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EXECUTIVE SUMMARY A. Introductio by pengxiang

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									                      EXCUTIVE SUMMARY: Cambodian Nutrition Investment Plan


                                  EXECUTIVE SUMMARY


A.     Introduction
This proposed updated Cambodian Nutrition Investment Plan (CNIP 2003-2007) is based on the
CNIP prepared in 1998 and also on the National Nutrition Plan of Action (NNPA) of 1995-96.

UNICEF Phnom Penh provided overall support to the National Council for Nutrition for this
revision and the Inter-Ministerial Technical Committee for Nutrition had an important input,
giving feedback from early drafts on.

B.      Proposed Investment
The Cambodian Nutrition Investment Plan (CNIP) proposes a $41.1 million investment plan for
nutrition over a five-year period (2003- 2007) and is structured to contribute to Cambodia’s
SEDP II and its Poverty Reduction Strategy Paper. The plan provides for a long-term strategy to
implement the more nutrition-relevant aspects of development.

Some new domestic resources will be mobilized to finance the plan, but a portion of the funding
will be raised from external sources in the form of grants and soft loans.

C.      Justification
The justifications given in the 1998 CNIP are still valid in 2001 at the time the CNIP was revised
to cover a period from 2003-2007 and can be found in that document.
•   Firstly it addresses a silent emergency that is both a major cause and outcome of poverty.
    The Government has declared the eradication of poverty as the overarching objective.
    Addressing malnutrition ensures that the poor become active participants in the eradication of
    poverty and not passive recipients of commodities and services. They become part of the
    solution rather than the problem;
•   Secondly, it ensures that poverty eradication occurs through economic growth with justice.
    This will positively reflect the ethical and moral position adopted in the Constitution of the
    Royal Government of Cambodia in acceding to the Convention on the Rights of the Child
    (CRC), signing of CEDAW and endorsement of several World Declarations. These include
    the 1990 World Summit for Children (WSC), the 1992 International Conference on Nutrition
    (ICN) and the 1996 World Food Summit (WFS);
•   Thirdly, investing in nutrition in Cambodia has high economic returns. The cost: benefit
    ratio is 1:8 which means for every dollar spent on improving nutrition, it produces US$8 in
    return as benefits;
•   Fourthly, controlling malnutrition addresses one of the serious results of the decades of civil
    conflict, and mitigates the bad effects of the current Asian economic crisis on children and
    women.

D.     The Context
The CNIP 2003-2007 is a nation-wide plan covering both rural and urban areas, focusing on
children and women. It is a response to address the very high rates of child and maternal
malnutrition and high levels of infant and maternal deaths that affect all provinces in Cambodia.
The basic causes of these problems are persisting widespread poverty and lack of availability,



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                       EXCUTIVE SUMMARY: Cambodian Nutrition Investment Plan


access to and control of needed resources and services by beneficiaries. The underlying causes
relate to a trial of inadequacies in access to food, care of mothers and children, primary health
care services and sanitation especially for the poor.

To put things in perspective, it is important to look at the magnitude of the PEM problem in the
country: First, in Cambodia, Protein-Energy Malnutrition (PEM) is still associated with more
than two out of three of the <5 mortality rate. Second, it is important to have an idea of how
many children are affected nationwide. In 2000, there were two million children <5 years of age
in the country. Around a little less than half of them (+/- 900,000) are the most vulnerable group
to malnutrition, i.e. the <2 years age group, since stunting peaks at the age of around 19 months.
Among the children under 5 years of age, 45%, we know, are malnourished. In view of this, if
the CNIP 2003 – 2007 includes plans to set up a reliable growth monitoring and promotion
system focused on the most vulnerable children that are not growing properly, the nutrition
situation in the country can be dramatically improved.

The focus of the CNIP should thus be on children under 2 years of age with follow-up
interventions for the 2-5 year old age groups. Data should be disaggregated for these two age
groups. But to succeed in this, interventions have to start before birth. So pregnant women are
also an important target group.

There are, therefore, only around 477,000 malnourished children aged 0-2 years in the entire
country (45% of 900,000) whose faltering nutritional status needs to be caught in time through
growth monitoring so that timely and decisive actions are taken. The CNIP 2003 – 2007 intends
to contribute to this. This surely is not an unrealistic challenge, and a lesser number of children
will need to be targeted in any of the initial years if it is decided to start first in the most affected
provinces, where more of an impact is likely.

