cooperation Strategy, 2009 to 2015 (CCS). WHO and the Royal Government of Cambodia remain fully committed to the strategies and priorities expressed in the HSP2 and the CCS. The WHO Representative Office in Cambodia, the Regional Office for the Western Pacific, and WHO Headquarters will continue to work in collaboration with all our partners, and to provide resources and technical support based on the highest international standards. We are confident that this cooperation, and the implementation of this CCS, will contribute to achieving the best possible health for the people of Cambodia. Phnom Penh, 11 September 2009

H.E. Dr Mam Bun Heng Minister of Health

Dr Michael J. O'Leary WHO Representative

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List of Abbreviations AC ADB AFD AOP BTC AusAID CCC CCS CDC CDCF CD CDHS CMDGs CVC DAC (OECD) D&D DFID DPs EDPs FCTC GAVI GDCC GFATM GHIs GHPs H&A HIS HMN HPs HSP1 HSP2 HSS HSSP1 HSSP2 IHP Assessed Contributions Asian Development Bank Agence française de développement Annual Operational Plan Belgian Technical Cooperation Australian Agency for International Development Country Coordinating Committee (Cambodia’s CCM) Country Cooperation Strategy Council for the Development of Cambodia Cambodia Development Cooperation Forum Communicable Diseases Cambodia Demographic and Health Survey 2005 Cambodia Millennium Development Goals Core Voluntary Contributions Development Assistance Committee of OECD Deconcentration and Decentralization UK Department for International Development Development Partners External Development Partners Framework Convention on Tobacco Control Global Alliance for Vaccines and Immunizations Government-Development Partner Coordination Committee Global Fund to Fight AIDS, Tuberculosis and Malaria Global Health Initiatives Global Health Partnerships Harmonization and Alignment Health Information System Health Metrics Network Health Partners Health Strategic Plan 2003-2007 Health Strategic Plan 2008-2015 Health System Strengthening First Health Sector Support Project Second Health Sector Support Project International Health Partnership

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IHR IMCI IMF IOM JPA JPIG LDF MCH MDGs M&E MMR MNCH MoH NCD NGOs NPO NSDP OD OECD PHC PIPs RGC SEDP SP SWAp SWiM TWGs TWGH UNAIDS UNCT UNDAF UNFPA UNICEF UNTAC USAID WB WHO 3YRP

International Health Regulations Integrated Management of Childhood Illness International Monetary Fund International Organization for Migration Joint Partnership Arrangement JPA Development Partner Interface Group Lead Donor Facilitator Maternal and Child Health Millennium Development Goals Monitoring and Evaluation Maternal Mortality Ratio Maternal, Newborn and Child Health Ministry of Health Non-Communicable Diseases Non-Governmental Organizations National Professional Officer National Strategic Development Plan, 2006- 2010 Operational District Organization for Economic Cooperation and Development Primary Health Care Public Investment Programs Royal Government of Cambodia Socio-Economic Development Plans Strategic Priority Sector-Wide Approach Sector-Wide Management Approach Technical Working Groups Technical Working Group on Health United Nations Program on HIV/AIDS United Nations Country Team United Nations Assistance Development Framework United Nations Populations Fund United Nations Children Fund United Nations Transition Authority in Cambodia American Agency for International Development The World Bank World Health Organization 3-Year Rolling Plan

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Executive Summary The economy in Cambodia is driven by agriculture, the garment industry, tourism and foreign direct investment, especially in construction. Many of these are vulnerable to global economic downturns.

Health and Development Cambodia has seen considerable socio-economic progress in recent years, accompanied by improvements in many health indicators. The economy expanded by over 10% per year in recent years and poverty declined, but despite this, 35% of the population still remained below the poverty line in 2006. Many more families are susceptible to being tipped into poverty, especially in times of personal health crisis. The national health budget has grown substantially but remains low on a per capita basis, and about 60% of health expenditure is out-of-pocket. This creates many challenges in ensuring universal access to quality health care, alleviated only in part by such additional measures as health equity funds, an embryonic system of social health insurance, decentralization in the health system, and the contributions of health Non-Governmental Organizations (NGOs). The epidemiologic transition is well underway. While communicable diseases remain substantial threats to health, the prevalence of HIV has fallen significantly (to less than 1% of the adult population), the malaria and tuberculosis programs have strengthened considerably, immunization rates are high with new vaccines being introduced, and national programs have developed substantially in control of parasitic diseases, dengue, and childhood respiratory infections and diarrhoeal diseases, (even though the supply of safe water remains irregular, and rural areas especially have low levels of sanitation). In addition to the continued efforts needed in these areas, Cambodia reports high rates of diabetes and hypertension, more than 50% of adult men smoke cigarettes, and community mental health and traffic-related injuries are regarded as significant under-addressed problems. While infant and child mortality fell by about 30% from 2000 to 2005, both rates remain high, at 66 and 83 per 1000 live births respectively. Even more worrisome is a sustained high level of maternal mortality, at 472 deaths per 100,000 live births (2005). Progress toward achieving the health-related Millennium Development Goals (MDGs) has thus been mixed, with MDG5 particularly at risk. Limited access to quality health care, especially in Maternal and Child Health (MCH) in rural and remote areas, and the lagging improvement in the Maternal Mortality Ratio (MMR) were driving forces behind the strategies enunciated in the second Health Strategic Plan 2008-2015 (HSP2),1 and in the declaration of a Fast Track Initiative in MCH in October 2008.2 Along with the ongoing dynamic maturation of the health system, it is an incremental process to achieve universal access to quality health services. This requires well-trained, motivated, and adequately-compensated staff, and adequate drugs, supplies and equipment across 26 referral hospitals and nearly 1000 health centers. Health care worker salaries are widely regarded as inadequate for this purpose, and remain constrained by a limited but improving national health budget and by the budgetary situation across civil service as a whole.

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To focus on these systemic issues, the HSP2 established 5 cross-cutting strategies to strengthen the health system: health planning, health information systems, health care financing, human resources for health, and health system governance. Both the Ministry of Health (MoH) and the Development Partners (DPs) in health are committed to Health System Strengthening (HSS) and continued improvement in service delivery to achieve universal access to quality health services across the entire country.

Partners Many development partners participate in the dynamic health sector in Cambodia. In addition to around 20 multilateral and bilateral donors, there are well more than 100 health-related international and national NGOs. Both the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) and the Global Alliance for Vaccines and Immunizations (GAVI) are substantial contributors to the health sector, complemented by several other Global Health Initiatives (GHIs). Looking beyond health, 2009 was the first year that the aggregate Official Development Assistance to all sectors almost reached US$1 billion in pledged aid.3 Cambodia has participated actively in realizing the goals of the Paris Declaration on Aid Effectiveness,4 with very active formal channels of collaboration between Government and Development Partners. In health, the monthly meetings of the Technical Working Group on Health (TWGH) provide the official mechanism to ensure harmonization and alignment among Health Partners (HPs) and Government/MoH. A smaller group of senior staff from the Ministry and selected representatives of HPs also meet monthly, as the Secretariat of the TWGH.

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As in other countries, the MoH is WHO’s official and principal counterpart. WHO serves a liaison role as the Lead Donor Facilitator (LDF) on the TWGH (and its Secretariat), and in this capacity also convenes meetings of HPs on a monthly basis, as well as ad hoc meetings to address specific issues of mutual concern. Cambodia is also a pilot or first-wave country for certain global initiatives, including the Health Metrics Network (HMN),5 and the International Health Partnership (IHP).6 For the latter, the Secretariat of the TWGH serves as the Country Health Sector Team, and WHO, with the World Bank (WB), serves as facilitator for the IHP. The commitment of HPs to harmonize their efforts is seen in the steady progress to a Sector-Wide Approach (SWAp) in Cambodia, currently in its most advanced state in the Health Sector Support Project, a management collaboration (with partial pooling of funds) among 7 key HPs. In addition, nearly 20 UN agencies are resident in Cambodia and work closely in programming and collaboration through bi-monthly meetings. A new United Nations Assistance Development Framework (UNDAF) is under development in 2009.

WHO Strategic Agenda To align with the strategies and priorities of the MoH as spelled out in the Health Strategic Plan 2008-2015, WHO in Cambodia has identified three Strategic Priorities in its CCS 20092015, each with specific areas of WHO focus: Strategic Priority 1: Technical excellence in disease and public health programs Targeted technical support in priority disease control areas Cross-cutting support to National Programs and Centers Programmatic support to under-resourced priorities Technical capacity-building, and transfer of skills and knowledge Support to the national implementation of global agreements Strategic Priority 2: Access to quality health services Delivery of priority health services

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Health care financing Human resources for health Essential medicines and products Quality of care and accountability across providers and programs Strategic Priority 3: Effective stewardship of the health sector, including health partnerships Policy development and advocacy Health information systems and health systems research Harmonization and alignment under a sector-wide approach in health The relationship between the public and private sector Integration of and linkages across disease control programs Governance and decentralization These priorities and focus areas are selected to enable enhanced support from the WHO Country Office in Cambodia, targeting particular areas of need in communicable diseases, advocating and providing support for relatively neglected or financially under-resourced areas, and re-defining and improving WHO’s support to country-level health partnerships and Global Health Initiatives.

