Country Coordinating Mechanisms (CCM) Harmonization and Alignment

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					      Country Coordinating Mechanisms (CCM)

                    Harmonization and Alignment:

                                            Cambodia




Disclaimer:
Note that the opinions expressed in this report are those of the author alone and do not represent or imply any
opinion or judgment on the part of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

You may not permanently store, copy, reproduce or retransmit any part of the contents of the pages of this
publication without the author’s prior written permission.




                                                                                                   October 2008
Global Fund Case Study – Harmonization and Alignment, Cambodia        Draft 2




                              Technical Support Consultant's Report


                              HIV/AIDS Technical Support Facility
                              Southeast Asia and the Pacific




TA Reference:              TA/KH/11/2007
October 2007




CCM Case Study – Cambodia:
Harmonisation and Alignment




Prepared by:
Shiv Kumar
Swasti – Health Resource Centre
#52 4th Main, Postal Colony, Sanjaynagar, Bangalore – 560 094
Ph: 080-23517241, 23517835, Fax: 23417714,
E-mail: shiv@swasti.org
http://www.swasti.org




For the Global Fund for AIDS, TB and Malaria (GF ATM)
Global Fund Case Study – Harmonization and Alignment, Cambodia           Draft 2




Abbreviations


AGM               Annual General Meeting
AIDS              Acquired Immune Deficiency Syndrome
AOP               Annual Operational Plan
CBO               Community Based Organisation
CCC               Country Coordinating Committee of Cambodia
CCC-SC            Country Coordinating Committee- Sub committee
CENAT             National Center for Tuberculosis and Leprosy Control
CNM               National Malaria Center
CoC               Chamber of Commerce
CMR               Crude Mortality Rate
CoCom             Coordinating Committee for Ministry of Health
CPN+              Cambodian Network for Positive People
CRC               Cambodian Red Cross
DFID              Department for International Development – UK
DWCD              Department of Woman and Child Development
EC                European Commission
EDL               Essential Drug List
FBO               Faith Based Organization
FGD               Focus Group Discussion
FHI               Family Health International
GFATM             Global Fund for AIDS, TB and Malaria
HACC              HIV/AIDS Coordinating Committee
HDR               Human Development Report
HIV               Human Immunodeficiency Virus
ICC               Inter Agency Coordinating committee
INGO              International Non-government Organization
JICA              Japan International Cooperation Agency
KHANA             Khmer Network of NGO Alliance
LFA               Local Fund Agent
M and E           Monitoring and Evaluation
Global Fund Case Study – Harmonization and Alignment, Cambodia         Draft 2

MoH               Ministry of Health
MSM               Men Having Sex with Men
NAA               National AIDS Authority
NCHADS            National Center for HIV/AIDS, Dermatology and STDs
NGO               Non Governmental Organization
NPTRP             New Proposal Technical Review Panel
PLHA              People Living with HIV/AIDS
PMU               Project Management Unit
PR                Principle Recipient
PRTRT             Principal Recipient Technical Review Panel
PIP               Program Implementation Plan
RBM               Roll Back Malaria
SR                Sub recipients
SWiM              Sector Wide Management
SWaP              Sector Wide Approach
TA                Technical Assistance
TOR               Terms of Reference
TWG-H             Technical Working Group Health
TB                Tuberculosis
TRP               Technical Review Panel
WHO               World Health Organisation
Global Fund Case Study – Harmonization and Alignment, Cambodia                                                                                Draft 2

                                                                 CONTENTS




1     Executive Summary ...................................................................................................................... 1
2     Introduction................................................................................................................................... 3
 2.1 Purpose: ................................................................................................................................ 5
 2.2 Methodology .......................................................................................................................... 6
 2.3 Sampling................................................................................................................................ 6
3 Description of the situation............................................................................................................ 8
 3.1  Cambodia Socio-political Context .......................................................................................... 8
 3.2  Health System ....................................................................................................................... 9
 3.3  Global Fund Grant History ................................................................................................... 13
 3.4  Cambodia Country Coordinating Mechanism ....................................................................... 14
4 Lessons from CCM-Cambodia .................................................................................................... 21
Annex A: Interview checklist ............................................................................................................. 29
Annex B: List of respondents ............................................................................................................. 32
Annex C: Sub-Committee constituency.............................................................................................. 33
Annex D: PR Selection Process......................................................................................................... 36
Global Fund Case Study – Harmonization and Alignment, Cambodia                                                       Draft 2




1 Executive Summary


The Global Fund has commissioned a series of case studies in eight thematic areas over 19
countries, in order to share with the global audience the practical implementation of the principles of
the CCM. This is the Case study of Cambodia CCM on Harmonization and Alignment. This case
study looked at how CCMs have facilitated or hindered efforts in harmonization and alignment,
examine what has worked, what has not, and highlight lessons learned.

Semi-structured guidelines were developed1 and used for one-to-one interviews and two focus group
discussions - one with the group of NGO sub recipients, and another one with a group of NGOs who
have been working within the sector for many years, but not part of GFATM funding. Review of
reports, minutes of CCC meetings, related documents, literature, guidelines and previous research on
similar subjects provided the background. As part of drafting this report, preliminary findings were
shared in a presentation to the Chair of the CCC. There are currently 29 members of the CCC.
Sampling was done through purposive selection and 21 respondents were covered.

This case study was conducted between September 18th and October 12th, which included 7 field
days. It has been a very rapid exercise wherein a number of respondents were met in the short
period of 7 days, while attempting to document the practices of this CCM and what has worked for it
and what has not. This report does not attempt to be a comparative study of different CCMs. The
report consists of a combination of perceptions and facts. Through the interviews we have elicited
several facts and different opinions and perceptions. Validation through multiple interviews has been a
part of the process of the case studies however the report does not contain sources of perceptions or
facts stated by respondents.

The CCC in Cambodia was established in February 2002 in order to coordinate and facilitate the
whole process of the GFATM in-country. As the membership of the CCC is very broad and consists of
high-level representatives of different organisations, the CCC Sub-committee was formed in
September 2002 to facilitate all administrative work of the CCC, to liaise with all partners, to
coordinate the assessment of new proposals, to keep the CCC fully informed of progress, to prepare
CCC meetings and document the whole process. There are currently 29 in the CCC members and
corresponding alternates of an equal number.

Findings and conclusions:
CCC members of Cambodia feel that their CCC works and is "as good as it can get". While
recognising that there is always scope for improvement, they view it as being successful – the five
rounds of successful proposals, the animated and engaged CCC that they have built and maintained
and overall level of engagement and value derived from GFATM funding are the signs they recognise
as the success of the CCC.

Cambodia, despite its many challenges, has made substantial strides in achieving harmony and
alignment and is an example for other countries. Efforts towards Harmonization and Alignment is at
multiple levels and robust. Approaches such as a broadly owned, Health Sector Strategy and Sector
Wide Program (SWiM) set the agenda and harmonisation frameworks. Within this, specifically there
are additional initiatives and mechanisms to improve the harmonisation and co-ordination:

1
    Draft developed by GFATM Geneva team, further discussed, elaborated and clarified in Kuala Lumpur in a meeting
Swasti –Health Resource Centre                                                                                            1
Global Fund Case Study – Harmonization and Alignment, Cambodia                                    Draft 2

    •   Multi sectoral and broadly owned and costed plans for each of the three diseases, which are
        regularly updated and aligned with broader Health Sector Strategy.
    •   The GFATM proposal priorities which are drawn down from the national programme priorities;
        which ensures complete alignment of the GFATM round funding to the larger national
        programme.
    •   Existing and functional mechanisms which are at very high Government level, which are also
        multi sectoral – such as the TWGs, NAA, etc, which bring together stakeholders for broader
        sector co-ordination and also for specific diseases profiles.
    •   Multi sectoral committees and steering mechanisms for all the three disease profiles, which
        exists and are functional and which is much broader then the GFATM co-ordination
        mechanisms.
    •   Joint and sometimes independent reviews which provide information and platform for
        accountability across stakeholders.

There are some broader facilitatory factors which push for the harmonisation and co-ordination:
   • That the national health programme is largely dependent on external funding and therefore is
       open to ideas and as well as needs to co-ordinate with various stakeholders to achieve
       optimum funding through SWiM mechanisms.
   • A broader culture of working together of Government, NGOs and donors, through a variety of
       forums and platforms.
   • Existence of the large civil society networks such as RHAC, KHANA and HACC which support
       such harmonisation and co-ordination among civil society and who also feed into broader
       processes for GFATM.