Moreover, the existing monitoring system for the recording and reporting of all children’s and
women’s data should more systematically collect nutritional outcome data. The system needs to
be modified and the corresponding training done to incorporate this data.

The growth monitoring and nutritional assessment of children below 2 years of age with follow
up for two to five years is already being implemented by communities with the support of health
staff in selected communes. Additionally, this community based monitoring system can also
report to the MOH system, to better assess the nutritional outcome of these community-based
programs.

E.     The Objectives
The overall objectives of the nutrition investment plan are:
•  To incorporate nutrition considerations in the second national Socio-Economic Development
   Plan, as well as in the Poverty Reduction Strategy Paper;
•  To reduce the levels of Protein Energy Malnutrition (PEM) in children under 5 years of age
   by ten percentage points in five years from the current (2000) level of 45% (underweight);
•  To virtually eliminate deficiencies of iodine and vitamin A over five years;




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                       EXCUTIVE SUMMARY: Cambodian Nutrition Investment Plan


•    To reduce by ten percentage points the current levels of anemia in children under 5 (63% as
     per CDHS), under 2 (70% as per HKI), childbearing age women and pregnant women (58%
     and 66% respectively) as per joint WFP/UNICEF baseline survey;
•    To increase the coverage of antenatal care so that weight gain during pregnancy can be
     monitored and to increase by 20% the number of women gaining 9 kg or more during
     gestation as compared with estimated levels in 2000;
•    To reduce the levels of low birth weight (LBW) from the current estimated 15 % to 10 % in
     five years;
•    To reduce the levels of malnutrition of women of reproductive age from 21% to15% in five
     years as measured by a body mass index (BMI) of below 18.5 kg/m2.
•    To triple the % of mothers giving colostrum and exclusively breast-feeding their infants for
     six months as compared with data from CDHS 2000.

F.   Six Basic Orientations of CNIP 2003 - 2007
     CNIP 2003-2007 will address:
1.   Nutrition, as part of the poverty alleviation strategies, following the explicit orientation of
     the Government in this respect.
2.   Nutrition, i.e. access to nutritionally adequate and safe food as a Human Rights issue. This
     means the CNIP 2003-2007 will aim at empowering families to claim services and resource
     inputs from relevant duty bearers (local and national service providers and authorities) for
     them to find workable solutions to communities’ problems.
3.   Participation of the community and households in assessing and analyzing their situation
     and in planning the actions needed to solve their nutrition-related problems.
4.   Nutrition along the life cycle with more emphasis on the proper nutrition of girls,
     adolescent girls, adult and pregnant women, as well as on starting breast-feeding within the
     first hour of birth, practicing exclusive breast-feeding from birth to 6 months of age and
     giving adequate safe and timely complementary feeding, ensuring proper frequency,
     amount, density and utilization according to the Frequency, Adequacy, Density and
     Utilisation (FADU) approach.
5.    Monitoring both processes to be used and outcomes to be achieved. Nutritionists will use
     varied nutrition outcome indicators (e.g. birth weight, young child anthropometry, BMI and
     one or two indicators for every major micronutrient deficiency). Additionally CNIP 2003 –
     2007 will need to set process indicators, e.g. for social mobilization, Village Development
     Committee (VDC) participation, and empowerment. Monitoring activities will then focus
     separately on both types of indicators.
6.   The principles of “convergence’’ and “phasing’’ meaning that several sectoral efforts will
     be directed to center around the same communities to solve a greater range of their multiple
     problems linked to nutrition. These efforts will be applied sequentially according to the
     receptive capacity of the same communities before moving on to cover further communities.
     UNICEF has had a working experience with both; they have concentrated their actions in
     six provinces.

G.      The Strategy
In Cambodia, the problem of malnutrition has a high profile, but needs to be more decisively
placed in the agenda of priorities.




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                      EXCUTIVE SUMMARY: Cambodian Nutrition Investment Plan


The main challenge still is the implementation and enforcement of sound plans and existing
regulations/policies. Bureaucracies move slowly everywhere in the world so a primarily bottom-
up, community-based approach is considered to be the one with the biggest potential for the
country.

The 1998 CNIP called for: “Investing in community-based programs by supporting existing
sectoral programs in different ministries and making them more community-based’’.