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édKU édKUGPivDÆn_CaeRcIn)ancUlrYmenAkñg ú visy ½ suxaPi)ald_manPaBsVahab;enAkñg ú RbeTskm<C ú a . eRkABIma© s; CMny Y eTVrPaKI nigBhuPaKIRbEhlCag 20 enaH enAmanGgÁkareRkArdæaPi)alkñg ú Rsuk nigGnþrCatiCag 100 GgÁkarEdleFIk V argarTak;TgeTAnwgsuxPaB . mUlniFs i kledIm,IRbyuTn §g w CMgeW Gds_ CMgrW ebg nigRKuncaj; (GFATM) nigsm<n ½P § aBBiPBelaksMrab;va:ks ; aMg nigkarcak;fañ b M gáar (GAVI) KWCaGñkEdl)ancUlrYmcMENk d_FeM nAkñg ú visy ½ suxaPi)al edayRtUv)anbMeM BjbEnßmedayKMeragsuxPaBBiPBelakdéTeTotCaeRcIn . eRkA BIvs iy ½ suxaPi)al qñaM 2009 enH KWCaqñad Mb Mg U EdlCMny Y GPivDÆn_pv Ú ø karsrubsMrab;vs iy ½ TaMgGs;mancMnn Y elIsBI 1ekadidl u aø shrdæGaemrik .

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RbeTskm<C ú a)ancUlrYmya:gskmµenAkñg ú karsMerc)annUveKaledArbs;esckþRI bkasTIRkug)a:rs I sþG IB MI RbsiTP § aBCMny Y edaymanbNþajpøv Ú karya:gskmµsrM ab;kc is © hkarrvagrdæaPi)al nigédKUGPivDÆn_ . enAkñg ú visy ½ suxaPi)al karRbCMru bs;Rkumkargarbec©keTssuxaPi)al)anpþly ; nþkarCapøv Ú karedIm,IFananUv PaBrlUn nig sIs u gVak;Kañ enAkñg ú cMeNamédKUsx u aPi)al nigrdæaPi)al¼RksYgsuxaPi)al . RkumbuKl Ák i fñak; dwknaMénRksYgsuxaPi)al nigGñktMNagEdlRtUv)aneRCIserIsrbs;édKUsx u aPi)alk_)aneFIk V arRbCMRu bcaMEx pgEdrkñg ú namCaelxaFikardæanrbs;Rkumkargarbec©keTssuxaPi)al . dUcKñaeTAnwgRbeTsdéTeTot RksYgsuxaPi)alKWCasmPaKIpv Ú ø kar nigmansar³sMxan; rbs;GgÁkarsuxPaB BiPBelak. GgÁkarsuxPaBBiPBelakbMeBjnUvtYnaTITn M ak;Tn M g kñg ú namCaGñksMrbsMrl Y d_sx M an;énm©as; CMny Y enAkñg ú Rkumkargarbec©keTssuxaPi)al (nigelxaFikardæanénRkumkargarbec©keTssuxaPi)alenH) ehIyenAkñg ú tYnaTIenH GgÁkarsuxPaBBiPBelakk_dk w naMeFIk V arRbCMRu bcaMExrbs;édKUsx u aPi)alpgEdr k_dc U CakarRbCMeu dayKµankareRKagTuk edIm,IeFIk V aredaHRsaynUvbBaðaCak;lak;EdlBak;Bn ½K § añ eTAvijeTAmk . dUcKñaenHEdr km<C ú ak_CaRbeTssakl,g b¤RbeTsdMbg U (first-wave) Edl)anGnuvtþnv U KMeragsakl Cak;lak; rYmman³ bNþajrgVas;sx u PaB (Health Metrics Network) nigédKUsx u aPi)alGnþrCati . sMrab;édKU suxaPi)alGnþrCati elxaFikardæanénRkumkargarbec©keTssuxaPi)albMeBjnUvtYnaTICaRkumkargarvisy ½ suxaPi)alfñak;RbeTs ehIyGgÁkarsuxPaBBiPBelakrYmKñaCamYynwgFnaKarBiPBelak bMeBjtYnaTICaGñk sMrbsMrl Y sMrab;édKsuxaPi)alGnþrCati . karsnüarbs;édKUsx u aPi)alenAkñg ú kareFI[ V kicR© bwgERbgrbs;eK manPaBrlUn nigsIs u gVak;Kañ enaH RtUv)anemIleXIjenAkñg ú karrIkcMerInCalMdab;eq<aHeTArkviFs I aRsþTT U aMg visy ½ enAkñg ú RbeTskm<C ú a Edlbc©b ú ,nñenHsßt i enAkñg ú PaBrIkcMerInbMpt u enAkñg ú kmµvF i RI TRTg;vs i y ½ suxaPi)al (Health Sector Support Program) EdlCakics © hkarEpñkRKb;RKg (edaymandak;bBa©l Ú KñamYyEpñk énmUlniFi) enAkñg ú cMeNamédKUsx u aPi)alsMxan;² cMnn Y 7 . eRkABIenH TIPañ k;garGgÁkarshRbCaCati RbEhl 20 mankariyal½yenAkñg ú RbeTskm<C ú a nwgeFIk V argarya:gCitsñT i e§ nAkñg ú kareFIk V mµvF i I nigkic© shkartamry³karRbCMB u rI Exmþg . Rkbx½NC Ðn My Y GPivDÆn_fI µ énGgÁkarshRbCaCatikB Mg u RtUv)anerobcM eLIgenAkñg ú qñaM 2009 .

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»kas karsnüaceM BaHeKalkarNé_ nesckRIþ bkasTRI kg u )ar: s I sG Iþ B M RI bsT iP § aBCn My Y ynþkarénkics © hkarrwgmaMrvagrdæaPi)al-édKUGPivDÆn_ édKs U x u aP) i alGnrþ Cati karpþlm ;n UF i i nigkarKaMRTEpñkneya)ay edIm,Ibegán I nUvPaBrlUn nigsIs u gVak;Kañ edIm,IseM rc)annUv RbsiTP § aBCMny Y . édKs U x u aP) i alsakl édKUsx u aPi)alsaklmYycMnn Y )anpþln ;v U mUlniFC ia eRcIneTA[visy ½ suxaPi)al nigbgðajGMBs I ar³ RbeyaCn_ enAkñg ú karbgáar nigkarTb;saá t;Cg MW. kmv µF i RI TRTgv ;s iy ½ sx u aP) i al (HSSP) édKUGPivDÆn_kan;EteRcIncUlrYmenAkñg ú karRKb;RKg rYm nig enAkñg ú krNIxHø )aneFIk V ardak;bBa©l Ú KñanUvkar ]btßmK Ö aMRTdl;vs iy ½ suxaPi)al .

karlM)ak édKs U x u aP) i aleRcn I enAkñg ú eBlEdlmankarKaMRTeRcInenaH karmanédKU suxaPi)aleRcInEdlmankarrMBg w TukepSg²KñaGac bgáeGaymankarRbECgdac;edayELkEdlminRtUv )anedaHRsayeBjeljenAeLIy . édKs U x u aP) i alsaklEdlKaµ nkarry i aly ½ enAkg úñ RbeTs édKUsx u aPi)alsaklpþln ;v U mUlniFC i aeRcIndl;vs iy ½ suxaPi)al . GvtþmantMNagRbcaMRbeTssMrab; édKUsx u aPi)alsaklCaeRcIn KµankarepÞrsiTG §N M ac b¤karKaMRTdl;Gk ñ tMNag GacbnÞc ú bg¥ak;nv U karcUl rYmrbs;eKenAkñg ú kics © hkard_saV hab;enH . i aBma© sC ;n My Y Gtl u üPaBrvagGaTP i aBCati ng i GaTP m©as;Cn My Y BüayameFIeV GayRsbeTAtamGaTiPaB Cati b:Eu nþGaTiPaBCaeRcInenAEtminmanmUlniFRi Kb; RKan; .

rebobvar³CayuT§saRsþrbs;GgÁkarsuxPaBBiPBelak

edIm,IeFI[ V manPaBrlUn nigsIs u gVak;Kañ CamYynwgyuTs § aRsþ nigGaTiPaBrbs;RksYgsuxaPi)al dUcEdlman Ecgc,as;las;enAkñg ú EpnkaryuTs § aRsþsx u aPi)aldMNak;TI 2 qñaM 2008-2015 enaH GgÁkarsuxPaBBiPB elak)ankMNt;nv U GaTiPaBCayuTs § aRsþcn Mn Y 3 enAkñg ú yuTs § aRsþénkics © hRbtibtþk i arfñak;RbeTssMrab;qañ M 2009-2015 rbs;xn Ü ø EdlGaTiPaBnImy Y ²manEpñkénkarepþatkarykcitT þk u dak;Cak;lak;rbs;GgÁkar suxPaBBiPBelak³ GaTiPaB 1³ KN u PaBEpñkbec©keTsenAkñg ú kmµvF iC Ig M W ng i suxPaBsaFarN³ karKaMRTEpñkbec©keTsEdlCaeKaledAcMNc u enAkñg ú EpñkTb;saá t;Cg MC W aGaTiPaB KaMRTKñaeTAvijeTAmkdl;kmµvF iC I ati nigmCÄmNÐlCati karKaMRTEpñkkmµvF id I l;GaTiPaBEdlKµanFnFanRKb;RKan; karksagsmtßPaBbec©keTs nigkarepÞrnUvCMnaj nigcMeNHdwg karKaMRTdl;karGnuvtþnn _v U kicR© BmeRBogsaklenAkñg ú fñak;Cati GaTiPaB 2³ lT§PaBeRbIR)as;esvaEdlmanKuNPaB karpþln ;v U esvasuxaPi)alEdlmanGaTiPaB