There is still scope for improvement in all of the above. Based on the above analysis, the following
are recommended:
    a) Operational co-ordination, particularly activities at provincial level between the three diseases
       as well as between the GFATM rounds is necessary and possible. There is a need to plot the
       duplicities and possible areas for alignment and implement specific set of proposals.
    b) GFATM recommended systems on M&E, finance and procurement create parallel processes
       within the country. There is need to review the benefits and problems of such global systems
       and whether they are actually beneficial and contributing to the key principle of country
       ownership and if they are not, what benefits it accrues.
    c) The ‘Rounds’ approach of GFATM is highly disruptive of processes within the Country.
       Instead a more regular and yearly process will help countries to co-ordinate their funding
       cycles with that of GFATM.
    d) There is a need to set up monitoring mechanisms across all rounds, which are likely to provide
       evidence and opportunities for better co-ordination.
    e) There is a need to review the constitution and effectiveness of the multiple institutional
       mechanisms which exists and see what improvements are possible.




Swasti –Health Resource Centre                                                                         2
Global Fund Case Study – Harmonization and Alignment, Cambodia                                                                     Draft 2




2 Introduction


The Global Fund has approved a total of US$ 8.4 billion to more than 136 countries in over 450
grants, including the latest grants to receive approval for Phase 2 funding (years three to five of the
grant lifespan). Of the US$ 8.4 billion approved, US$ 4.2 billion has been disbursed to public and
private recipients in 134 countries; and 93 percent of approved grants have signed grant agreements.
The Global Fund awards grants through proposal rounds. There have been six proposal rounds, with
Board approval of accepted proposals given in April 2002, January 2003, October 2003, June 2004,
September/December 2005 and November 2006. Round 7 proposals are currently being reviewed by
the Technical Review Panel (TRP) and will be voted on by the Board in November 2007. Round 8 will
be launched 1 March 2008. 2


The Fund’s main principles include the establishment of a simplified and innovative process with
efficient, effective and transparent disbursement mechanisms, support of programmes that reflect
national ownership and respect country-led formulation and implementation, and focus on
performance by linking resources to the achievement of clear, measurable and sustainable results.3
The main innovative features of the Fund are its emphasis on partnerships and participation of
stakeholders from civil society at the recipient country as well as the international level, and the
disbursement of further funds in following phases of the program based on the performance and
outcomes achieved by the recipients. The Global Fund has prioritized AIDS, TB and malaria as the
most important diseases to combat worldwide. It endeavours to be a new and comprehensive
minimalist mechanism for an efficient and effective battle against the three diseases. Not slowed down
by the heavy bureaucracy, it presents its work as “guided by three major imperatives: Raise It.
Spend It. Prove It.”4


While the Fund has an explicit focus on three diseases, it has also stated its commitment to support
“programmes that address the three diseases in ways that contribute to the strengthening of health




2
    http://www.theglobalfund.org/en/files/publications/basics/progress_update/progressupdate.pdf Last Accessed October 5th 2007.
3
    The Global Fund, Framework Document
4
    The Global Fund to Fight AIDS, TB and Malaria, Annual Report, 2003, p.15.

Swasti –Health Resource Centre                                                                                                          3
Global Fund Case Study – Harmonization and Alignment, Cambodia                                        Draft 2

systems”.5 Indeed, a major new initiative such as the Global Fund is likely to affect health care
systems in a variety of direct and indirect, hopefully all positive ways.


The Global Fund was established with the premise that it would supplement and complement funding
efforts within the existing country led systems. Recognising that every donor, be they multi lateral or
bilateral, operate within their own system, the Global fund reserved the right to be unique and
endeavoured to operate within country-led systems. The Global fund started operations in 2002,
recognising that there were already many systems in place. The uniqueness of this fund was to
integrate efforts towards these three diseases in the backdrop of strengthening health systems of the
country. The challenges this posed was that in each country the effort towards these diseases were
individual and unique within the public health system and each of these operated in very strict silos
leaving very little room for integration.      Usually the institutional arrangements and management
structures in health systems have limited scope for integration. The approach of global fund of working
through existing networks, linkages and national systems has forced the countries to examine existing
structures and evolve them towards an integrated approach to the three key diseases thus providing
an impetus to strengthen the existing health system.


In addition to working in an integrated and harmonized fashion, the principle of country ownership
rides high in the Global Fund’s agenda. Recognizing that the ownership of health outcomes is not just
government led but also civil society and donor led, the Global Fund has set a revolutionary milestone
by encouraging collective ownership and responsibility for the country’s health outcomes.


The structure and the concept of the country coordinating mechanism (CCM) of the Global Fund is
intended to reflect the principles of national ownership and participatory decision making. This unique
public- private partnership at the national level represents the governing body for the use of Global
Fund resources in recipient countries. CCM is responsible for: a) coordinating the submission of fresh
proposals; b) process requests for continued funding; c) selecting Principal Recipients; and d)
oversight on all GFATM grants. The CCM and its effectiveness, has a large role to play in the
success of the country in accessing funds and the quality of the program implementation and its
oversight.    In this the participation of the civil society, the role of the secretariat, role of the other
donors and country partners are crucial. To guide countries, there are guidelines available on building
and running an effective CCM. Different countries have approached CCM and its governance in very
many ways, with varying successes. Some countries have been successful, others less so. The last


5
    Ibid.

Swasti –Health Resource Centre                                                                             4
Global Fund Case Study – Harmonization and Alignment, Cambodia                                   Draft 2

few years there is a wide tapestry of interesting models, experiments and experiences in CCMs
across the globe.


The Global Fund has commissioned a series of case studies in eight thematic areas over 19
countries, in order to share with the global audience the practical implementation of the principles of
the CCM. Through reports of CCMs across the globe, formal and informal communication from Fund
Portfolio managers, LFA reports, a purposive selection of 19 CCMs (countries), across eight themes -
42 such case studies in all. In some countries, more than one case study has been commissioned.


The eight themes are:
    1. CCM Governance and Civil Society Participation
    2. Harmonization and Alignment
    3. CCM Secretariat Funding
    4. Conflict Of Interest
    5. Leadership and Partnership
    6. CCM-PR-LFA Communication
    7. PR and SR selection Processes
    8. Oversight Practices


This is the Case study of Cambodia CCM on Harmonization and Alignment




2.1 Purpose:
This CCM case study will look at how CCMs have facilitated or hindered efforts in harmonization and
alignment of donor resources and program streams which are of concern to both national
governments and GF donor partners. This case study will determine and examine what has worked,
what has not, and highlight lessons learned. This exercise will document lessons learnt regarding
harmonization and alignment of the CCM model with pre-existing structures. The case study will also
document how, in some cases, a new CCM model has become the national organizing body around
which the three diseases of HIV, TB, and malaria are being addressed. This can be used by the
Secretariat, country level stakeholders, and other development partners to improve design, monitoring
and implementation of Global fund.




Swasti –Health Resource Centre                                                                        5
Global Fund Case Study – Harmonization and Alignment, Cambodia                                                                  Draft 2

2.2        Methodology


Semi-structured guidelines were developed6 and used for one-to-one interviews and two focus group
discussions - one with the group of NGO sub recipients, and another one with a group of NGOs who
have been working within the sector for many years, but not part of GFATM funding. Review of
reports, minutes of CCC meetings, related documents, literature, guidelines and previous research on
similar subjects provided the background. The interview questions are in Annex A.


As part of drafting this report, preliminary findings were shared in a presentation to the Chair of the
CCC.


2.3        Sampling


There are currently 29 members of the CCC. Sampling was done through purposive selection. There
were over 21 respondents. 9 out 13 CCC-SC members were interviewed. This ensured that the most
active members were interviewed. Out of this, 16 members in addition to the Secretariat were
interviewed. Out of these 5 members were from the government including the Chair of the CCC, 4
members from NGOs who are sub-recipients, one PLWHA representative, 2 from multi lateral, and 2
from bilateral, one each from the academic and private sector. A group discussion comprising of
NGOs in the sector who are neither CCC members nor sub-recipients was conducted. The Chair, the
two Vice chairs, the PR, some of the SRs, person living with HIV, and the Secretariat were interviewed
among these. List and Schedule of persons interviewed are in Annex B.