It is proposed to modify the above strategy; the CNIP 2003-2007 does not recommend ministries
to start their own new sectoral community participatory processes for improving nutrition and to
adopt community mobilization skills they still do not have.

Instead, the CNIP 2003- 2007 calls on the different sectors and ministries to direct their
resources inputs to existing and working community mobilization schemes such as those from
Seth Koma, Seila, PRASAC, Food and Agriculture Organisation’s special program for food
security, and those of many NGOs. The MRD estimates that, by mid-2001, 5,600 of the 13,000
villages in the country (43%) have established VDCs and have set a target of 70% of villages
having working VDCs by 2005. Because of the rapid expansion of Seila, this target may be
surpassed.

The above projects already have the knowledge and know the shortcomings. They have learnt
from their mistakes; have the know-how and have active communities already engaged; they
have the vocation and have already trained the trainers; they are ready to expand, to discuss new
technical tasks/proposed interventions with the organized community and to scale-up. After start-
up investments - in training, water and sanitation, food security, micro-credit and other - their
recurrent costs per beneficiary have dropped dramatically to reach levels of as low as $1.78 per
child (Seth Koma). Using integrated intersectoral nutrition planning and community mobilization
processes they have been able to maximize resource utilization to ensure positive outcomes - not
only in nutrition.

The overall strategy of the proposed investment plan is thus a community-based approach
emphasizing actions at the commune and household level with supportive national level
approaches.

National level plans will receive 20% of the CNIP’s funding; for micronutrients, breastfeeding
promotion, implementation and strengthening Baby Friendly Hospital Initiative/Baby Friendly
Community Initiative (BFHI/BFCI) and Code implementation and enforcement, establishment of
a nutrition information system, supporting focal points and the development of national
policies/strategies.

Local community-based plans will absorb 80% of the funding, mostly to fund village action
plans (VAP). Seth Koma has arrived at a good mix of nutrition-relevant interventions chosen by
the people; these are the ones that should be funded by CNIP.

Locally, the focus of the CNIP interventions is to remain at the level of the underlying and basic
causes of PEM. Caring practices for children and women, household food security (access to



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                      EXCUTIVE SUMMARY: Cambodian Nutrition Investment Plan


food), health, sanitation, food safety, Family Planning, Ante-Natal Care/Post Natal Care
(ANC/PNC), Primary Health Care (PHC), and income generation, education and literacy for
women. The challenges of nutrition in HIV/AIDs will also be addressed.

The CNIP will use the commune as the basic unit for costing the decentralized plan. This, in an
effort to avoid falling back into mostly sectoral approaches that have been top-down and less
performing, less empowering and less sustainable. The basic strategy at the community level will
be to ensure sustainability by supporting actions that build capacity, are empowering, and derive
from the triple A process of assessment, analysis and action. This community focus will now be
strengthened with the upcoming election of Commune Councils that will put new funding at their
disposal.

The Government will invest some of its own funds in this plan as a priority and will raise funds
with donors to fill the gaps. To facilitate the fund-raising exercise, a more detailed and costed
work plan for year one of this CNIP will be prepared. The Government will also put resources
into increasing its institutional and absorptive capacity and into applying a reliable system to
monitor and evaluate the plan. The MOP will take up this role.

As relates to micronutrients, for the duration of this plan, the national programs for Iron
Deficiency Anemia (IDA), Vitamin A Deficiency Disorders (VADD), Iodine Deficiency
Disorders (IDD), infant and young child feeding and PEM will continue to exist and will set
strategies and plans to be followed in their nationwide implementation. They will also be
responsible for all logistical arrangements; further, they will be responsible for giving technical
support to provinces and community-based activities aimed at improving their knowledge and
use of a more diversified diet, fortified foods and micronutrient supplements.

Nutrition training and capacity building is crucial. The acquisition by an existing Cambodian
academic institution of a public nutrition training and research capability is a high priority, as is
the development of an ad-hoc public nutrition curriculum. Of greatest urgency is the short-term
training of central and local mid-level technical cadres in public nutrition, breastfeeding, and
nutritionally adequate and safe complementary feeding practices, growth monitoring and
promotion (GMP) and micronutrient deficiencies. Their role as trainers of health staff, teachers,
volunteers and community leaders needs to be strengthened to match the pace of the rapidly
growing demand for community-based programs.