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hirBaØb,TansuxaPi)al FnFanmnusSsMrab;vs iy ½ suxaPi)al »sf nigplitplsarv½nþ KuNPaBénkarEfTaM nigKNenyüPaBenAkñg ú cMeNamGñkpþle; sva nigkmµvF iT I aMgGs; GaTiPaB 3³ karRKb;RKgRbkbedayRbsiTP § aBnUvvisy ½ suxaPi)al rm Y TaMgédKUenAkñg ú visy ½ suxaPi)al karbegát I nUveKalneya)ay nigkartsUm ‘ tisrM ab;eKalneya)ay RbB½nB § t’mansuxaPi)al nigkarRsavRCavenAkñg ú RbB½ns §x u aPi)al PaBrlUn nigsIs u gVak;Kañ tamry³karGnuvtþnn _v U viFs I aRsþTT U aMgvisy ½ enAkñg ú visy ½ suxaPi)al TMnak;Tn M grvagEpñkrdæ nigEpñkÉkCn kardak;bBa©l Ú Kña nigkarpSarP¢ab;Kañ enAkñg ú kmµvF ib I gáarCMgT W aMgGs; GPi)alkic© nigvimCÄkarkmµ GaTiPaB nigEpñkénkareepþatkarykcitT þk u dak;TaMgenHRtUv)aneRCIserIseLIgedIm,IbgáeGaymannUvkarKaMRT kan;EtRbesIreLIgBIsN M ak;kariyal½yRbcaMRbeTsénGgÁkarsuxPaBBiPBelakenAkñg ú RbeTskm<C úa edayeFIk V arepþatkarykcitT þk u dak;eTAelIEpñkCak;lak;éntMrv U karenAkñg ú CMgq Wg ø kareFIk V arts‘m U ti nigkarpþln ;v U kar]btßmK Ö aMRTeTAdl;EpñkEdlminRtUv)aneGIeBI b¤EpñkEdlmanFnFanhirBaØvtßm ún i RKb;RKan; karkMNt;eLIgvij nigkarEklMGnUvkar]btßmK Ö aMRTrbs;GgÁkarsuxPaBBiPBelaksMrab;édKUsx u aPi)al enAkñg ú fñak;RbeTs nigKMeragsuxaPi)alfñak;BP i Belak .

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Introduction This Country Cooperation Strategy (CCS) comes at an important juncture for WHO and the Cambodian MoH. It was developed in parallel with the HSP2, which has shaped its content. HSP2 outlines the Ministry’s vision for how it will build a stronger and more equitable health system, more effectively prevent diseases and improve the health of all Cambodians. It also documents a remarkable improvement of national health outcomes and access to health services over the last decade, the result of joint efforts by government, NGOs and international development partners. WHO intends to continue to play an important role in the health development process. Cambodia is entering a crucial new phase in health development in the years leading to the year 2015 targets of the MDGs. Elucidating WHO’s role and comparative advantages for supporting the implementation of HSP2 and achieving the health related MDGs has been at the center of the CCS development process. The WHO Country Office team worked on questions of fundamental importance for the organization’s work in Cambodia, including: What are the critical new challenges in this rapidly developing country where the transition to a more multifaceted public health has just started, and how should WHO respond to those challenges? What is WHO’s preferred role and comparative advantage in the complex health development environment in Cambodia? Which of WHO’s institutional assets will most effectively contribute to an improvement of the health and well-being of all Cambodians? Increased political stability, economic growth, gradual improvement of government accountability and sustained development support are factors that contribute to a renewed commitment in a fair and effective health system in Cambodia.

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Section 2

Cambodia’s Health and Development Challenges 2.a Overview The 1991 Paris Peace Accords7 marked the end of dark times for the people of Cambodia and reset the clock for a long and complex nation-building agenda. Such a process takes much longer to complete than the ink on a peace agreement takes to dry. Nation building is a gradual and intricate process of institutional strengthening sector by sector over many years. If participatory mechanisms can appear very early in the process, free elections can often be organized within a couple of years. However the fulfilment of social and economic rights (education, housing, health, and others) takes much more time as they require an established democratic foundation and sustainable development processes. Cambodia has been on this path for almost 20 years. Since the July 1993 elections, important nation-building milestones have gradually turned the battlefield into a place of relative prosperity. Today, Cambodia’s institutional development allows a vision of universal social and economic protection of the people. Even so, many socioeconomic indicators remain of great concern. It is important to keep in mind that Cambodia’s development agenda operates not only in the context of poverty-linked drawbacks but also within a much more complex mix of post-war recovery, social trauma, and institution-building. As the health system has built itself over the years, national authorities have shown increasing readiness to reclaim full ownership of the health sector. In doing so, they reassess the roles and responsibilities of government and non government parties, to best address issues of sustainability and equitable access for all Cambodian people.

2.a.i. Demographics and Mortality The provisional population totals of the General Population Census 2008 from the National Institute of Statistics8 establish a population for the country of 13,388,910 people, with an annual population growth rate of 1.54%, reduced from 2.5% ten years ago. With a sharp decline in infant and under-five mortality, a drop in total fertility rate and a concomitant increase in life expectancy at birth, Cambodia is normalizing its population figures along regional averages, but it is also facing the burden of demographic transition, with large numbers of young adults entering the labour market. Of significant concern is the MMR of 472 deaths per 100,000 live births (Cambodia Demographic and Health Survey 2005, CDHS),9 which remains one of the highest in the region and shows no significant progress since 2000. There are many contributing factors to the unfavorable MMR in Cambodia but the poor access to, and low utilization of professional delivery services is at the heart of the problem. These results have prompted the MoH to rank the maternal health determinant of maternal mortality very high in the current strategic agenda.

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2.a.ii. Socioeconomic Development Economic growth in Cambodia increased from 1.2% in 1991 to a double digit pace fifteen years later, although with a GDP per capita of US$ 2,00010 and a Human Development Index of 0.598,11 Cambodia still ranks below the average for the region. In 2004, the Cambodia Poverty Assessment Report12 concluded on a positive note, the poverty rate having declined by 12% nationwide between 1994 and 2004. At the same time, the Report highlighted how fragile these achievements are and how much more must be done before the Cambodian people can rely on solid social safety nets. Poverty remains highly endemic and multidimensional: land ownership, road access, access to commercial markets, irrigation, electricity, literacy among adults, and other measures especially among the bottom income quintiles confirm the depth and magnitude of poverty in Cambodia. The current global economic recession is expected to reduce economic growth to around 5% annually13 or even less in the coming two years. A severe contraction in most macro and micro economic indicators in 2009 is to be expected, with a lengthy recovery. The labour market in most key economic sectors could record significant losses, which would deprive hundreds of thousands of people of their current income. The long term impact of the current economic turmoil on household consumption, on poverty and on people’s health behaviour is difficult to predict. It is certainly hoped that recent achievements in poverty reduction and overall access to services will not be reversed. However the current macro and micro economic situation in Cambodia and in the region is a potential determinant of ill health in the years to come, and must be monitored closely.

2.b. Government and Macro-level In recent years, Cambodia has strengthened its institutional apparatus and embarked on an ambitious program of government reforms. Between 1996 and 2005, the Royal Government of Cambodia (RGC) developed two consecutive Socio-Economic Development Plans (SEDPs).14 Both SEDPs took shape in three-year rolling Public Investment Programs (PIPs)15 to spell out in greater detail the investment and project proposals in the public sector. The RCG also prepared a set of Cambodia Millennium Development Goals (CMDGs)16 in 2003. Through an intensive and inclusive consultative process the RGC adopted in 2004 its Rectangular Strategy17 for addressing governance and socio-economic development comprehensively and holistically. In an effort to materialize these planning initiatives, the RGC adopted the National Strategic Development Plan (NSDP)18, 2006-2010, which in a single overarching document contains the Government’s priorities and strategies to reduce poverty rapidly, and to achieve its CMDGs. It is also intended to align sector strategies and planning cycles and to enhance better aid effectiveness across all external development partners (EDPs). More specifically, the Council of Ministers in May 2006 adopted the Public Service Delivery Policy,19 followed two years later by the Law on Administration and Management of the Capital, Province, Municipality, District and Khan (the “Organic Law”).20 Both policies

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provide the framework for Deconcentration and Decentralization (D&D) reform21 and for various incentive-based initiatives aimed at “serving people better”. The health sector is fully engaged in these institutional reform processes. These incentives and D&D efforts are meant to alleviate the financial burden of health system financing and are used to enhance the health system’s capacities at peripheral level, especially in the area of human resources for health. Such measures have generated mixed results globally. In Cambodia, the health sector has witnessed significant progress in many areas, despite some stagnation in key indices such as maternal mortality. These realities have guided the development of HSP2 (see below).

2.c. Progress and Constraints, Situation Analysis The health of the Cambodian people and the epidemiological transition that prevails in the country ultimately influence the strategy under which the health system fulfils its goals over the coming decades. Child health is improving in Cambodia and the country is currently on track to achieve the CMDG 4. The rapid progress in child health over the 5 year period leading up to the CDHS 2005 is attributed to socio-economic development, reductions in under-nutrition (despite recent data suggesting an impact of the economic context on food security), increasing coverage with preventive interventions, improved family planning practices and better access to health services for sick children. Measles immunization coverage increased to > 80% in 2008.22 Exclusive breastfeeding rates have risen to over 60%.23 Access to health services, including Integrated Management of Childhood Illness (IMCI) at health center level, is steadily increasing. More families have access to safe water and sanitation. Along with these encouraging trends, the data also demonstrate lower morbidity associated with major communicable diseases. A decline in HIV transmission among at-risk populations brings the population prevalence below 1%. Similarly, both malaria and tuberculosis show declining morbidity and mortality. This progress results from aggressive detection and accessible treatment programs at community and health center level. These major health gains are shadowed however by growing concerns in non-communicable diseases (diabetes and hypertension with urban rates at 10% and 25% respectively),24 environmental health, and road traffic injuries (Cambodia has one of the highest rates of fatal accidents in Southeast Asia). These issues reflect changing life styles (urban stress, nutrition patterns) coupled with increasing life expectancy (demographic and epidemiological transition). With more than half of Cambodian men now smoking, cardiovascular diseases will demand a strong health service delivery response. A well functioning emergency care system needs to respond to this increased demand for specialized care. This should be also associated with the improved Emergency Obstetric Care required at the most peripheral level possible (health center level) in order to address the issue of maternal mortality. Although

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there is considerable data on the health situation in Cambodia, detailed analysis of the social determinants of health and of health outcomes is less available.