The table below provides the details:

                                                       No in
    Constituency             Representative                              Respondents Mode of enquiry                 Remarks
                                                       CCM
                                                                                                 Individual
    Government               Government                11                5
                                                                                                 Interview
                                                                                                                     KHANA serves
                                                                                                                     as alternate for
                                                                                                                     RHAC and
    Civil society            NGO ( SR)                 4                 5                       FGD                 both
                                                                                                                     organizations
                                                                                                                     were
                                                                                                                     interviewed
                                                                                                 Individual
    Civil society            NGO non SR                1                 1
                                                                                                 Interview

6
    Draft developed by GFATM Geneva team, further discussed, elaborated and clarified in Kuala Lumpur in a meeting
Swasti –Health Resource Centre                                                                                                          6
Global Fund Case Study – Harmonization and Alignment, Cambodia                                  Draft 2

                                                                                     part of NGO
                    Person Living
 Civil society                           1            1           FGD                group
                    with disease
                                                                                     discussion
                                                                  Individual
 Civil society      Private Sector       1            1
                                                                  Interview
                                                                  Individual
 Civil society      Academic             2            1
                                                                  Interview
                                                                  Individual
 Donors             Multilateral         5            2
                                                                  Interview
                                                                  Individual
                    Bilateral            4            2
                                                                  Interview
                    NGO non SR
 Non CCM                                 -            4           FGD
                    non member
                                                                  Individual
                    Secretariat          -            4
                                                                  Interview
 TOTAL                                   29           26

Time Line


This case study was conducted between September 18th and October 12th, which included 7 field
days.


Some caveats:


    1. It has been a very rapid exercise wherein a number of respondents were met in the short
        period of 7 days, while attempting to document the practices of this CCM and what has worked
        for it and what has not. This report does not attempt to be a comparative study of different
        CCMs.
    2. The report consists of a combination of perceptions and facts. Through the interviews we have
        elicited several facts and different opinions and perceptions. We have attempted to find
        documentation and sufficient evidence of facts as best possible.
    3. There were no opportunities to observe the CCC in action during one of their meetings.
    4. Validation through multiple interviews has been a part of the process of the case studies
        however the report does not contain sources of perceptions or facts stated by respondents.




Swasti –Health Resource Centre                                                                       7
Global Fund Case Study – Harmonization and Alignment, Cambodia                                                                          Draft 2




3 Description of the situation


3.1       Cambodia Socio-political Context
After the brutality of the 1970s and the 1980s, and the destruction of the cultural, economic, social and
political life of Cambodia, it is only in recent years that reconstruction efforts have begun and some
political stability has finally returned to Cambodia. The stability established following the conflict was
shaken in 1997 during a coup d'état7 but has otherwise remained in place. Cambodia has been aided
by a number of more developed nations like Japan, France, Canada, Australia and the United States,
primarily economically. The nation's constitution (1993) is a framework for a parliamentary,
representative, democratic monarchy. The Prime Minister of Cambodia is the head of government,
and of a pluriform multi-party system, while the king is the head of state. The Prime Minister is
appointed by the King, on the advice and with the approval of the National Assembly; the Prime
Minister and his or her ministerial appointees exercise executive power in government. Legislative
power is vested in both the executive and the two chambers of parliament, the National Assembly of
Cambodia and the Senate. On October 14, 2004, King Norodom Sihamoni was selected by a special
nine-member throne council, part of a selection process that was quickly put in place after the surprise
abdication of King Norodom Sihanouk a week before. Sihamoni's selection was endorsed by Prime
Minister Hun Sen and National Assembly Speaker Prince Norodom Ranariddh (the new king's
brother), both members of the throne council. The monarchy is symbolic and does not exercise
political power.


Freedom of expression and association are included in the Constitution, and Cambodia enjoys an
ostensibly free media and press (both English and Khmer).


As observed during this case study and also through interviews, Cambodians largely follow Asian
traditions of respect for hierarchy and age; drawing comfort in the hierarchical nature of the public
sector systems.




7
    UN OHCHR Cambodia, http://cambodia.ohchr.org/Documents/Statements%20and%20Speeches/English/40.pdf. Last accessed 7th October 2007
Swasti –Health Resource Centre                                                                                                               8
Global Fund Case Study – Harmonization and Alignment, Cambodia                                                                  Draft 2



3.2       Health System


The Cambodian MoH adopted health district development as the official national policy and by 1996 a
health coverage plan had been designed that divided Cambodia’s 22 provinces into 69 operational
districts (ODs) of between 100,000 and 200,000 inhabitants. Each OD was equipped with one referral
hospital and a network of health centres each covering on average a population of 10,000 to 12,000
people. By 2003 considerable achievements had been made, e.g. 81% of the planned 940 health
centres had been reconstructed or newly built and essential equipment and essential drugs were
supplied in adequate quantities. However, serious problems, such as poorly motivated health staff,
low quality of care and poor access to health services remain. Due to the almost complete annihilation
of skilled Cambodian human resources during the Khmer Rouge period many foreign experts got
involved in the task of rebuilding the Cambodian nation, and foreigners continue to have a presence in
the Cambodian health system until today. This continues to pose a particular challenge for the MoH,
even though its role has been gradually strengthened over the years. The latest health sector strategic
plan 2003 – 2007, supported by the World Bank, ADB and DFID and endorsed by WHO, has again a
strong focus on institutional strengthening of the central MoH, using the sector-wide management
(SWiM) approach, the Cambodian version of a lower mechanism of donor coordination than a sector-
wide approach (SWAp). Most of the multilateral and bilateral support to the health system in
Cambodia goes to the central level of the MoH and to the vertical national programmes, particularly to
HIV/AIDS. The presence of foreign NGOs in Cambodia has always been strong, and, as civil society
in Cambodia is developing, the number of national NGOs is also growing rapidly, particularly in the
field of HIV/AIDS. Most of these NGOs are donor-funded.8




8
    The Early Steps of The Global Fund in Cambodia January 2002 – October 2003, Katharina Kober & Wim Van Damme ( Case Study)


Swasti –Health Resource Centre                                                                                                       9
Global Fund Case Study – Harmonization and Alignment, Cambodia                                                                                Draft 2



Given below is the complex web of donors and funds to the various factions of the health department.



                                        ADB                  CDC                     COM
           KfW          DFID                                                                    CAR
                                              WB                       MOP
    GTZ                          HSSP
              AusAid
                                                             GDCC
                                                              GDCC
           CDC          FC/AFD
                                                UNDP
                                     UNFPA                                                   MEF
    JICA          USAID                                 TWG-
                                                         TWG-           AOP
                            UNICEF
                                              WFP        F/N
                                                          F/N           (3y-rp)
           BTC
                                        WHO                                            MTEF
     EC
                             HPM
                              HPM                    TWG-H
                                                      TWG-H            MOH
                  RACHA                     UNAIDS


                          MEDiCAM                       TWG-
             SRC                            CCM          TWG-
    CHAI                                     CCM         H/A         JAPR-NHC
                                                          H/A
                                    KHANA
                          RHAC                 GFATM
       URC         HU
                                 HNI
                                              GAVI                                NSDP
                          MSF
           CARE
                                                       HSP
                                HMN


Source: Health Sector Review (2003-07)


Health financing
The financing of the health system poses some particular challenges in Cambodia. From the
Cambodian Medium Term Expenditure Review: in 2001 public spending on health was US8.3$ per
capita, of which 33 % came from the government, 67% from external sources. Private out-of-pocket
expenditure is thought to amount to more than 75% (almost US$15 per capita) of total spending on
health. External resources make up the remainder, circa 12% of total health expenditure. This
enormous share of out-of-pocket expenditure is mainly spent in the burgeoning and almost completely
unregulated private-for-profit sector, and frequently translates into catastrophic health expenditure,
often causing people to take up debts, sell productive assets and leading them into poverty.9 The
Cambodian public health system is thus seriously under-funded and additional financial resources –
such as those forthcoming from the Global Fund – are necessary to improve access to essential
services for the poor.




9
  A survey by Oxfam found that 46% of people who had recently lost their land did so as a result of debts related to health expenditures, see Biddulph
R, Landlessness and development research report: Cambodia Land Study Project. Sept 2000, Oxfam, Oxford 2000.

Swasti –Health Resource Centre                                                                                                                     10
Global Fund Case Study – Harmonization and Alignment, Cambodia                                       Draft 2

Health status in Cambodia continues to be poor relative to other Asian countries in the region. A
maternal mortality ratio of 473 per 100.000 life births, an infant mortality rate of 95 per 1000 life births
and an under–five mortality rate of 125 per 1000 life births are among the worst in the region. Ten
infectious rather than chronic diseases still constitute the major health issue in Cambodia, even
though the latter are on the rise.