In addition, staff from selected ministries need to be trained at diploma level. The chosen
academic institution needs to upgrade its capabilities slowly to eventually set up a degree
program in nutrition. Academic twinning arrangements with a university in the region or in the
West are desirable.

Simultaneously, at least three Cambodian professionals, preferably a team from the Ministry of
Health, Ministry of Planning and Ministry of Rural Development, will be sent for post-graduate
training in public nutrition.

The role of the National Council for Nutrition (NCN) will continue to be one of giving direction
to the CNIP, coordinating and monitoring it while holding the different Government Agencies



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                      EXCUTIVE SUMMARY: Cambodian Nutrition Investment Plan


accountable for its implementation. The NCN will also coordinate with pertinent donors and
NGOs and will be responsible for the preparation and evaluation of annual plans. It will also
liaise with and support the Provincial Committee for Nutrition Coordination. The capacity of the
NCN to monitor and coordinate needs to be enhanced through the placement of a Nutrition
Advisor in the MOP.

The existing Inter-Ministerial Technical Committee with one nutrition focal point person per
agency will meet quarterly to report on progress and to hear about progress in all sectors, as well
as to plan future actions and contribute to and endorse yearly work plans.

An active Permanent Secretariat for the National Council for Nutrition will be created to follow
the implementation of this CNIP on a daily basis and to prepare annual work plans. It will be
composed of 10 professionals from the MOP working part time on CNIP follow-up activities.
They will have direct access to the Under-Secretary of the MOP responsible for all CNIP matters
that need high level executive powers for their implementation.

Donors and NGOs involved in the CNIP will participate in the Inter-Ministerial Technical
Committee (IMTC) meeting and periodically the Permanent Secretariat meeting as needed.

The Nutrition Information System (NIS) called for by this CNIP will use the CDHS 2000 data as
a baseline. It is proposed to set up a Nutrition Sentinel Surveillance System with sites in selected
locations where CDHS data have already been collected. Selected data that the CDHS collected
in 2000 will be followed longitudinally to give an idea of trends; these will be considered to
influence the future direction of annual plans. A budget for technical assistance, training,
monitoring and data analysis will be needed for this.

CNIP 2003 – 2007 favors the expansion and scaling-up of existing community-based projects
and activities. It suggests first covering all districts and communes in the provinces where these
projects already operate, as trainers are already at hand and Provincial Officers are already
participating. Second, communes that have had Provincial Local Government (PLG)/Seila
support will need to retrain their Village Development Committee /Commune Development
Council (VDC/CDC) to incorporate health and nutrition-relevant actions in their village action
plans (VAPs). Seth Koma and Seila are already negotiating on this issue starting in provinces
where they can work together. A greater gender balance has to be given priority when scaling up.

As regards CNIP 2003-2007 monitoring, as said, the MOP will take this responsibility and will
be setting up operations in the MOP to do this. What will be monitored, how, and using which
indicators are proposed later on in this CNIP.

Finally, the MOP is expected to continuously lobby to put nutrition and food safety in the
government’s investment plans and national budgets of the future.

H.      Organization of the Document
The document builds up a case for investing in nutrition by providing an analysis of the context,
the current nutrition situation, the current programs and policies and then progresses to the
formulation of a strategy and ultimately a financing plan.



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                      EXCUTIVE SUMMARY: Cambodian Nutrition Investment Plan


Cambodia has to be looked at in context, highlighting its traumatic past, its administrative
structures, economic trends and the quality of life of the people in a period of rapid social and
economic transition.

Chapter 1: Presents a picture of the national nutrition situation, including trends and causes:
•  The primary nutritional problems are PEM and vitamin A, iodine and iron deficiencies. PEM
   is widespread, affecting about 45% of children 6-59 months and about 20% of women of
   reproductive age.
•  The most vulnerable children are in households headed by a female under the age of 35
   years. Children from households headed by a woman over 35 are best off nutritionally.
•  The main underlying causes of malnutrition are related to inadequate care practices and
   access to health and environmental sanitation including safe complementary food. The main
   basic cause is poverty.
•  Children whose mothers start complementary feeding after six months tend to be at greater
   risk of malnutrition than those where complementary foods are introduced at around 5
   months of age.
•  Children who are growing well despite low family incomes (positive deviants) have a lower
   diarrhea prevalence rate.
•  Children who are taken to the clinic, health worker, or hospital more regularly when they
   have fever grow better than others.
•  Children who are negative deviants most often are from families that spend proportionately
   more money on food and medical care.