2.d. Health System and Cross-cutting Strategy Alignment While the first Health Strategic Plan 2003-2007 (HSP1)25 was mostly focused on achieving Maternal and Child Health (MDGs 4 and 5) and controlling epidemic hazards (MDG 6), HSP2 2008-2015 focuses on health system development “based on a robust platform of experiences gained from both strengths and weaknesses of the implementation of HSP1”. The current strategy marks a constructive evolution from theme-focused and vertical programs towards far more complex health system-based endeavours. The HSP2 gives prominence to five health system cross-cutting strategies: health service delivery, health care financing, human resources for health, health information system, and health system governance. This is an ambitious but timely agenda. With the current level of institutional maturation in the country and the capacity of the government to conduct and lead complex development processes, it reasonable to say that the conditions are in place for the HSP2 to succeed, and to generate very significant health gains. However, to make a health system strengthening agenda work, it is necessary to find appropriate and cost effective programmatic entry points. Basic therapeutic and preventive interventions in the area of communicable diseases like tuberculosis, malaria or HIV/AIDS on the one hand, or obstetric care, child health and immunization on the other, offer countless health system building options. All these avenues are pursued in Cambodia: both the GAVI and GFATM are heavily supporting core health system functions (e.g. health service delivery, financing through drug procurement) and many donors are aligning and even pooling contributions, through the Second Health Sector Support Program, (HSSP2) in line with the HSP2.

2.e. Ongoing Challenges 2.e.i. Health Service Delivery Although evidence from facility based surveys is limited, some data from ad hoc assessment and key informants suggests that the quality of services among both public and private providers is often below standard. Basic infection control measures are insufficient in many large hospitals and at health centers; the skill level of health professionals is often low; poor staff motivation may lead to a high absenteeism rate and often to a dual public/private practice. A strong and aggressive health system stewardship by the MoH will improve the regulation of medical and public health practice at all levels of the health system, especially in the private sector (which represents >80% of total health spending)26 where deregulation remains problematic. The multiple elements that represent the burden of disease in Cambodia are best tackled by a continuum of care strategy for women and children, providing the backbone of the health care service delivery system. A comprehensive package of services to address the needs of the population (especially the poor) may be achieved by linking other service delivery

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programs with this continuum of care, strengthening referral pathways, and upgrading infrastructure (basic infrastructure at hospital and health center level, proper health financing measures, non structural supply and facilities, laboratory services, procurement services). This approach is fully in line with the current Primary Health Care (PHC)27 strategy to strengthen a national health system at all its levels and scale it up towards universal access.

2.e.ii Human Resources for Health A key priority area for Government is that of improving the capacity of one of its most important assets: the health, medical and paramedical professionals working at all levels of the health system, from the bedside of the sick to the central offices for health policy and planning. This includes the improvement and harmonization of education curriculum and working conditions, the creation of salary incentive packages (e.g. Merit-Based Performance Incentives),28 incentive-based deployment of health professionals in underserved areas, the appropriate mix of competencies by level of care, and regulation of private practice.

2.e.iii.Health Financing A very important concern is the proportion of households impoverished through catastrophic health expenditure (around 40% of cases of families losing land involve health crises, a confirmation that health often precipitates poverty.)29 Current health financing strategies focus on social safety nets, such as the (currently) donor-dependent Health Equity Funds.30 To ensure sustainability, high level political commitment and mechanisms to enhance system capacity may result in expanded health financing mechanisms to unlock financial barriers faced by the poor.

2.e.iv. Governance Despite a positive trend in government’s role and leadership, the health sector remains fragmented, with multiple implementing partners. This is partly a consequence of many years of humanitarian operation in the aftermath of the 1991 Peace Accords and the establishment of the United Nations Transitional Authority in Cambodia (UNTAC).31 Sector unification continues to pose a challenge for the MoH. The health system stewardship function of the “governance” cross-cutting priority of the HSP2 will translate in an improved capacity for the MoH to set norms and make them implementable throughout all health system constituencies, both public and private, governmental and non-governmental, and at both central and peripheral level.

2.e.v. Epidemiological Transition and Double Burden of Diseases In the years to come, the challenge for the health sector in Cambodia will be to achieve a health system able to absorb and be responsive to the needs of a population in epidemiological transition, meaning a population displaying a double burden of diseases. The demand of care covers a large span of interventions generated by both communicable and non-communicable diseases, from simple therapeutic ones to long term complex interventions, and requiring as well a variety of preventive measures.

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Historically health system and non-communicable disease problems have received less donor attention; hence the importance of future resource allocation and distribution to ensure that relatively neglected areas are addressed. All of the above issues have direct implications for the expected future WHO support in Cambodia.

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Section 3

Development Assistance and Partnerships: Aid Flows, Instruments and Coordination Cambodia enjoys a dynamic health sector, with strong support from a wide variety of health partners working together to align with national priorities. The HSP2 includes an initial consolidation phase (2008-2010) during which further policy decisions are made on implementation of strategies, and scaling-up is facilitated in many areas. Building on the HSP2, operational planning is accomplished on a yearly (the Annual Operational Plan, AOP)32 and medium term (3-Year Rolling Plan, 3YRP)33 basis. These processes are strongly led by the MoH, with inputs and consultation among Development Partners. Increasingly, plans are linked at an early stage to budgets. In the broader context, Cambodia has been an active participant in the harmonization and alignment agenda as set forward by the Paris Declaration, and has been an Organization for Cooperation and Development (OECD) pilot country. Donors and the Government signed a formal agreement, the Declaration by the Royal Government of Cambodia and Development Partners on Harmonization and Alignment in December 2004,34 and followed this with an Action Plan on Harmonization, Alignment and Results: 2006-2010.35 This has taken practical form in the establishment of Government-Development Partner Technical Working Groups (TWGs), each chaired by a Government Ministry or agency, and co-chaired by one or two Lead Donor Facilitators representing development partners. In 2009 there are 19 TWGs across many sectors. In health, the principal one is the TWG for Health (TWGH),36 which meets monthly, bringing together about 60 participants from senior staff of the MoH, and health partners, including multilateral and bilateral donors and agencies, NGOs and civil society. Additional TWGs that have a bearing on health include TWGs for HIV/AIDS, Water and Sanitation, and Education. Overall development assistance to Cambodia is overseen by the Council for the Development of Cambodia (CDC), which convenes the Government-Development Partner Coordination Committee (GDCC)37 three times a year under the Chairmanship of the Ministry of Economy and Finance, and the Cambodia Development Cooperation Forum (CDCF) every 18 months or so, under the Chairmanship of the Prime Minister. These forums bring together the Chairs and Co-Chairs of all TWGs, and other senior staff of Government Ministries and Development Partners, with NGO participation. Among DPs, more than 20 are actively engaged in the health sector, where contributions for 2009 are expected to exceed $120 million.38

3.a. Matrix of Development Partners in Health Development Partners contribute to the health agenda in a variety of ways. Since the inception of the Action Plan for Harmonisation, Alignment and Results, the MoH and Health Partners have identified WHO as the LDF, partly because both perceive WHO as a “neutral partner” and due to its statutory convening role.

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To support the TWGH, Health Partners (HPs) meet monthly at WHO to optimize alignment and collaboration. Representatives of the Health Partners then participate in the monthly meetings of the Secretariat of the TWGH. This is a subset of the TWGH, under the chairmanship of the MoH and co-chaired by the LDF, which includes a number of senior staff from the Ministry, and one representative for each of the bilateral, multilateral, and NGO constituencies. These health partner representatives are rotated on an annual basis, as may also be the case with the LDF. As an NGO umbrella organization, MEDiCAM has been representing approximately 120 NGOs active in Cambodia in these fora. The TWGH Secretariat sets the agenda for the monthly TWGH meeting to discuss progress in the sector and contains standardised feedback presentations from two Provincial Technical Working Groups. Increasingly Health Partners have formalized their collaboration in the health sector. In addition to the harmonization of approaches fostered by the TWG mechanism, the First Health Sector Support Project (HSSP1) brought together 4 partners (World Bank, UK Department for International Development (DFID), the United Nations Population Fund (UNFPA), and ADB) to support the first MoH HSP (2003-2007) with a common management framework, as part of a so-called Sector-Wide Management (SWiM) approach. This was substantially extended in 2008 with the HSSP2 (see Box 1), formally including 7 partners: World Bank, UNFPA, the United Nations Children Fund (UNICEF), DFID, Belgian Technical Cooperation (BTC), Agence française de développement (AFD), and the Australian Agency for International Development (AusAID). Some of these were able to take the further step of pooling funds, as Cambodia moved closer to a full-fledged Sector-Wide Approach.

The HSSP2 partners have signed a formal Joint Partnership Arrangement (JPA) with Government, and established a JPA Development Partner Interface Group (JPIG) with rotating chairmanship and internal lead responsibility for particular technical areas. Harmonization among JPIG/ HSSP2 and other health partners is fostered in the Health Partner meetings and TWGH mechanisms, and further promoted through activities of the International Health Partnership (IHP)39 that identified the TWGH Secretariat as the IHP Country Health Team. These processes have steadily moved partners to greater harmonization and alignment in accordance with Paris Declaration principles. Broader collaboration in the Mekong Region among Development Partners is also reflected in various mechanisms and programs.