3.2.1      HIV/AIDS


The first case of HIV infection was detected in Cambodia through the screening of voluntary blood
donors in 1991. In 1993 the first cases of AIDS were diagnosed. In 1997 the HIV prevalence rate
among adults was at 3.2 % but has since then decreased to 2.8 % in the year 2000.10 This has further
decreased to adult prevalence of 1.9% in 2005.11 In particular, the HIV prevalence among sex workers
has dropped from 42% in 1998 to 29% in 2002, and further declined to 26.3% in 2005. This decline in
prevalence is attributed to both the effect of preventive interventions, including a 100 % condom use
programme, and a rising mortality of people with AIDS. Still, with an adult prevalence rate of 2.8%
Cambodia remains the country with the highest HIV prevalence in the Asia-Pacific region. The
national response to HIV/AIDS is less streamlined than for TB and malaria. The National Centre for
HIV/AIDS, Dermatology and STD (NCHADS) was established in 1998 within the MoH. It has some 50
staff and is responsible for overseeing and implementing the MoH’s response to the HIV/AIDS
epidemic. The National AIDS Programme is implemented nationwide through Provincial AIDS Offices.
In 1999 the National AIDS Authority (NAA) was created to coordinate the intersectoral response to
AIDS. Its policy board consists of the secretaries of state from a total of 12 ministries. At provincial
level Provincial AIDS Secretariats have been established and District AIDS Secretariats are planned.
Apart from these two national bodies there is a multitude of other actors within the area of HIV/AIDS in
Cambodia. The member agencies of the UN Theme Group on HIV/AIDS have a variety of projects
and between them are providing substantial financial and technical assistance to NCHADS and NAA,
to various Cambodian ministries and NGOs.


In addition to this, there is a Technical Working group on HIV comprised of ministries, and
development partners including some NGO networks and all the major actors in the HIV sector. Most
of these members are also members of the CCC. This facilitates the alignment in policy thought and
political will.




10
     UNAIDS 2001
11
     UNAIDS 2006
Swasti –Health Resource Centre                                                                            11
Global Fund Case Study – Harmonization and Alignment, Cambodia                                   Draft 2

The major bilateral donor agencies involved in the Cambodian response to HIV/AIDS are DFID and
USAID, the former mainly working with the Cambodian government, the latter through funding of
NGOs. Besides these bilateral and multilateral agencies, there are nationwide more than 110 NGOs
working in the field of HIV/AIDS.


3.2.2   Tuberculosis


Cambodia is one of the 22 high burden countries (HBC) and has the highest estimated incidence and
notification rate in the Western Pacific Region. WHO estimates that 64% of the total population is
infected with TB bacilli (WHO estimation 1997). The WHO Global Tuberculosis Control Report 2007
provides the following estimates for the year 2005:
•   Prevalence of all forms: 703/100,000
•   Estimated incidence of smear positive cases: 226/100,000
•   TB mortality rate: 87/100,000.


Preliminary data for the year 2006 shows that the National TB Program (NTP) reports 34,660 new TB
cases (all forms) of which 19,985 were new smear positive pulmonary TB cases (new SS+). This
corresponds to case notification rate of 145/100,000 new SS+ and a case detection rate of 65%.


According to the projected annual change in incidence, as published in the Joint Program Review
Report (September 2006) the decline in incidence was estimated to be one percent in 2005-2006.
However, as a result of an increasing detection rate and high treatment success rate, the annual
decline in incidence is expected to reach 5.4% in 2012. The National TB Programme is implemented
by the National Center for Tuberculosis and Leprosy Control (CENAT) in Phnom Penh with around 20
health professionals. The management capacity of the CENAT is considered as being quite strong
and it has been receiving considerable support from JICA who started a five-year technical
cooperation project in 1999.


3.2.3   Malaria


Malaria is an endemic public health problem mainly in the mountainous and forested regions of
Cambodia, above all along the border areas with Laos, Thailand and Vietnam. About 5% of the
population, most of them ethnic minorities, temporary migrants and plantation workers, live in areas of
high malaria transmission. The majority (88%) of cases are due to infections with P. falciparum. The
P. falciparum strains in Cambodia are among the world’s most multi-drug resistant. The National
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Malaria Programme is implemented by the National Malaria Center (CNM). The CNM possesses good
management capacity and has been receiving technical assistance over several years from the EC
and WHO. Major projects currently implemented include partnership with WHO, World Bank,
European Commission, USAID, JICA, IFRC and a host of national and international NGOs in addition
to Ministry of Health, Ministry of Defence, Ministry of Education, etc.




3.3       Global Fund Grant History


Cambodia has so far been successful in Round 1, 2, 4, 5 and 6. The total amount approved for all
three diseases under Round 1 was USD$ 15,714,629 million over a period of 5 years. Round 2 was
approved for a total of USD$ 30,665,703 million over 5 years for the three diseases. USD 46,404,025
million over 5 years was approved in Round 4 for HIV/AIDS and malaria components only, and Round
5 was approved for tuberculosis, HIV/AIDS and Health systems strengthening for a total of USD
49,641,419 over 5 years. In Round 6 only malaria component was approved for a total of USD 31,
113,760 million for 5 years.


           Rounds      Principal Recipient                        Total Funding          Approved Maximum       Approved        Approved        Total Funds
                                                                  Request                                       Funding Phase 1 Funding Phase 2 Disbursed:

HIV/AIDS
           Round 1 :   The Ministry of Health of the Government         $15,714,629.00         $15,714,629.00     $11,242,538.00    $4,472,091.00   $15,432,557.00
                       of the Kingdom of Cambodia

           Round 2 :   The Ministry of Health of the Government         $14,765,625.00         $14,765,625.00      $5,370,564.00    $9,395,061.00   $12,011,098.00
                       of Cambodia
           Round 4 :   The Ministry of Health of the Government         $36,546,134.00         $36,546,134.00      $8,794,982.00   $27,751,152.00   $10,433,846.00
                       of Cambodia
           Round 5 :   The Ministry of Health of the Government         $34,963,654.00         $16,292,779.00     $16,292,779.00                    $12,117,659.00
                       of Cambodia
Total :                                                                $101,990,042.00         $83,319,167.00     $41,700,863.00   $41,618,304.00   $49,995,160.00
HSS
           Round 5 :   The Ministry of Health of the Government          $5,015,741.00          $1,841,600.00      $1,841,600.00                     $1,111,836.00
                       of Cambodia
Total :                                                                  $5,015,741.00          $1,841,600.00      $1,841,600.00                     $1,111,836.00
Malaria
           Round 2 :   The Ministry of Health of the Government          $9,730,345.00          $9,730,345.00      $5,013,262.00    $4,717,083.00    $9,059,281.00
                       of Cambodia
           Round 4 :   The Ministry of Health of the Government          $9,857,891.00          $9,857,891.00      $5,221,242.00    $4,636,649.00    $5,516,065.00
                       of Cambodia
           Round 6 :   Principal Recipient information will             $31,113,760.00         $13,105,132.00     $13,105,132.00
                       become available upon Grant Signature
Total :                                                                 $50,701,996.00         $32,693,368.00     $23,339,636.00    $9,353,732.00   $14,575,346.00
TB
           Round 2 :   The Ministry of Health of the Government          $6,169,733.00          $6,169,733.00      $2,505,255.00    $3,664,478.00    $5,211,558.00
                       of Cambodia
           Round 5 :   The Ministry of Health of the Government          $9,662,024.00          $3,268,750.00      $3,268,750.00                     $2,497,164.00
                       of Cambodia
Total :                                                                 $15,831,757.00          $9,438,483.00      $5,774,005.00    $3,664,478.00    $7,708,722.00
Total                                                                     $173,539,536          $127,292,618        $72,656,104      $54,636,514      $73,391,064




In all, Cambodia has approached the GFATM in 6 rounds, of which it has been successful in 5 rounds.

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Globally and particularly in this region, Cambodia is known for its successful HIV and AIDS
Programme (a special mention was made in the recent International Conference of AIDS in Colombo
during the plenary speeches) and its successes with GFATM programmes. The TB and Malaria
control programmes are also known to be successful.


3.4   Cambodia Country Coordinating Mechanism


The Country Coordination Mechanism (CCM) in Cambodia is expected to function as a “national
consensus group” that coordinates proposal submission and as a supreme decision-making body for
projects funded through the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). The CCM
is expected to facilitate the proposal development process, including the translation of national
strategies into concrete implementation plans with clear responsibilities; plan the timing of activities,
budgets and expected outcomes; approve and endorse the final version of a single Country
Coordinated Proposal; play a major role in overseeing and following-up on the implementation of
proposed activities.


The CCM in Cambodia is known as the Country Coordinating Committee (CCC). In addition, various
entities and groups participate in GFATM activities, including the Ministry of Health as Principal
Recipient, three Technical Review Panels – one per disease, a Country Coordinating Committee Sub-
Committee (CCCSC), various Sub-Recipients and Sub-sub-recipients.