Chapter 2: The assessment of ongoing nutrition-relevant programs shows that:
•  There are many such programs although their scope and scale is limited. They are
   uncoordinated, and nutrition is not always addressed explicitly as an outcome. A notable
   exception is the Seth Koma project that is integrated, is relatively large, and has an explicit
   nutrition goal.
•  All nutrition-specific interventions are supported by and largely driven by donor agencies
   and/or NGOs. This CNIP 2003 – 2007 proposes the Cambodian Government also mobilizes
   its own resources to explicitly address the problem of malnutrition.
•  Current and future nutrition-relevant programs need to be more coordinated and should move
   current small-scale community-based programs with nutritional relevance to critical scale.
•  The lack of an information system to capture nutrition trends calls for the setting up of a
   sentinel system as proposed above to guide the fine-tuning of this CNIP.

Chapter 3: This chapter analyzes public policy relevant to nutrition.
Bridging the gap between policies and their implementation requires improved Government
allocation of resources, institutional capacity for their implementation, and a system of
monitoring and evaluating both process and impact indicators. Another major requirement is the
building of an adequate human resource capacity at all levels to ensure that staff has the ability to
translate policy into specific programs and activities, implement and monitor those programs and
activities, and then analyze experiences to influence needed changes in public policy.

Chapter 4: Proposes an improved nutrition strategy plan for Cambodia based on the analysis and
conclusions reached in Chapters 1-3.



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                      EXCUTIVE SUMMARY: Cambodian Nutrition Investment Plan


As said, the strategy emphasizes a community-based approach focusing on the household level
and supported by national level approaches. The two components are costed, the costing is
justified, and this chapter proposes a management framework for the plan.

Chapter 5: Provides arguments of the need for Cambodia to invest in nutrition, citing the
benefits that will accrue to the people.

The cost benefit ratio for investing in nutrition is high. Every dollar invested in nutrition is
estimated to yield eight dollars. The financial strategy is then discussed, in the light of current
expenditure patterns, their expected efficiency and their impact on equity.

Note:
This 2002 revised version of the CNIP:
   Summarizes a number of the still relevant contents of the 1998 version in order to avoid
   ending up with a long repetitive document. For example, the still relevant preface of the
   former is omitted here and many of the still relevant tables and figures are left out.
   Updates all materials for which new data is now available including data from the recent
   Cambodia Demographic and Health Survey (CDHS 2000) and the description of what
   different agencies working in nutrition are doing in 2002.
   Complements the text of the 1998 CNIP.




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                      CHAPTER 1: Analysis of the Nutrition, Trends and Causes



                                        CHAPTER 1

  ANALYSIS OF THE NUTRITION SITUATION, TRENDS AND
                     CAUSES
1.0 - Introduction
The nutritional profile of Cambodia resembles more closely the countries of South Asia. There
are as yet no routine information systems that gather nutrition-related data, except in the selected
community based project areas. A Cambodia Demographic and Health Survey (CDHS) was
carried out in June 2000 and its results were released in October 2001; they are rich in
representative, reliable and nutrition-relevant data.

1.1 - Micronutrient Malnutrition

1.1.1 - Iodine Deficiency Disorders (IDD)
Results of the first national goiter survey (MOH, 1997) indicated a projected national average
total goiter rate of about 12% in the age group 8-12 years, but with some areas having as much as
45% total goiter rate. The gross goiter rate from the survey was 17%. It is estimated that there
are nearly 1.3 million individuals at risk of IDD. This makes Cambodia fall into the category of
countries with a mild IDD problem. A national program to achieve Universal Salt Iodization
(USI) by the end of 1998 was planned and pursued with UNICEF support. However, due to
many operational problems, the objective has not been achieved to date. The CDHS 2000 shows
that, nationwide, only 12% of households are adequately using iodized salt; a high proportion of
the salt sampled has inadequate levels of iodine.

1.1.2 - Vitamin A Deficiency Disorders (VADD)
Micro surveys conducted between 1990-1996 in about three-quarters of the provinces all suggest
the presence of a significant problem of VADD. Prevalence rates of up to 12% of night
blindness have been recorded in Takeo (WHO cut-off in 1%). Low consumption of vitamin A
rich foods by children is seen, particularly during the dry season when lack of water prevents the
growing of vegetables in home gardens. Vitamin A rich foods (fruits and vegetables) do not
form a regular part of the children’s diet. Only 29% of the children <5 years of age nationwide
received a vitamin A supplement six months prior to the survey in 2000 (CDHS).