3.b. Global Health Initiatives and Partnerships Cambodia has been a pilot country for, or a major beneficiary of, support provided by a number of Global Health Initiatives and Global Health Partnerships (GHPs). Many of these

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are hosted by or maintain a special relationship with WHO at global level. While important contributors to the health sector in Cambodia, a particular challenge has been their status as non-resident donors, therefore not participating directly in the harmonization and alignment mechanisms described above. WHO has played and can maintain an important intermediary role in this situation. For example, WHO has been a significant facilitator, for both technical and administrative issues, for Global Fund proposal development and implementation, and the national-level functioning of the Global Fund through the Country Coordinating Committee (Cambodia’s CCM). This role of “neutral partner” helped fill an important need in collaboration among Government, Development Partners, and Civil Society. This is also the case for other Global Health Initiatives such as GAVI, and the Health Metrics Network (Box 2)

3.c. International Health Partnership Of particular note at the time of writing is the International Health Partnership. Cambodia was one of the original seven IHP pilot countries when a global compact was signed in London in September 2007. WHO and the World Bank were asked to serve as national-level facilitators of the IHP. A “Country Compact” signed by Government and DPs is considered a key measure of IHP-fostered commitments. Formal agreements and a number of processes were already in place in Cambodia, and others recently achieved such as the HSSP2 and JPA. While WHO is not a signatory to the HSSP2, it actively supports these initiatives and, through its role as LDF and convener of the Health Partners Group, seeks to support extension of harmonization and alignment efforts to all partners.

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3.d. UN System in Cambodia The United Nations Country Team (UNCT) in Cambodia is40 represented by the heads of 22 UN agencies and programs (4 UN health agencies from the High Level Health Group), 19 of which are resident in Cambodia, and 3 are UN-affiliated agencies: the World Bank, the International Monetary Fund (IMF), and the International Organization for Migration (IOM). Among them, WHO is one of the largest in term of staff and budget, and it cooperates very closely with UNAIDS, UNFPA, UNICEF, and the WB. An important area of cooperation is through IHP, GHIs and GHPs, as well as through HSSP2 and the GFATM. By 2008 elements of UN Reform were in place or under development, including the placement of a Country Director in UNDP and an Office of the UN Resident Representative and freeing the Representative to focus more on the coordinating role of UN Resident Coordinator. WHO has been committed to UN Reform and remains closely engaged with a view to maximizing collaboration among UN agencies in areas of common concern, and minimizing duplication and inefficiency. In addition to UN efforts to harmonize administrative and management procedures, another means for accomplishing this is through the UNDAF. WHO will continue to work closely with its major UN partners in the health sector and in areas where there are overlapping interests with many or all of the other UN agencies.

3.e. WHO’s Evolving Role in Partnership The convening role of WHO has been part of the organization’s mandate since it was founded in 1948. The international realization over the past 10 years of the need for harmonization and alignment of development cooperation was reflected in the OECD/Development Assistance Committee (DAC) Paris Declaration. The evolution of Global Health Initiatives, which often lack in-country representation, has added a new dimension to the convening role of WHO. In Cambodia, aid effectiveness has intensified both in the number of partnerships and initiatives, and in the level of resources channelled through them. On the one hand, the government is facing an increasingly complex aid architecture prone to numerous coordination and integration challenges, and on the other, concerns arise over how the substantial resources are actually benefiting the institutional building agenda, and focusing on systemic and cross-cutting sectoral issues. The very dynamic development processes in Cambodia and the perceived “neutral partner” position of WHO has meant an increased role for WHO as convener and facilitator of Health Partner interaction with the MoH; and more widely in representing health sector interests in the UN, and also Government and international coordination mechanisms such as the International Health Partnership. This gradual shift of the WHO Country Office from a mostly disease specific and health sector reform orientation represents an opportunity that seems appropriate to WHO’s international mandate. However, due to the labour intensive nature of the processes to facilitate dialogue among DPs, this requires, for WHO, a revised organizational policy and human and financial resources to fulfil country and international expectations.

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Section 4

Current WHO Cooperation with the Government and People of Cambodia A growing economy, strong commitment for health, opportunities in decentralization, the availability of a clear health sector strategic plan, and as mentioned, a sustained institutional maturation and reform process together constitute critical elements favorable to health system strengthening and universal access, and to collaboration in all areas of health between the Government and WHO.

4.a. WHO’s Work in Cambodia The health of the Cambodian people and the epidemiological transition ultimately influence the composition of health service delivery, and of WHO collaboration. WHO’s technical cooperation in Cambodia is currently focused in four strategic elements (through four core work teams, as below) in alignment with the core strategic components of the HSP2. In parallel to technical work, the WHO Representative and senior management in Cambodia are actively involved in the harmonization and alignment agenda, through collaboration with MoH and with Development Partners around aid effectiveness issues, and with the Global Health Initiatives and Partnerships. This health diplomacy role is of critical importance to maintain coherency in the technical work of WHO in Cambodia.

4.a.i. Maternal, Newborn and Child Health WHO is collaborating closely with government and other health partners around the implementation of the Child Survival Strategy. This Strategy identifies a set of key interventions to reduce child mortality in an equitable way. These include the promotion of healthy practices and the provision of public health services such as immunizations, improved nutrition, and promotion of the Integrated Management of Childhood Illness for improving access to quality health services. The Organization has focused on support for policy development, planning and management, and evaluation of child health programs and interventions. This includes day-to-day engagement with government counterparts in the Child Survival Management Committee, capacity building through training and coaching of provincial child health teams and support for the conduct of household and facility surveys to estimate coverage of services and practices. As mentioned in Section 2, maternal health is of particular concern in Cambodia, with a sustained MMR of about 450 to 500 per 100 000 live births over the last 10 years.41 WHO has increased its support and engagement with Government and NGOs aimed at reducing MMR and assisting Cambodia to achieve MDG 5. Technical assistance is provided in the areas of Human Resources for Health, Reproductive Health and Making Pregnancy Safer.

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4.a.ii. Communicable Diseases WHO’s collaborative program in communicable diseases encompasses many activities in HIV/AIDS (including harm reduction), tuberculosis, malaria, dengue and communicable disease surveillance and response. In addition to direct WHO technical support in national disease control planning and policy development, these program areas incorporate planning elements that represent health system strengthening entry points and opportunities. This is particularly the case for issues of procurement and financing, health services delivery, quality of health care, health information system, and laboratory strengthening. WHO provides, as part of its mandate and through its technical assistance to the respective MoH programs, a large support in the various programmatic phases of the GFATM and GAVI (proposal development, reporting, implementation, monitoring and evaluation), and in implementation of global initiatives such as the International Health Regulations (IHR).42

4.a.iii. Non-Communicable Diseases and Environmental Heath Non-communicable diseases and environmental health require the involvement of the health sector as a whole as well as close cooperation with other relevant sectors and stakeholders. The major roles of the health system response are in strengthening legal and institutional frameworks and mechanisms which are still relatively weak; improving clinical experience and re-training of medical professionals on disease detection and management; improving public awareness on the need to change behaviors and improve life-styles; costing of noncommunicable disease treatment, incorporating the costs in the health financing strategies and proper budgeting for the sector; and increasing efforts on prevention through cooperation between ministries and sectors in a multi-sectoral approach. WHO is providing technical support along these lines in four programmatic areas: environmental health; traffic injury prevention; emergency and disaster management; and non-communicable diseases and risk behavior management including tobacco control. As for the communicable diseases work stream, non-communicable diseases and environmental health offer wide opportunities for improving health systems functions, mainly the improvement of health services delivery.

4.a.iv. Health System Development Central to WHO cooperation in Cambodia, WHO work in health system development mirrors very closely the five cross-cutting health strategies retained in the HSP2: health service delivery, health care financing, human resources for health, health information system and health system governance. As distinct elements, the approach is to identify, develop and promote innovative methodologies and techniques to address highly complex health system issues. In health financing, for example, WHO works on civil service reform and on the design of sustainable social safety nets in collaboration with the Ministry of Finance. WHO also works on systems planning, aid effectiveness and system decentralization. These areas of work are in fact highly correlated and very much aligned

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with governmental reform approaches and instruments that are gradually developed and implemented. In addition to these cross-cutting strategies, WHO is providing technical assistance on essential drug management under the health system development umbrella.

4.b. WHO Human Resources WHO has a substantial presence in Cambodia. With a current total of 25 professional staff and 22 support staff, this office is the second largest in the WHO Western Pacific Region. WHO´s organigram for Cambodia is a reflection of the MoH structure. It distributes the staff in six groups: the Office of the Representative, administrative support, and the four technical teams responsible for the four strategic directions described above. With an evolving focus on more specialized technical assistance and the MoH´s attention to health system constraints, WHO has strengthened its staffing in key areas (Table 1). Table 1: WHO Staff – Mid 2009

A major distinguishing feature of WHO in its program of technical cooperation at country level is the capacity to draw on the three levels of the Organization. Country Office technical staff is backed up by Regional technical experts (in Manila) who are available for country visits as well as remote technical backstopping. WHO at global level (Geneva) has a responsibility for international standards and best practices, whose dissemination and promotion is readily available through, and supported by, the Organization. WHO technical assistance is therefore provided within a global framework of technical excellence.