The CCC in Cambodia was established in February 2002 in order to coordinate and facilitate the
whole process of the GFATM in-country. As the membership of the CCC is very broad and consists of
high-level representatives of different organisations, the CCC Sub-committee was formed in
September 2002 to facilitate all administrative work of the CCC, to liaise with all partners, to
coordinate the assessment of new proposals, to keep the CCC fully informed of progress, to prepare
CCC meetings and document the whole process.


There are currently 29 members and corresponding alternates of an equal number. The
constituencies represented are Government, UN agencies, Multi and bilateral organizations, NGOs,
civil society and private sector, and academic and scientific society. For purposes of simplifying, the
constituencies have now been grouped as Government, Development partners and Donor agencies,
and civil society. Civil Society consists of NGOs, private sector, academic/scientific community,
persons living with disease and other civil society bodies. The graph below illustrates the distribution
of the members across the different constituencies.
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                          Distribution of Members across constituency



     Civil Society, 9,
           31%                                                  Government,
                                                                  11, 38%



                                                                                        Government

                                                                                        Multilaterals/bilaterals
            Multilaterals/bila
             terals, 9, 31%                                                             Civil Society




CCC structure
Governance of the CCC has been along the guidelines of the CCM developed by the Global Fund.
The other structures within the CCC include the CCC Sub Committee, the Principal Recipient (PR),
Principal Recipient Technical Review teams (PRTRT), the Sub-recipient and the Local Fund Agents
(LFA).


          CCC
          In each of the constituency, there is a Constituency Coordinator that will be named by the CCC
          who will manage the process of nomination, selection and replacement of constituency
          members. Membership of the CCC is reassessed every two years. The system of alternates12
          ensures adequate representation and quorum. There is a system of tracking and implementing
          attendance of the CCC members. If a particular candidate is absent for 2 out of 4 meetings,
          s/he is sent a letter of warning by the Secretariat and then subject to dismissal of the
          participant unless two-thirds of members present vote to retain the institution. A new
          representative of the same constituency is then nominated to serve out the term.13 The CCC
          acts as the decision making body within Cambodia for all matters regarding Global Fund. This
          is a consensus building, decision making group that represents all the relevant stakeholders in


12
   Each member can nominate one person on his/her behalf to attend the meetings. As most of the CCC members are very busy people this system is found
to be very useful
13
   This is an extract from CCC membership Procedure of Election and Succession Draft 4 Dec 06, rev 4 Jan, 22 Feb 07.
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        the sectors of AIDS, TB and Malaria. Main roles include proposal development and oversight
        of GL grants


        CCC Sub – committee (CCCSC)
        Since the CCC in Cambodia is large and unwieldy, a sub committee has been constituted
        which is the working group within the CCC. The CCC-SC was established in 2002 to act as a
        Secretariat. CCCSC acts like an executive board of the CCC, functioning like a technical
        working group consisting of the most active and important members of the CCC. The CCC-SC
        is responsible for acting as a secretariat to essentially distil information received to facilitate
        decision making of the entire CCC, and to forward received proposals to the appropriate TRPs.
        It also reviews TRP’s recommendations to accept or reject proposals, work closely with the PR
        in its communications to the CCC, review the performance of the PR, oversight of all Global
        fund activities etc. Currently the CCCSC has 13 members.


        Principal Recipient (PR)
        The PR is the legally accountable body of the country that signs the Program Grant
        agreements with Global Fund and the MoA with SRs of the country. PR is responsible for day
        to day grant implementation of the program. In Cambodia, the PR is the Ministry of Health,
        Department of Communicable Disease Control.


        Principal Recipient Technical Review Team (PR-TRT)
        There are three PR-TRTs, one for each disease. Their role is to report to the PR on their
        review of relevant program plans and reports. Membership of the PR-TRTs include national
        programs, some civil society etc. Memberships of PR-TRTs have been brought in line with the
        existing sub TWGHs.


        Sub Recipients
        These are the actual grant implementers of the program. They can be the national disease
        control program or they can be civil society representatives that implement program on the
        ground. Sub recipients in Cambodia include national and international NGOs, the three
        national programs and ministries. SRs are required to report every six months and annually to
        the PR on financial matters as well as on progress made towards achieving agreed program
        results. SRs also need to provide a yearly financial and procurement audit report.




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        Local Fund Agent
        LFA’s function is to oversee, verify and report on PR performance, progress in program
        implementation and make recommendations for further funding. LFA functions as the ‘eyes
        and ears’ of the Global Fund, in-country. They have to provide independent, evidence based
        recommendations to the Global Fund at the country level. In Cambodia, the LFA is KPMG.




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Given below is the management structure of the CCC:



                                                     New Proposals
            GFATM
                                                                                         CCC


        Project
      Management                  PR ( MoH)                                              CCCSC




       PRTRT HIV/AIDS             PRTRT TB           PRTRT Malaria
                                                                               NPTRP     NPTRP   NPTRP
                                                                              HIV/AIDS    TB     Malaria


The Process of election of the members is as follows:


There are three main constituencies comprising the Cambodia Country Coordinating Committee:
     1. Government (11 members, including from the HIV, TB, and Malaria National Programs)
     2. Bilateral, multilateral, and UN agencies (9 members)
     3. NGOs, civil society, academia, private sector, and PLWAs (9 members)


In each case, a Constituency Coordinator14 will be named by the CCC, only for the purpose of
managing the process of nomination, selection, and replacement of Constituency members. The
Constituency Coordinator will have no power or authority beyond that of other members.


•       Membership of the CCC is reassessed, and members elected or re-elected, every two years.
        Inaction on the part of the CCC will result in continuation of existing membership.


Election and re-election of members


•       Once every two years, the election is declared by the Chair.
•       In the weeks before the next meeting, each of the three constituencies will determine their
        proposed list of candidates for the next term of office, and will present this list to the Secretariat, at
        least two days before the next CCC meeting.


14
     In December 2006, these are (1) Ministry of Health, (2) WHO, and (3) MEDiCAM
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•       At the next meeting, each constituency’s slate of candidates will be presented by the Constituency
        Coordinator (proposed new members will not be at that meeting, as they will not take their seats
        until the following meeting). The slate of candidates must be endorsed by a majority of the CCC.


The constituencies may use their own procedures to ensure a transparent and inclusive process and
to nominate candidates, but should be guided by the following:


•       Access to proposed membership should be made widely available to those who might be
        interested, in a transparent and inclusive manner.
•       Procedures for proposing and nominating members should be described in writing and made
        available to the CCC membership as a whole.
•       The “mix” of members from any constituency should fairly reflect the diversity of stakeholders in
        that constituency.
•       The points above apply especially to the two non-Government constituencies, whereas
        Government, being a single entity, may use a more direct nomination process while still seeking a
        representative cross-section of stakeholders in Government.




Election of the Chair and Vice Chair
At the CCC meeting following the one at which 2-year new or renewal membership is confirmed, the
first agenda item will be nomination of a new Chair and Vice-Chair. Any member of the CCC may
nominate candidates (at least two must be proposed). A secret ballot will be used in which each
member cast one vote. The person securing maximum votes becomes the Chair, and the second
highest swill be Vice-Chair (in case of a tie, there will be a re-vote). The Chair and Vice-Chair cannot
come from the same constituency. The new Chair and Vice-Chair will take office immediately following
the vote.15


CCC Meetings
There are four mandatory meetings every quarter; sometime ad hoc meetings are held in case of
emergencies. These are regularly attended, with an attendance average of 20 out of 29 (69 %).


Awareness of CCC roles and responsibilities.


15
     Taken from CCC Membership Procedures for Election and Succession, Draft 4 Dec 06, rev 4 Jan, 22 Feb 07



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The CCC members were mostly aware of their roles and responsibilities. They were also in tune with
the national programs and priorities. Most of them have been inducted, especially those who were
members from the very beginning. A couple of members were not formally inducted although they
were given the Terms of Reference of the CCC members. They were all aware of the functions of the
CCC as well as the roles and responsibility each member had toward as a member of the CCC.




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4 Lessons from CCM-Cambodia


CCC members of Cambodia feel that their CCC works and is "as good as it can get".                  While
recognising that there is always scope for improvement, they view it as being successful – the five
rounds of successful proposals, the animated and engaged CCC that they have built and maintained
and overall level of engagement and value derived from GFATM funding are the signs they recognise
as the success of the CCC.


The key aspects of the learnings from the Cambodian experience of CCC are captured below. They
are analysed in terms of:


    •   Harmonization of programs among the different players and donors
    •   Alignment of global fund program with national program and plans




Harmonization between the national programs
Cambodia had set up a Technical Working Groups for key development activities such as health,
education, etc. The TWG on health (TWG- H) further has working groups for specific diseases such
as HIV and AIDS. This group consists of national program players, donor partners as well as some
representatives of civil society. The TWG-H is a strategic group and focuses on the broader health
sector initiatives, including health systems while the working group focuses specifically on the specific
disease profile, within the broader remit of the health sector.