The high prevalence of diseases known to predispose children to VADD, particularly Acute
Respiratory Infections (ARI), diarrhea and especially measles serve as a proxy measure of the
severity of the problem. In some places, prevalence of these illnesses is over 40%. The
importance of the measles vaccination in the control of VADD cannot be overemphasized.
Measles vaccination coverage in Cambodia reached a national average of only 55% in 2000
(CDHS). 11 out of 21 provinces had lower coverage rates.

While vitamin A supplementation using vitamin A capsules has been given prominence in the
Expanded Progam on Immunisation (EPI) in Cambodia, so far there are limitations in the
promotion of dietary approaches as a strategy and this needs to be strengthened. Breast-feeding
is fortunately a universal phenomenon in Cambodia with median breast-feeding periods of about


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                      CHAPTER 1: Analysis of the Nutrition, Trends and Causes


24 months (CDHS). Colostrum, a highly precious source of vitamin A for the newborn, is
traditionally discarded, but in recent years, nutrition education seems to have slightly increased
the proportion of women breastfeeding colostrum. As regards mothers, 11% of them take post-
partum vitamin A supplements (CDHS). The CDHS also revealed that only 5% of babies are
exclusively breastfed up to 5 months of age.

1.1.3 - Iron Deficiency Anemia (IDA)
Regarding IDA, in 2000, the prevalence in children was 63%; for women the rate was 58%
(CDHS); for children under two years of age it is 70% (HKI). IDA prevalence in pregnant
women is higher, at 65% (CDHS 2000) and anemia is considered to be one factor associated
with a high maternal mortality rate, estimated at 473/100,000 live births (United Nations
Common Country Assessment). Only 16% of pregnant women took iron supplementation during
pregnancy in 2000 (CDHS).

Prevention of anemia in pregnant women is included in the MOH Minimum Package of
Activities (MPA) to be provided at all health units. Iron and folic acid tablets are available to all
health units. Apart from iron tablet supplementation, dietary based approaches have not been
emphasized. The coverage of iron/folate tablets is still too low and does not reach the rural
women who are at greatest risk of maternal anemia.

1.2 - Protein-Energy Malnutrition (PEM)

1.2.1 - Maternal Nutrition and Low Birth Weight
A 1993/94 UNICEF survey of 12 provinces found that 34.5% of women restricted their diet
during pregnancy and 77.8% during lactation. In Cambodia, women continue working as hard
during pregnancy as when non-pregnant. The combined effect of dietary restrictions and a heavy
workload results in low birth weight babies. Although there is no available data on the level of
weight gain during pregnancy, it is likely to be significantly below the recommended weight gain
of 10-12 kilograms.

A low Body Mass Index (BMI <18.5 kg/m2) is reported for 20% of women in 2000 (CDHS).
Low birth weight figures (less than 2500gm) of around 18% are reported, but are mostly
estimated given the low percentage of newborns that get weighed. Low birth weight babies have
been reported as high as 26% in individual hospitals.

Low birth weight reflects maternal malnutrition and is associated with high neonatal and infant
mortality. A high prevalence of low BMI in women has also been proposed as a proxy indicator
for household food insecurity. Since good maternal health and nutrition provides the first line of
defense for the child, improving the nutritional status of women must be an important priority for
investing in child nutrition.

1.2.2 - The Nutritional Status of Children Under the Age of Five.
Data from CDHS (2000) and from MICS (1996) showed the prevalence of malnutrition (for both
underweight and stunting) for children of 0-59 months of age in 2000 was around 45%, which is
a slight improvement from a prevalence rate of 48% reported in 1996. Wasting, however,
increased from 13% in 1996 to 15% in 2000. Severe malnutrition (<-3 SD) is alarming as severe



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                        CHAPTER 1: Analysis of the Nutrition, Trends and Causes


underweight is reported in 13% and severe stunting in 21% of children in 2000. However, it is an
improvement from 1996 where severe underweight and severe stunting were reported at 14%
and 28% respectively (MICS). Severe wasting doubled from 2 % in 1996 to 3.8% in 2000. It
appears that socio-economic development efforts have not equally benefited all strata’s of
society.