4.c. Financial Situation The financial situation for WHO in Cambodia has recently been stable (to 2009), with very few changes from the previous to the current biennium. This situation replicates the regional and global financial contributions by donors to program funding. However, the evolving global economic crisis, and the redirection of donor resources in Cambodia, mean that new financial challenges are arising. Although WHO programs in Cambodia receive broad and diversified donor support, they largely rely on just a few principal bilateral donors, plus some

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multilateral contributions to supplement core funding. It remains challenging to mobilize resources for cross-cutting health system issues. Such horizontal activities are more dependent on limited transfer of resources from better-funded disease-specific programs. Such transfers can only be granted through an appropriate program planning exercise in which core health system activities may be implemented with a disease angle. WHO in Cambodia, as in the Region, suffers from a low proportion (around 20%) of nonearmarked funds, either in the form of Assessed Contributions (AC) from member countries, or of Core Voluntary Contributions (CVC). This, again, has consequences on the program capacity to move and shift funding from well-funded to underfunded activities. WHO operates primarily as a technical rather than a donor agency, providing direct support to government counterparts. Technical staff is therefore regarded as WHO’s principal and essential asset, in comparison with program funding agencies. In this respect, the balance between human resources and activity costs remain in favor of the former. It is critical to ensure that there are enough people with the appropriate skills to deliver the needed technical support. It is also WHO´s responsibility, through its technical assistance, and through its convener and neutral broker roles, to promote coherence in the way other agencies’ resources are channeled to Government-led programs.

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Section 5

WHO Policy Framework: Global and Regional Directions, Strategic Agenda and Priorities WHO in Cambodia shares the MoH vision of a strong health system that responds effectively and fairly to the needs of the population – thereby contributing to poverty elimination and socio-economic development, and to the achievement of MDGs. Being strategic in planning support to Cambodia requires WHO to focus on what the Organization does best, and how it can be done in the local circumstances and context. This CCS, which is based on discussions with Government and other health partners, identifies priority areas of work for WHO and describes how WHO will align its support with development partners in order to most effectively contribute to the development of Cambodia’s health system. The identification in the CCS of focus areas of support is a strategic decision to execute WHO’s core functions (Box 4) in areas where the organization will add most value to the efforts of the MoH to reduce mortality and improve health for the population of Cambodia. 43

Taking into account WHO’s institutional strengths and limitations, this CCS reflects the intersection of WHO’s overall mandate with Cambodia’s national priorities. This section articulates the choices WHO as an organization is making with regard to the elements of the national health agenda it is best positioned to support.

5.a. WHO’s Mission in Cambodia WHO’s overall mission in Cambodia is twofold: to support the Government and people of Cambodia to achieve national health and development goals; and beyond that, to contribute to the advancement of international health more broadly. Cambodia is both a member and an important program country of the Organization – with specific development needs as well as its own critical contribution to make to regional and global public health. WHO´s work in Cambodia should be seen as a genuine partnership with mutual benefits, and a particularly close accountability that distinguishes WHO´s perspectives from those of other development partners. WHO’s work in the medium term is closely linked with and organized around Cambodia’s HSP2. For the purpose of defining WHO´s overall Strategic Objective under this CCS (Box 5), the two elements of WHO’s mission are coming together in its contribution to the HSP2.

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The HSP2 is the framework for WHO’s work in Cambodia and the starting point for the CCS. It reinforces linkages between the MoH and its counterparts, and allows for a shared understanding of the challenges that lie ahead. WHO has identified strategic priorities and focus areas in HSP2 to engage with the MoH and partners. These are areas where the Organization’s involvement is critical, specifically requiring a substantial part of WHO’s resources while maintaining programmatic flexibility and responsibility for the full health agenda. Any changes in WHO operations will be consulted with the MoH making sure they have the intended benefits and do not open new gaps. In all aspects, WHO’s work in Cambodia will be guided by a firm commitment to international norms and agreements on human rights and equity, technical excellence and ethical programmatic practices. These terms lie at the heart of the identity of an Organization founded under the UN Charter44 and the Universal Declaration of Human Rights45, and are directly relevant to its work.

5.b. Mapping WHO’s Strategic Priorities in Cambodia The CCS incorporates the visions for health development from partners and counterparts in and outside the Government, and considers what can realistically be achieved with the timeframe of the strategy. It also draws its conclusions on past experiences and trends in Cambodia’s broader development and on how these factors can affect health development and outcomes in the future. Three distinct but interrelated Strategic Priorities (Box 6) which will guide WHO’s engagement in Cambodia have emerged from this process.

These strategic priorities are central to WHO’s global core functions. They do not represent separate areas of work but cut across workplans and adviser teams. While WHO’s technical assistance to national programs (SP1) will continue to form the foundation for WHO support, intensified engagement in horizontal functions means increased support for improved access and utilization of services (SP2), as well as to overall sector stewardship (SP3). These integrated functions translate into sector-wide implementation strategies as described in the diagram below. This goes beyond alignment with the HSP2 and recognizes WHO’s vision of a strong health system that is capable of integrating multiple functions that currently are dependent on separate planning, technical assistance and external funding. The HSP2

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embodies this thinking and reflects global thinking on health systems. The five cross-cutting strategies in HSP2 cover the full range of WHO’s inputs and provide entry points for all partners. WHO will continue to adjust its support as capacity development continues in the MoH and more resources become available in the health system. Areas in which WHO currently anticipates continued or strengthened support may later require less attention. The challenges of realizing the vision of HSP2 are substantial and Cambodia’s health sector will continue to depend on considerable external support in the foreseeable future. WHO’s role as a facilitator and broker of policy dialogue and of coordination and harmonization of donor programs and efforts will remain a critical part of its work. With all large donors involved in sector-wide approach efforts in Cambodia, WHO’s interaction with health partners will be central, at technical as well as at policy level. These efforts will also extend beyond discussions within Cambodia, and include aspects of global partnerships and the international aid architecture under the framework of the IHP.

of the health sector

5.c SP1: Technical Excellence in Disease and Public Health Programs Promoting technical excellence (Box 7) involves the provision of up-to-date evidence-based information on medical products, technologies and interventions, as well as advice on how to most effectively scale up programs aimed at reducing the burden of disease. WHO believes that there is a need to adjust the focus of technical assistance and the way it is delivered by taking into account the growing local capacity and the capacities of international health partners. The area of communicable diseases control is one example where local achievements have been most pronounced and where WHO will be refocusing its TA towards more targeted support within priority disease areas. Stronger emphasis will be placed on cross-cutting aspects of communicable disease control, such as infection control, drug resistance, nutrition and sanitation. The support for implementation of public health measures under global frameworks and agreements will be sustained or increased. WHO’s

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aim is to integrate technical advice for disease control with health system strengthening and sector-wide policies, whereby the Primary Health Care approach is an essential modality to further develop the Cambodian Operational District (OD)46 based health system.

5.c.i. Focus Area 1a: Targeted Technical Support in Priority Disease Control Areas WHO will restructure the way it provides technical support to the MoH and its national programs and centers for the control of communicable diseases including HIV/AIDS, tuberculosis, malaria and dengue. By providing assistance for specific technical issues, WHO will focus on improving coverage and utilization of services and on the use of information for M&E. In addition WHO will promote synergies between disease control programs and decentralized management of health services.

5.c.ii. Focus Area 1b: Cross-Cutting Support to National Programs and Centers These include aspects of infection control, drug resistance, and the development of an integrated system of surveillance and laboratory support, as well as other functions that cut across disease programs. To that end, WHO will draw from specialised international expertise to work closely with the MoH and its national programs to refine and develop national responses in these areas. WHO´s engagement on these issues will be done with a perspective for the full span of functions and services under the Cambodian health system, and will involve an increased focus on aspects associated with the growing noncommunicable disease burden.

5.c.iii. Focus Area 1c: Programmatic Support to Under-Resourced Priorities WHO will enhance its technical engagement in these areas not receiving adequate resources and attention. Increased WHO technical assistance to the MoH in these areas will aim at strengthening the national response and local capacity. It will also contribute to efforts for presenting more systematically the relevant evidence and programmatic needs, such as through a burden of disease assessment as planned under the HSP2. Based on evidence WHO will support the MoH in making the case for investing appropriate resources to address major determinants of health within the overall health financing framework. This effort will include measures to improve coordinated prevention and care across disease programs, as well as

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targeted engagement with other sectors and relevant branches of government to collaborate on broader determinants of health. As an example, the Government has identified improving maternal health as the top priority in HSP2 and has announced a fast-track initiative to address this issue. WHO will intensify its support for MCH and will work closely with UNICEF, UNFPA and other partners to help Cambodia implement the Child Survival Strategy and the interventions aimed at reducing maternal deaths. Other under-resourced priorities include non-communicable diseases and health system strengthening.

5.c.iv. Focus Area 1d: Technical Capacity Building and Transfer of Skills and Knowledge When providing direct technical assistance, WHO will more explicitly contribute to strengthening local technical capacity in the Ministry’s counterpart institutions. It will identify together with partners the right approaches and support to match local needs. WHO´s TA will range from hands-on technical collaboration in some areas, to supportive supervision systems and research capacity strengthening, and to up-stream policy advice. WHO will focus on strengthening existing capacity and on contributing to the Ministry’s own efforts for education and in-service training. It will draw from both national and international best practices aiming at the sustainable transfer of technical skills, competencies and knowledge of relevant research and technologies.

5.c.v. Focus Area 1e: Support to the National Implementation of Global Agreements WHO will continue to provide targeted technical support to the ongoing efforts of its national partners to fulfil international obligations and compliance with global agreements such as the MDGs, the IHR, and the Framework Convention on Tobacco Control (FCTC).47 While much of the specific work and technical assistance under these frameworks falls within conventional streams of WHO support, WHO identified the need to ensure effective and continuous follow up at country level, as well as the appropriate institutional linkages with mainstream public services and institutions.