The individual disease programs such as HIV and AIDS, TB and Malaria largely operate as vertical
programmes. The only institutional mechanism that brings harmonization is the TWG-Health and the
fact that the Managers of the Programmes report into specific Secretariats, which then co-ordinate.


The TWG-H working group on HIV and AIDS is largely consisting of the same members who are in
the CCC. While CCC is mandated by the Global Fund, the working group on HIV/AIDS is mandated
with co-ordination of the various stakeholders. This is not seen as a problem as the CCC is seen
more as a mechanism for the GFATM and the working group for broader sectoral issues.



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Between the disease control programs, there is minimal harmonisation and co-ordination, except in
the case of HIV and AIDS and TB where there is operational harmonization between the diseases is
the linking of HIV and TB laboratories.         The institutional mechanisms are often isolated due to
boundary issues and the hierarchical structure and context within each program sets forth very broad
priorities under which the strategic focus and priorities are designed.


Harmonization between stakeholders

Tuberculosis and Malaria programs carefully utilized its existing and well established mechanisms for
cross sectoral response. Interagency coordinating committee of TB and Roll Back Malaria committee
are existing mechanisms that brought donors, government and civil society together for decision
making and planning. The coordination of the HIV/AIDS sector is being attempted through the setting
up of the National AIDS Authority (NAA) which brings together inter-ministerial co-ordination and
action on HIV and AIDS.           The NCHADS is responsible for implementation of the HIV/AIDS
Programme in the country. The TWG HIV is a body hosted by NAA to bring all the stakeholders
together for policy development and decision making.


The strength of GFATM is the opportunity it provides for CCMs to develop integrated responses to
HIV/AIDS, TB and Malaria. This includes integrated approaches to disease management and control
and universal access. The Global Fund also has tremendous potential to provide impetus to building
and strengthening health systems and health infrastructure. Ideas such as the Cambodian Equity
Fund that addressed coordinated responses to AIDS, TB and Malaria by strengthening of health
system by offering a comprehensive package of services for AIDS, TB and Malaria in certain referral
hospitals were apparently not accepted for GF support, which is seen as a set back for efforts on
harmonisation.



Harmonization with other donors in the sector

Most of the major donors except GTZ are a part of the CCC. The TWG Health includes all donors in
the health sector, the TWG HIV include all major stakeholders of HIV program. Most of the
representatives of these two groups provide the Health sector support program which follows the
SWiM Approach. JICA, EC, World Bank, UNAIDS, DFID, USAID, and French Embassy, WHO,
UNICEF etc are all a part of the CCC. The SWiM for the Cambodian Health Sector is an approach,
under the leadership of the Ministry of Health (MOH), for all stakeholders (including NGOs and other
health related private sector, donor-lending agencies as well as MOH staff and others to work together

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within a (i) common strategic framework for 2003-2007; and (ii) mutually reached management
agreement without establishing a mandatory pooled fund and/or completely adopting common project
implementation arrangements. Subsequently, the success of SwiM may create an enabling
environment for proceeding to a full SWAp.


In the case of the health sector-wide management (SWiM) program, the discussions with development
partners began in 1999 and a Joint Health Sector Review was held in December 2000. A Health
Sector Strategy (HSP) and a Health Sector Support Program (HSSP) for 2003-2007 were
subsequently prepared. The implementation of the 5-year HSSP began in January 2003. It has
enabled AsDB, DFID, UNFPA and the World Bank, to coordinate their financial inputs to the health
sector.


All spending unit requests for HSSP fund (AsDB, DFID, UNFPA & WB) are channelled to the HSSP
Secretariat through their own 1st Health Sector Operational Plan (AOP 2005) plan process. Joint
annual health sector performance reviews were undertaken in 2003 and 2004. The majority of donor
assistance to the health sector under the SWiM arrangement is being provided in the form of project-
type support.


As compared to the SWAp in the education sector, the SWiM approach in the case of the health
sector has not so far produced a significant reduction in the administrative burden on the Government
from coordinating with each donor bilaterally.


All donors have agreed to support the government’s decision to merge into one government-led and
government-owned exercise the MDG/SEDP-II (Socio Economic Development Plan)/NPRS (National
Poverty Reduction Strategy) in the planning process for 2006-2010. Major donors produced joint
operational procedures, and a joint financial management manual designed to train local government
staff managing development assistance. AsDB, DFID, UN and the World Bank have collaborated
extensively in the preparation of new assistance strategies. The UN system in Cambodia has agreed
to use the NPRS as the basis for its country-level planning rather than produce its own UN Common
Country Assessment (CCA).

In October 2003, the Prime Minister approved a proposal to restructure the working groups under the
CG mechanism. Seventeen Technical Working Groups (TWGs) will be formed as follows: (1)
Education, (2) Health, (3) HIV/AIDs, (4) Food security and nutrition, (5) Agriculture and water
resources, (6) Land Management, (7) Forestry, (8) Fisheries, (9) Legal and judicial reform, (10) Public

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Global Fund Case Study – Harmonization and Alignment, Cambodia                                   Draft 2

administration reform, (11) Public financial management, (12) Local governance, (13) Private sector
development, (14) Infrastructure and regional integration, (15) Peace and security and demining, (16)
Gender equality, and (17) the PWG will remain. In addition, a Government-Donor Coordination
Committee (GDCC) ensures coordination among the 17 technical groups. All TWGs will be co-chaired
jointly by government and donors16.



Alignment with country plans

The Ministry of Health has developed a National Health Sector Strategic Plan 2003 to 2007. During
the review of GFATM rounds 1, 2 and 4 it was proved that the objectives of all the approved rounds of
Global Fund programs were consistent with the HSP (2003-2007). Some of the stakeholders had
pointed out that the project approach of GFATM conflicted with the Sector Wide Management
approach advocated by the HSP 2003-7. Some of the partners claimed that development of proposals
for the various rounds may be linked to the overall strategies but have limited alignment with Annual
Operational Plans and three year rolling plans for the health sector as a whole. But on closer look at
relevant documents, this perception seems unfounded.


Alignment with National programs, priorities and strategies
All three national disease programs have country plans. As a precursor to inviting and preparing the
proposal, the priorities were selected such that they were aligned to the national program. The
process included not just the government representatives but also the civil society and development
partners, all those who have a stake in the development of the country. Strategies and priorities are
outlined in the national plan, which is shared among all the stakeholders. With this, the invitation to
submit a global fund proposal was sent out. When the CCP was developed, all the plans, strategies
and approaches were according to country plans, priorities and strategies.


The CCM utilized a participatory approach to solicit submissions and to enable stakeholders to have a
voice in the priority identification and the response process.


HIV/AIDS
The National AIDS Program is the country program for Cambodia. There are two bodies in Cambodia
representing the fight against AIDS. National AIDS Authority (NAA) is the policy making, multi sectoral
body whereas the National Center for HIV/AIDS, Dermatology and STDs (NCHADS) is the
implementing body of the program. The National AIDS program has currently a National Strategic

16
     www.aidharmonization.org Last Accessed October 15th 2007.
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Plan ( NSP) for HIV/AIDS and STI Prevention and Care, Ministry of Health, Cambodia: 2004-2007 and
is currently finalizing the next plan. This plan incorporates support from NGOs and incorporates all
sources of funding; however this is not a common plan, but a plan for NCHADS.


Work plans are made at a provincial level. There are Letters of agreement that are shared across
donors to avoid duplication, replication and promote cost efficiency and effectiveness of the entire
program. As part of the National plan, there are Letters of Agreement between provinces,
development partners and implementing partners. The plan is shared openly and easily accessible to
all on the NCHADS website. The priorities and strategies were guided by consultative processes
through the TWG-HIV, TWG-Health, and the Government-Donor Joint WG .

Tuberculosis
The National Tuberculosis Program is implementing its first five year strategic plan. The second five-
year plan is wok in process. Global Fund grant is a gap filler. Where strategies or activities are
unfunded or under funded, global fund grants are requested to fill the needs. Cambodia’s NTP
operates under the responsibility of the National Center for Tuberculosis and Leprosy Control
(CENAT) and within the overall national health system. National Inter Agency Coordination Committee
(NICC) for TB control is a coordinating body that acts as advisory for making National TB policy,
strategic plan. NICC includes and involves all major stakeholders in the different working groups. ICC
is the common mechanism for all the donor funded program as well as national program and this
allows for effective alignment along the national program. The National TRP for the new proposals in
TB consists of the same individuals who serve on the different committee and represent different
constituencies.