Table 1.1 - Prevalence of Malnourished Children (6-59 months) in Cambodia by
            Urban/Rural Status (CDHS 2000)

                        % underweight          % stunted               % wasted
    Urban                    38                   38                     13
    Rural                    46                   46                     15

A further analysis of the data shows that:
•  Regional differences indicate a severe problem in Kampong Thom, Prey Veng, Banteay
   Meanchey and Mondol/Ratanakiri while Phnom Penh and Battambang/Krong Pailin are the
   least affected by malnutrition. (CDHS 2000)

•     On the basis of population, in 1996, the four provinces of Kampong Cham, Kandal, Takeo,
      and Prey Veng accounted for nearly half of all severely malnourished children in terms of
      absolute numbers. In addition, almost three-quarters of the severely malnourished children
      identified from the 21 provinces surveyed in the 1996 Multi Indicator Cluster Survey (MICS)
      resided in only nine provinces. From a policy perspective, targeting these provinces will
      have the greatest impact on malnutrition and child mortality in Cambodia.

•     Gender differences among boys and girls are smaller than 2% (higher for girls) for both
      stunting and underweight. (CDHS)

•     The rates of underweight and stunting rise with age with a first peak at 13-14 months and
      reaching a highest level of 52% for underweight and 58% for stunting in the 45-50 months
      age group. Wasting peaks at 23% in the 14 months age group. (CDHS)

•     Overall, there is a seasonal variation with rates higher during the rainy season (July) than in
      the dry season (November). (MICS 1996)

Data from Seth Koma for six provinces in 2000 show malnutrition indicators to be mostly lower
than those from the CDHS:

Stunting: severe: 10% (CDHS: 20%); moderate: 38% (CDHS: 44%)
Underweight: severe: 9% (CDHS: 12%); moderate: 49% (CDHS: 45%)
Low BMI of women: 14% (CDHS: 20%)

Other indicators such as the access to clean water and sanitary disposal of excreta, ANC, child
vitamin A supplementation, literacy rate of women, BCG, Diphtheria Pertusis Tetanus (DPT)
and measles immunization rates are all significantly higher in Seth Koma sites than the national
CDHS averages.


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                    CHAPTER 1: Analysis of the Nutrition, Trends and Causes


Table 1.2     Summary of the CDHS 2000 Findings

MAJOR NUTRITION INDICATORS, CDHS 2000, OTHER SOURCES AND TARGETS
                                        FOR 2007.
Indicators                                               Other    2000  Target
                                                        sources   DHS    2007
Breast-feeding:
Mothers who start breast-feeding newborn child within 1         11%    35%
hour of birth
Infants exclusively breastfed up to 5 months of age*             5%    25%
Mean duration of breast-feeding                                 24m    24m

 Nutritional status of children under 5 years:
 Underweight                                                                  45%   31%
 Stunting                                                                     44%   30%
 Wasting                                                                      15%   10%

 Nutritional status of women 15-49 years old:
 Women with BMI <18.5 Kg/Sq. metre                                            21%   15%
 Women stunted (<145cm tall)                                                   6%    5%
 Low birth weight babies                                                      15%   10%

 Iron Deficiency Anaemia (IDA)
 Children 6-59 months age                                                     63%   42%
 Women 15-49 years old:                                                       58%   40%
 Pregnant women                                                               66%   43%
 Women taking iron supplements for at least 2 months                           4%   40%
 during pregnancy

 Vitamin A Deficiency (VAD).
 Night Blindness among pregnant women                                          8%    4%
 Women got a post-partum Vitamin A supplement                                 11%   80%
 Children got Vitamin A capsules 6 months prior                               29%   80%

 IDD:
 Households using iodized salt                                          12%        80%
 Goitre                                                      12%*                   4%
* MOH policy is exclusive breastfeeding up to 6 months of age. CDHS indicator
   reported above was collected for babies exclusively breastfed up to the age of 5 months.
** National Micronutrient survey 2000 and National Goitre Survey 1997

1.3 - The Causes of Malnutrition
Malnutrition is an outcome of many biological and social processes; there is no single major
cause, which could be shot at with a single magic bullet. The situation in Cambodia is no
exception. Causes of malnutrition are immediate, underlying and basic.