5.d SP2: Universal Access and Coverage to Quality Health Services Most Cambodians do not have access to quality health services which underlines the importance of focussing on aspects of availability, affordability, and acceptability of facilities, goods and services. More, universal coverage (coverage implies that the needs are covered from a supplier perspective) is equally problematic in the absence of protective unified health financing policy. Working within an integrated and intersectoral PHC approach, WHO will provide targeted technical assistance and policy advice aiming at strengthening those horizontal functions required to improve access and coverage of services and interventions. WHO will thus link up directly with the MoH strategies underpinning health service delivery, health financing and human resource development, procurement and drug management systems. WHO will support the MoH to build upon successes to improve quality in priority health programs, to respond to both pressing constraints and to anticipate innovative service delivery models - in the public and private sectors - that reach underserved

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and vulnerable populations, in particular as part of the government Policy on Public Service Delivery, “Serving People Better” (Box 8).48

5.d.i. Focus Area 2a: Delivery of Priority Health Services WHO will work closely with the MoH to strengthen delivery mechanisms that, from the perspective of an individual patient, provide a continuum of essential services and efficient referral pathways across health conditions and disease programs, across levels of care, and over the life cycle. Improving the continuum of services and reducing fragmentation in the delivery system is a central aspect of the HSP2. WHO recognizes that the management of health service delivery by ODs and PHDs is key for improving accountability of expenditures and the quality of services. The new contract based internal purchaser-provider approach and the evolving D&D policy offer opportunities to improve priority setting and responsiveness to address population needs. Priority will be given to supporting initiatives that improve the quality of and access to maternal, newborn, and child health care services, with particular attention to addressing health system constraints. WHO will also devote particular attention to the growing burden of non-communicable diseases and its implications for the supply of relevant health services. More specifically, linkages between existing capacities of disease control programs with care for chronic conditions and injuries will be scaled up.

5.d.ii. Focus Area 2b: Health Care Financing WHO will expand and adjust its support to the MoH under Cambodia’s health care financing strategy, both on aspects of overall investments in the sector and on ways to address supply and demand-side aspects of health system financing. This will include focused support to reduce out-of-pocket expenses (which currently account for about two-thirds of all health expenditure) towards pre-payment and social transfer mechanisms as indicated in the HSP2, strengthened social protection and pooling mechanisms, consolidation of different purchasing practices, alternative payment options and innovative demand-side financing mechanisms benefiting the poor. WHO will draw from our global and regional experience and strategies on matters of universal coverage to provide evidence-based technical support to the MoH, and work with other relevant national institutions and partners.

5.d.iii. Focus Area 2c: Human Resources for Health WHO will substantially strengthen its engagement concerning Cambodia’s health workforce, including more direct support to the resolution of some long-standing problems in this area. Key objectives of the HSP2, namely to lower high maternal and infant mortality rates, are

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directly associated with the insufficient number and quality of midwives and other categories of health workers. Within the HSP2 strategy for human resources for health, WHO will work with the MoH on the quality, availability and motivation of health professionals at all levels of the system, and also on their deployment based on needs, especially at the primary care level. WHO will actively support broader civil service reforms, and promote innovative approaches to human resource development, including partnerships with the private sector and civil society. Together with others WHO will also engage with the education sector on improved education for health and medical professions, and on continuing training for practitioners. Issues in registration of health professionals and mechanisms for addressing malpractice and unethical conduct will be incrementally addressed.

5.d.iv. Focus Area 2d: Essential Medicines and Products Ensuring equitable access to safe, inexpensive and effective essential medical products and technologies is central to any functioning health system. WHO will consolidate its support to Cambodia in this area as a critical building block to strengthen and integrate Cambodia’s health system. WHO´s TA will draw from its regional and global resources and aim at strengthening overall the MoH´s institutional capacity to provide effective governance and regulatory oversight. To that end WHO will emphasise practical solutions based on assessments, and work with others to enlist the support from other government agencies. The organization will support work towards an effective and accountable national procurement, drug management and logistical supply system. Other important issues include those of rational drug use, preventing drug resistance and the control of counterfeit drugs for which experiences of national programs represent valuable inputs. Overall, WHO will work with the MoH to bring together both national and external stakeholders under a common approach to improve transparency in all aspects of medical products and technologies.

5.d.v. Focus Area 2e: Quality of Care and Accountability Across Providers and Programs WHO will identify new ways for providing effective support to efforts by the MoH to ensure the quality of health services in Cambodia, more specifically the improved quality of care, professionalism and accountability of service providers, and the empowerment of patients. With a view to the nationwide scale up of packages of essential services as envisaged under the HSP2, WHO as a normative agency has an important role to play in supporting the MoH to ensure and raise standards of care, especially when it comes to the regulation of private clinical practices. WHO´s contribution to relevant components under the MoH health service delivery strategy will focus on the development and implementation of evidence-based quality standards and protocols for clinical care, will back the work of service delivery monitoring teams, and overall aim at establishing a culture of excellence in medical practice and public health programs. Support to other health systems functions such as health financing and information will also be oriented towards improving quality of services.

5.e. SP3: Effective Stewardship of the Health Sector and Health Partnerships Strengthening government’s stewardship role in the health sector is a cornerstone of WHO

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work in Cambodia (Box 9), mainly through a commitment to undertake policy analyses and to conduct broader governance and development processes. Increasingly important is to work with the MoH and other institutions to advocate for policy change and effective implementation for improved equitable health outcomes, in particular as part of D&D. The HSP2 stresses the importance of a common policy framework on Harmonization and Alignment between government and development partners for health development. Within the global context of the aid effectiveness agenda, WHO supports the MoH for a move towards a full Sector-Wide Approach in health. WHO will link up predominantly, though not exclusively, with the MoH strategies underpinning Health System Governance, the HIS, and the sector’s planning processes including M&E. MoH will benefit from WHO’s convening role in the sector to advance policy dialogue among health partners and within the Government in critical and complex issues such as human resources for health and health system financing, MCH, as well as aspects of aid delivery and SWAp development. Being host to and having direct institutional links with most GHPs, WHO as an Organization is also well positioned to assist the MoH in managing partnership contributions to Cambodia’s health sector. As the UN’s lead agency for health, WHO supports UN Reform49 and its related inter-agency processes.

5.e.i. Focus Area 3a: Policy Development and Advocacy WHO will continue to provide policy advice and encourage dialogue in support of decisionmaking in the MoH and other sectors on a broad range of topics, based on scientific evidence and lessons learned within Cambodia, the region and globally. The organization will facilitate the generation of political support and resources across government for the effective implementation of existing and new policies designed to improve health outcomes, both within and outside of the health sector. It will advocate for areas requiring substantial boosts to achieve national and international targets, as well as others associated with the rapid transformation in Cambodia’s disease burden.

5.e.ii. Focus Area 3b: Health Information Systems and Health Systems Research WHO’s global role in health information and health systems research is important also at country level: the Ministry’s Strategy to strengthen the national HIS emphasises routine collection and analysis of decentralized and disaggregated data from both public and private sectors; research and program evaluation to generate evidence on key determinants of health are critical aspects to inform policy making, track program performance, and adjust technical approaches. WHO will work with partners in and outside the Government towards improved

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surveillance systems across disease programs, and the analysis and dissemination of new data. International initiatives to improve health information, including those under the IHR and HMN, need to contribute to the development of national HIS and be synchronised with government efforts. In the area of health systems research, WHO will work with the MoH and others to strengthen existing and build new national capacity.

5.e.iii. Focus Area 3c: Harmonization and Alignment under a SectorWide Approach in Health WHO strongly supports the development of Cambodia’s sector-wide approach in health, building on past successes and MoH leadership to align and harmonise the delivery of external aid around the national health strategic plan. To this end WHO will seize on international trends favouring program-based approaches to advance sector policy dialogue and help alleviate bureaucratic and political bottlenecks. Drawing from SWAp experience in many countries, WHO will synthesize best practices and provide policy advice for deepening sector-wide management in health – such as in the context of the multi-donor HSSP2. This involves working with health partners and MoH on aid modalities and concrete ways in which external assistance, including from GHPs, can be better aligned with national priorities and harmonize with national systems. WHO at regional and global level will facilitate dialogue with partnership secretariats to bring them more directly into the national policy dialogue in support of integrated health plans, and to adjust partnership operations to existing local frameworks.

5.e.iv. Focus Area 3d: The Relationship Between the Public and Private Sector Health development in Cambodia needs a more systematic engagement between the public and private sector – both are critical to the improvement of health outcomes. WHO is committed to facilitate such a dialogue with government and private providers, including not-for-profit and commercial providers. WHO will work with the MoH to assess the challenges of moving towards a more integrated health system under the regulatory authority of the MOH, and assist in the institutional cooperation with other relevant branches of government to enforce and back up this role. WHO will see engagement with the private sector as a theme cutting across all focus areas and priority health programs. Evidence will be provided that draws from experiences in other countries, with particular attention to ensured equitable access to needed health care through a pluralistic health system and broader efforts for the development of social health protection schemes under the HSP2.

5.e.v. Focus Area 3e: Integration of and Linkages Across Disease Control Programs WHO supports the MoH vision of a fully integrated national health system. It will take into account the different levels of capacity, resources and attention given to programs and disease control efforts, and work with disease programs and more central MoH departments towards a more integrated approach to planning, managing, and evaluating public health efforts. WHO will provide targeted guidance and options to the MoH leadership, drawing from international experiences and lessons from ongoing cooperation in Cambodia. With an increasing share of non-communicable and chronic health conditions, and the resulting double burden of disease on many Cambodians, it is becoming even more important to build

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bridges and collaborative mechanisms between programs and providers, especially at PHC level where individual patients need to access a continuum of care as envisaged under the HSP2.