Malaria
National Malaria Program is run by the National Centre for Malaria. The overall goal of the malaria
control program is to improve the health status of the people in Kingdom of Cambodia by contributing
to the reduction of malaria morbidity & mortality. In 2005 the NMCP developed its National Strategic
Plan for 2006-2010. The overall aim of the NMCP is ‘to reduce malaria related mortality by 50% and
morbidity by 30%, among the general population in the Kingdom of Cambodia by 2010 through the
implementation of a comprehensive national malaria control strategy’. Four key objectives are
described: improved access to early diagnosis and appropriate treatment; improved access to
effective prevention; increased community awareness; and strengthened national capacity to control
malaria effectively. Global Fund funding has allowed CNM to scale up malaria health education and
distribution and re impregnation of bed nets. Malaria component is included in Round 2 and Round 4


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of the GF proposals. The global fund program is well aligned with the priorities and focus areas of the
National Malaria Program.


Awareness of the CCC of the country plans
All the respondents claimed to have a full understanding and knowledge of the national program
plans. All the program divisions have shared their plans on their website, which is accessible to all.
The donor group certainly is fully aware of the plans and priorities. The Civil society representatives
also seemed to be fully aware of the national program plans and priorities.


Harmonization with country led processes and country led systems

The global fund strives to utilise existing systems in-country for procurement, finance , M&E etc.
Cambodia does have its own system of M&E, procurement and finance. Procurement is done through
the national program, and Cambodia has a strong national system which was spearheaded by WB
and AsDB. The Global Funds’ systems of M&E, finance and procurement is seen to be a parallel
system and being maintained as it is a requirement for GFATM. Most stakeholders feel that this at the
insistence of the GFATM has lead to these parallel systems, which then disregards the use of the
country’s’ own system.


The outcome indicators are common across all programs, however the process indicators for the
Global Fund program are distinct and owned by GFATM. The TB program M&E is run by the MoH, but
other donors run their parallel systems. The CCC is supposed to oversee whether the M&E system of
Global Fund is aligned with the national program.



Mutual Accountability

Within GFATM, accountability seems to be largely donor driven. The SRs report upward to the PR,
who then shares the summary of the findings to the CCC. The PR seldom shares program
performance reports with the CCC; shares only key progress. There was a joint review held in
December 2006. This review was conducted for the national program as a whole and was not looking
specifically at Global fund program. Review of the national program is annual. This was the first time a
multi stakeholder approach was used to valuate the program.


At a policy level, the management mechanism of mutual accountability was developed in a group
including government representatives and civil society as well as donor partners. At an
implementation level, there is co-management of the program, and reports are supposed to be shared
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across all the stakeholders. Some respondents claim that this never happens, whereas some other
claim that reports are always shared.


Duplicity

The various rounds of the global fund often clashes with Government planning cycles and other donor
schedules for funding. There have been instances of duplicity of efforts but these have not been of a
very major level. At an operational level, particularly for HIV and AIDS sector, there are duplicity and
co-ordination problems seen – particularly at the activity level and also geographically at the provincial
level.    Sometimes Sub recipients’ activities are not known to the national programme.              Most
stakeholders feel there is adequate scope for improvement of harmonisation and co-ordination at this
level.


Conclusion:
Cambodia, despite its many challenges, has made substantial strides in achieving harmony and
alignment and is an example for other countries. Efforts towards Harmonization and Alignment is at
multiple levels and robust. Approaches such as a broadly owned, Health Sector Strategy and Sector
Wide Program (SWiM) set the agenda and harmonisation frameworks. Within this, specifically there
are additional initiatives and mechanisms to improve the harmonisation and co-ordination:
    •    A multi sectoral and broadly owned and costed plans for each of the three diseases, which are
         regularly updated and aligned with broader Health Sector Strategy.
    •    The GFATM proposal priorities which are drawn down from the national programme priorities;
         which ensures complete alignment of the GFATM round funding to the larger national
         programme.
    •    Existing and functional mechanisms which are at very high Government level, which are also
         multi sectoral – such as the TWGs, NAA, etc, which bring together stakeholders for broader
         sector co-ordination and also for specific diseases profiles.
    •    Multi sectoral committees and steering mechanisms for all the three disease profiles, which
         exists and are functional and which is much broader then the GFATM co-ordination
         mechanisms.
    •    Joint and sometimes independent reviews which provide information and platform for
         accountability across stakeholders.




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There are some broader facilitatory factors which push for the harmonisation and co-ordination:
    •    That the national health programme is largely dependent on external funding and therefore is
         open to ideas and as well as needs to co-ordinate with various stakeholders to achieve
         optimum funding through SWiM mechanisms.
    •    A broader culture of working together of Government, NGOs and donors, through a variety of
         forums and platforms.
    •    Existence of the large civil society networks such as RHAC, KHANA and HACC which support
         such harmonisation and co-ordination among civil society and who also feed into broader
         processes for GFATM.


There is still scope for improvement in all of the above. Some ways forward are laid out in the
recommendations.


Recommendations:
While there are robust mechanisms for achieving harmonisation and alignment, based on the above
analysis, the following are recommended:
    f)   Operational co-ordination, particularly activities at provincial level between the three diseases
         as well as between the GFATM rounds is necessary and possible. There is a need to plot the
         duplicities and possible areas for alignment and implement specific set of proposals.
    g) GFATM recommended systems on M&E, finance and procurement create parallel processes
         within the country. There is need to review the benefits and problems of such global systems
         and whether they are actually beneficial and contributing to the key principle of country
         ownership and if they are not, what benefits it accrues.
    h) The ‘Rounds’ approach of GFATM is highly disruptive of processes within the Country.
         Instead a more regular and yearly process will help countries to co-ordinate their funding
         cycles with that of GFATM.
    i)   There is a need to set up monitoring mechanisms across all rounds, which are likely to provide
         evidence and opportunities for better co-ordination.
    j)   There is a need to review the constitution and effectiveness of the multiple institutional
         mechanisms which exists and see what improvements are possible.




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Annex A: Interview checklist

         Case Study Area: CCM Governance and Civil Society Participation
                                          Interview Check list

         Issues for Investigation            Lead Questions
    1        Description of the CCM and      Profile of the Membership (org.type represented, number etc)
             Governance structures and
                      Principles
                                             What is the Selection Process of CCM members?
                                             How Frequently the meeting take place and what is the
                                             participation levels (in terms of numbers)
                                             What is the process of leadership selection?
                                             Decision making process
                                             Do you think that the leadership and the members of CCM
                                             fully understand their roles and responsibility? If yes/no - Why
                                             do you think so?
                                             During the process of the meetings, do you think that due
                                             respect is shown to each other while involving in deliberations
                                             and discussions
                                             Do you think that the decision making process is transparent
                                             and not taking unilateraly (strong public sector bias)

                                             Understanding of the Members on the vision and purpose of
                                             the CCM
    2          Existence and Clarity of      Does the CCM have governance tools eg. Constitution, TORs,
                 Governance Tools            SOPs, By-law, Rules of Procedures, operational Manual etc?
                                             If yes please provide a list of these
                                             Were the governance tools approved by the CCM, how
                                             detailed are they for effective governance? How were these
                                             instruments developed, what were the processes involved in
                                             developing (were they involved?)
    3        Members Knowledge on the        Are CCM Members Familiar with the governance tools
                Governance Tools
                                             Do all members have copies of the governance tools
                                             Was an orientation done to the CCM on the tools? If not how
                                             are these communicated to the members
                                             Is there any system to communicate on the tools to the new
                                             members who come in
    4      Usage/application/compliance to   Does CCM follow its laid down governance instruments in its
               the governance tools          day to day operations
                                             To what extent are the tools used for resolving problems,
                                             issues or challenges within the CCM? Please give specific
                                             situations where these were applied or used as reference for
                                             resolving issues?
    5       Documentation of CSO roles       What are the strengths and weakness of the civil society
                                             participation on the CCM in terms of its overall governance

                                             What are the activities that civil society is involved in within GF
                                             grants in the country
    6             Information Flow           Do you get regular update on the key decisions and directions
                                             from the GFATM Secretariat
                                             How is this information passed on to the CSOs - channels of
                                             Communication?
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    7         Knowledge of Process and           What according to you are strengths and weakness of the
          Procedures and Participation level -   GFATM fund process and procedures - especially in the
              knowledge of roles in grant        context of CSO participation
                      oversight                  Do you think that in the process of decision making CCM
                                                 adheres to the constitution, by-laws or TOR of CCM (other
                                                 governance tools). What are the key challenges in this? Any
                                                 instance where it had gone against the rules and procedures -
                                                 any reason
                                                 what are the key challenges of decision making process in
                                                 CCM? How transparent is the process? Explain your response
                                                 with examples
                                                 What is the level of participation of CCM members in general
                                                 and CSO reps in particular in the deliberations and decision
                                                 making process
                                                 What are the three critical role of CCM members in fund
                                                 management in the country? And how well they are executed