5.e.vi. Focus Area 3f: Governance and Decentralization WHO will strengthen its involvement and expertise on a range of broader aspects of Cambodia’s development and governance, including efforts to strengthen the public service and its institutions, their efficiency, transparency and accountability to the population. WHO will provide advice to the MoH and other partners on broad Government reform programs as they involve both challenges and opportunities for governance and service delivery in the health sector. Most notable are ongoing and future changes in the area of public financial management and the D&D. The ability of MoH staff to manage, plan and implement the organization of public services in an increasingly complex environment is critical to the achievement of better outcomes. WHO will support the MoH at all levels in managing and formalizing decentralization processes in the health sector as a critical part of strengthening MoH stewardship. The organization will work closely with the MoH and other partners in identifying ways to strengthen institutional capacities, including at sub-national level, and related efforts to move towards integrated service delivery across health conditions and delivery programs.

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Section 6

Expected Evolution of WHO Presence in Cambodia The strategic agenda as described in Section 5 is focused primarily on supporting the HSP2. It identifies three Strategic Priorities to align with the three Program Areas and 5 crosscutting Health Strategies of the HSP2. This alignment is reflected in the 4-team structure: Maternal and Child Health (MCH), Communicable Diseases (CD), Non-Communicable Diseases (NCD), and Health System Strengthening (HSS) in the WHO Country Office.

6.a. Strategic Priorities 6.a.i. SP1: Technical Excellence in Disease and Public Health Programs “Technical excellence in disease and public health programs” indicates WHO’s intention to provide strategic targeted support to the 3 principal program areas of the HSP2: MCH, CD, and NCD. Among these, communicable diseases have been most consistently and strongly supported by donors, including support provided through WHO. The resulting gains in many areas of CD control, and the substantial capacity building within the MoH, the semiautonomous communicable disease control centers and NGOs, is testament to this support. CDs will remain a serious public health problem in Cambodia in both the short and long term and it is critical to sustain and build on the gains in CD control. However, this development of national capacity in vertical programs has refocused the attention of both MoH and WHO on relatively neglected priorities. It is clear that the epidemiologic transition is well underway in Cambodia, and NCDs come increasingly to the fore: diabetes mellitus, hypertension, cancers, injuries, and mental health disorders, among others. In MCH, the MoH provides clear and strong guidance to its own staff and to development partners to focus on improving the status of MNCH, where much remains to be done, and for which general system strengthening is clearly important, potentially providing the core for WHO advocated PHC. For these reasons WHO proposes, in this first Strategic Priority, increasingly targeted but flexible technical and financial support addressing neglected technical areas, and complementing MoH’s own strengths. This will be a dynamic challenge, and requires WHO to respond with technical expertise and some financial support to shorter term needs (3 months to 2 years), as well as sustaining core WHO presence.

6.a.ii SP2: Universal Access and Coverage to Quality Health Services WHO’s second (and third) Strategic Priorities address the critical cross-cutting elements of the HSP2, to strengthen access and coverage to quality health services and to effectively manage the health sector. This health systems strengthening focus on the MoH strategies is highly consistent with WHO’s own emphasis on PHC, and on broadly strengthening public health and clinical services available to all, ensuring equity and quality. SP2 acknowledges that all health systems are challenged by the need to put well-trained, motivated, and compensated staff in well-supplied and supported facilities; and to ensure that the services provided are accessible to all. Accessibility and coverage to quality services requires special

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attention to the needs of the poorest and most vulnerable, including those in rural and remote areas, and minority and mobile populations. The cross-cutting strategies of the HSP2, and SP2, aim to complement the public health and disease program areas by ensuring a continuum of care for all those in need of health services in Cambodia.

6.a.iii. SP3: Effective Stewardship of the Health Sector and Health Partnerships The above are challenges being faced forthrightly by the MoH and the Government, and are issues of great importance to WHO and the development community. Because they can be successfully addressed only in a coordinated manner, a critical task is that of harmonization among donors, as well as civil society and the private sector, in aligning with Government priorities and strategies, a process that WHO sees as essential to its own country activities. This function, and the evidence and policy to support it, is at the core of SP3.

6.b. WHO Contributions from its Country, Regional, and Headquarters Offices The re-focus of WHO from a general core-function based TA to more targeted support for disease control, and strategic technical support to HSS and partnerships, has implications for WHO staff and financial resources in Cambodia – and also with regards to regional and global inputs to this country office. While the four focus areas on which WHO staff is aligned need continued strong support, the priority emphasis in recent years requires substantial strengthening of health systems broadly, in particular the decentralization of skills, capacities, and resources to provincial, district, and health center level. Given the much increased capacity of MoH in many areas, WHO aims to support especially those areas most lacking in human and financial resources and thus still in greatest need of strengthening.

6.b.i. WHO at Country Level WHO’s three-tiered organizational structure starts in country offices, where the focus is on providing technical support, and limited financial support, to member states in addressing priority areas. The needs widely vary from country to country and evolve within a specific country depending on the epidemiologic situation, national capacities, political stability, conflict, risk of natural and manmade disasters, and the contributions of development partners, civil society, and the private sector. The complement of staff in a country office thus depends on the national situation at a given point in time, and will need to develop over time. WHO strives to be a neutral partner in the collaboration between Government and donors, fostering harmonization in alignment with government priorities. The development partner community is large and dynamic in Cambodia and WHO plays an important role in coordination and enhancing collaboration. This role has increased substantially in recent years with the proliferation of GHIs and GHPs which collectively make substantial financial resources available to Cambodia. Although the overall impact of these new entities is positive, it is also recognized that asymmetrical resources can distort planning and priorities in a weak health sector. Many of them are non-resident in Cambodia and they rely, often substantially, on WHO’s support. Many have formal administrative relationships with WHO at global level while the working relationships at country level are still evolving.

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6.b.ii. WHO at Regional Level WHO’s historical role in technical support at country level has required access to highly specialized technical expertise, which cannot be practically deployed as such in 193 member states, even in larger offices such as Cambodia. This is addressed through the network of 6 Regional offices, whose technical staff provides this level of backup to the country offices of the Region. WHO has a strong Regional Office in Manila, whose staff remains in close contact with country staff and routinely provides technical support when needed, at a distance or in country visits.

6.b.iii. WHO at Global Level WHO’s work is overseen from its Headquarters in Geneva, whose normative function includes the development and promotion of global standards and agreements, and production and distribution of technical papers, international guidelines, and resource materials. As in the Regional Office, there is a complement of technical staff available to provide back-up to Regions and country offices.

6.c. Expected Evolution of WHO Support in Cambodia With guidance in standards and norms from WHO Headquarters, and specialized technical support from the Regional Office, the Cambodia Country Office would continue to provide country-specific technical support to align with the strategic priorities of the HSP2, and the more flexible operational priorities identified in the annual and medium-term planning processes. In addition, WHO envisages its continuing involvement in the partnership arena, facilitating harmonization within the complex aid environment in Cambodia, ensuring alignment with Government priorities. In terms of human resources at WHO Cambodia Office, the current ratio of international to national professionals in the WHO office is about 4 to 1 (Table 1, Section 4), although until recently there were hardly any National Professional Officers (NPOs) at all. However, national capacity has grown in the last 10-15 years, and the need for and intensity of external technical support should consequently decline. In the future, WHO should foresee a gradual shift to a ratio which is more balanced and responsive to the changing environment. In such a scenario, WHO might move toward a 4-team structure in which teams are led by international professional staff, supervising selected international experts and, especially, NPOs. In this case it is ideal for Team Leaders to have both extensive and broad experience in the subject area; i.e. well-experienced “generalists”, working with a mix of proficient international and national staff. Teams would be augmented on a shorter-term basis (3 months to 2 years) with international specialists in specific areas of identified need. With such a shift, the proportion of WHO country budget support allocated to WHO staff salaries would be expected to decline even if overall staff levels remained similar, because of the differential in budget allocation between international and national professional posts. This could help in freeing some flexible (non-earmarked) resources from staff cost to activity cost to address specific gap areas where additional support is needed. This will be very much welcome to compensate the decreasing ratio between non-earmarked money and earmarked contributions from governments, international organizations and philanthropists. However, WHO budget will also fluctuate according to global economic realities, but the importance here is to allow a greater degree of financial flexibility for WHO support to the MoH and the Government.

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Conclusion In summary, the implementation of a re-directed program of collaboration among WHO, MoH, and other partners, as reflected in this Country Cooperation Strategy, represents an important shift in strategic priorities for WHO and in the staffing and resources to address these priorities. This CCS commits to a strong emphasis on alignment with HSP2, and especially to the relatively under-resourced areas of Maternal, Newborn and Child Health, and selected non-communicable diseases, as well as a substantial emphasis on strengthening the health system overall. These changes occur in the context of a steadily increasing capacity in the health sector generally in Cambodia. As may be seen in this document, this implies a gradual shift of WHO technical support, contingent on funding, to these relatively under-resourced areas, and a focus on technical teams comprised of international professional Team Leaders, and a mix of specialized international staff and national professional experts to address the evolving needs of the MoH. In this dynamic and critical collaboration among all partners, under the leadership of the MoH and the Royal Government of Cambodia, WHO remains committed to its mandate and mission for the attainment by all peoples of the highest possible level of health.

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Annex 1: Mapping of CCS Strategic Direction and Objectives into the WHO 2008-13 Mid-Term Strategic Plan Framework Strategic Priority 1: Technical excellence in disease and public health programs Targeted technical support in priority disease control areas Cross-cutting support to National Programs and Centers Programmatic support to under-resourced priorities Technical capacity-building, and transfer of skills and knowledge Support to the national implementation of global agreements Strategic Priority 2: Access to quality health services Delivery of priority health services Health care financing Human resources for health Essential medicines and products Quality of care and accountability across providers and programs Strategic Priority 3: Effective stewardship of the health sector, including health partnerships Policy development and advocacy Health information systems and health systems research Harmonization and alignment under a sector-wide approach in health The relationship between the public and private sector Integration of and linkages across disease control programs Governance and decentralization

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 31 décembre 2009

Source Organisation mondiale de la santé