                                             how is the flow of information on grant performance from PRs
                                             and LFA which would help in performing their grant oversight
                                             role
                                             Do they know and are clear about the guidelines for CSO
                                             participation
    8     Level of Representation and Voice How many seats does the Civil society have in the CCM
                                             What is the quality of the CSO representation
                                             To what extent do decisions taken by CCM represent or take
                                             care of civil society interests?
                                             Is there regular communication between civil society CCM
                                             representatives and their constituencies? What is the
                                             mechanism of communication
                                             Are CSO representatives recognized as equal and key
                                             members fo the CCM
                                             What role do CSO representative paly in the CCM
    9      Level of CSO participation in the What is the level of CS participation in the CCM
                        CCM
                                             What factors facilitate meaningful and effective paricipation of
                                             the members fo the CS including the marginalized and
                                             vulnerable groups and People Living with the Disease.

                                                 What are the barriers of meaningful and effective CS
                                                 participation including marginalized and vulnerable groups
                                                 What are the characteristics of good civil society involvement
                                                 and participation in GF programmes in the country

   10     Grant implementation programme         Are civil society representatives’ organizations also
          oversight                              implementing grant activities?
                                                 Are there any conflicts of interest and how have these been
                                                 resolved by the CCM? Or what plans are there to address
                                                 these conflicts?
   11     Civil Society roles in TB and          Does civil society play a role in grant activities on malaria and
          Malaria grants                         tuberculosis? If yes please detail where and how this
                                                 involvement and participation occurs?
                                                 If civil society does not play an active role in implementation
                                                 on the two diseases what are the reasons for and against?

                                                 Are there any opportunities for civil society engagement and
                                                 participation in grant activities within these two diseases?


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   12     Level of funding of Civil society   What proportion of resources within the existing grants is
          within existing grants              available to civil society?
                                              Are there any variations between amounts proposed for civil
                                              society in the approved proposals and final grant budgets and
                                              plans? If so what are the reasons associated with these
                                              variations and who made the decisions to vary the allocation
                                              and why?
   13        Transparency and participation   To what extent do you think that the CCM meet the principles
                                              of tranparency and participation
                                              According to you is it critical to ensure participation of CSO in
                                              the CCM, if so why do you think so (rationale and principles of
                                              CS participation)
                                              Do you know of any other such partnership in the country
        14 Governance and Participation       According to you what are the key governance and
                                              participation issues, practices and procedures in the working
                                              of the CCM in the country that has enabled or disabled CSO
                                              active engagement?
        15 Recommendations                    Have you any recommedations to improve the governance
                                              and CSO participation in the country CCM?




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Annex B: List of respondents


Annex B
Respondents

S No.      Respondents            Names                  Type of interaction   Designation
         1 CCM Chair                                                           Secretrary of State,
                                                                               Ministry of Health,
                                  H E Dr Mam Bun Heng Individual int           Principal Recipient
         2 Vice Chair ( WHO)      Michael O'Leary
                                                                               WHO Representative,
                                                                               CCC Vice-Chairperson
                                                                               and CCC-SC Co-Chair
                                                         Individual int
         3 VC ( NGO)                                                           Executive Director,
                                  Dr. Sin Somuny                               MEDICAM
                                                         Individual int        CCCSC Co-Chair
         4 Govt rep                                                            Deputy-Director
                                  Dr. Mean Chhi Vun                            General for Health
                                                         Individual int        Director of NCHADS
         5 Govt rep
                                  Dr. Mao Tan Eang                             Director, CENAT
                                                         Individual int
         6 Govt rep               Dr. Duong Socheat      Individual int        Direct, CNM
         7 Govt rep
                                                                               Secretary General,
                                  H.E. Dr. Teng Kunthy
                                                                               National AIDS Authority
                                                         Individual int
         8 NGO rep                                       Group discussion      Executive Director,
                                  Oum Sopheap
                                                                               KHANA
        10 NGO rep                                       Group discussion      Country Director,
                                  Peggy Cook                                   University Research
                                                                               Co., LLC
        11 CCM Secretariat        Uth Sophal             Individual int        CCM Secretariat
        12 PR ( govt rep)         Dr. Sok Touch          Individual int        CDC Director, MoH
        13 SR (NGO rep)                                  Group discussion      Associate Executive
                                  Dr. Var Chivorn
                                                                               Director of RHAC
        14 Private sector                                Individual int
                                                                               Secretary General
                                  Dr. Nang Sothy                               Cambodia/Phnom Penh
                                                                               Chamber of Commerce
        15 bilateral                                     Individual int        Deputy Director, Office
                                  Jonathan Ross                                of Public Health,
                                                                               USAID/US Embassy
        16 bilateral                                     Individual int
                                                                               DFID Program Support
                                  Dr. Nicolet Hutter
                                                                               Officer HIV/AIDS
        17 PLWA                                          Group discussion      Country Coordinator,
                                  Mr. Heng Sokrithy
                                                                               CPN+
        18 Academic               Prof. Seang Tharith    Individual int        Vice Dean of the
        18 Multilateral           Mr. Tony Lisle/Jane    Individual int        Country Coordinator,
                                  Batte                                        UNAIDS
        18 Non CCM/non SR         Kimchoeureng Teng      Group discussion      Hope of Orphanage
                                                                               Association
        22 Non CCM/non SR         Von Vachan             Group discussion      Public Health Care
                                                                               Organization
        23 Non CCM/non SR         Uth Sophal?            Group discussion      ?
        24 Non CCM/non SR         Uth Sophal?            Group discussion      ?




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Annex C: Sub-Committee constituency




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Annex D: PR Selection Process.

Excerpt from Approved Minutes of 28th CCC meeting on May 29, 2007


Selection of the Principal Recipient for Round 7
A representative of Task Force (Peggy Cook) presented in the last CCC meeting decided to set up TF to more
deeply working on PR options. TF met 4 times to develop selection criteria to evaluate, requested and reviewed
additional information of applicants including reports on the current PR, clarify willingness of interest
organizations to cover component and develop a list of options with pros and cons which have been distributed.
She presented the first vote (secret ballot) which include i. MoH alone (current PR), ii. NCHADS/CENAT, iii.
MoH (for gov. SRs)/NGO (SHCH, MEDiCAM, PACT, KHANA, HNI) (for NGO SRs), iv.
NCHADS/CENAT/NGO(s), and v. Other (multiple combination of PRs (not recommended by the task force);
and second vote (will proceed depend on the result of the first vote) which include NGOs to be pair with either
current PR or NPs such as HNI, KHANA, MEDiCAM, PACT and SHCH. She also presented the pros and cons
of the first vote and second vote options.

It was informed that there will be no problem for the Global Fund if the selected PR is also a sub-recipient.

Dr. Sin Somuny explained the process of voting that it will be accepted unless the outcome of voting will obtain
the majority (50%+1), for example CCC composition is 29, so the majority is 15 votes. Actually, members
presented at this meeting is only 24, so the majority is 13 votes. If number iii or v is selected then it is required to
process the second vote to get one NGO to pair with either current PR or NPs.

Committee members raised that we should consider on the composition of the CCC members if the election will
take the majority votes, for example from government and outside government. In this case, there are four
options, so it should be no problem.

First vote:

Voting (1st Round)
Organizations                                                                                  Result
1. MoH alone (current PR)                                                                      4 votes
2. NCHADS/CENAT                                                                               11 votes
3. MoH (for gov. SRs)/NGO(SHCH, MEDiCAM, PACT, KHANA, HNI)                                     5 votes
(for NGO SRs)
4. NCHADS/CENAT/NGO(s                                                                          4 votes

Based on the first round result none organization get majority votes, so it require another voting round, but
number 1 and 4 are excluded from the next voting process.




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Voting (2nd Round)
Organizations                                                                        Result
2. NCHADS/CENAT                                                                     14 votes
3. MoH (for gov. SRs)/NGO(SHCH, MEDiCAM, PACT, KHANA, HNI)                          10 votes
(for NGO SRs)
Based on 2nd Round voting result, number 2 is the winner because received more than (50%+1) votes, so
NCHADS/CENAT is selected as PR for Round 7. In this case there is no need to proceed second voting process.




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