                                                                                          12
                      CHAPTER 1: Analysis of the Nutrition, Trends and Causes


However, the situation in Cambodia is more complex. For example, there is very little exposure
of the population to modern health care. Self-treatment with traditional remedies and
inappropriate use of medications is highly prevalent. CDHS 2000 assessed health seeking
behavior and showed that when ill, 11% of households report no treatment, 33% seek treatment
at the private medical sector and 35% take treatment from the non-medical sector or from drug
vendors and drug stores. Only 19% seek health care from the public sector. EPI still has
moderate levels of coverage. Infant feeding practices, health care practices, and household food
security have all been identified as nutritional risk factors and will all be addressed.

1.3.1 - Immediate Causes
The immediate causes are a mutually reinforcing interaction between food intake (child/pregnant
mother do not eat enough and/or not the right foods) and diseases (child/pregnant mother suffer
from preventable illnesses). Due to a lack of time, women tend to feed complementary foods to
children only about two or three times a day. These foods are of low nutrient density, of low
variety and are often contaminated. The situation is further aggravated by frequent illnesses that
decrease the appetite and increase the body’s utilization of food. One main approach to address
this issue is to use the FADU concept – i.e. to improve food Frequency Adequacy, nutrient
Density, and Utilization.

1.3.2 - Underlying Causes
The underlying causes are related to the following:
•   Household food insecurity (not enough food, land, cash, post-harvest food losses, no home
    gardens).
•   Inadequate care of children (non-exclusive breast-feeding and in adequate, untimely and un-
    safe complementary feeding).
•   Inadequate care of women (inadequate food intake and rest during pregnancy and lactation).
•   Poor access to health care services/facilities (high fees for services, drugs shortages, low
    vaccination rates, no impregnated mosquito nets), no access to clean water and safe food and
    sanitation (latrines, hand washing and garbage disposal).

1.3.3 – Basic Causes
These causes include a wide variety of causes such as:
•   High illiteracy rates of women and limited access to education by girls.
•   No structures to enforce the respect for human rights.
•   Urban and rural poverty, low wages, limited access to credit, unemployment.
•   Low status of women.
•   The poor having no influence on decision-making on plans that distribute development
    resources that affect them directly, skewed income distribution, and
•   Insufficient government resources for health and nutrition.

1.4 - Household Food Security
Household food insecurity is an important constraint in some geographic areas in Cambodia,
largely as the result of poor access to food rather than availability of food. At the national level,
rice production levels meet national consumption requirements in normal years.
It is estimated that about 40% of all Cambodian households live in poverty. Key constraints to
household food security include land tilling, inputs and technology, crop diversity, infrastructure



                                                                                                  13
                      CHAPTER 1: Analysis of the Nutrition, Trends and Causes


and markets. Indebtedness is reported to be high. Traditionally, women-headed households are
known to be vulnerable to household food insecurity. It is estimated that women are at the head
of 20% of all households in Cambodia. Given the high illiteracy rates in the country (estimated
nationally at more than one third and at 47% for all adult women), female-headed households
would be expected to be particularly vulnerable.

In 1996, the MICS survey discovered that children living in houses headed by females older than
35 years of age are better off nutritionally than children living in male-headed households.
However, households headed by females under the age of 35 years appeared to be the most
vulnerable to malnutrition.

1.4.1 – Household Expenditure and Nutritional Status
In 1996, the MICS survey provided some insight into the expenditure patterns of Cambodians
which has served as a proxy measure of income. From the lower to the upper quintiles, the gap
between total food expenditure and total expenditure decreases as does the mean weight-for-age
z-score.

1.5 Care
1.5.1 – Breastfeeding and other Feeding Practices
Breastfeeding is nearly universal (more than 96%, CDHS). However, there are cultural practices
that negate some of the benefits of breast-feeding. Initiation of breast-feeding within one hour is
very low (11% in 2000) and only 24% within 24 hrs. 57% of newborns get prelacteal feedings
(CDHS).

The average duration of breast-feeding in Cambodia is 24 months (CDHS). Exclusive breast-
feeding (no introduction of other foods), is practiced by 14% of mothers for the first four months
and by 5% for a full five months. 98% of mothers breastfeed their infants six times or more per
day (CDHS). Aggressive promotion of breast milk substitutes by milk marketing companies and
the HIV/AIDS epidemic threaten to undermine traditional breastfeeding practices in Cambodia.

1.5.2 - Positive and Negative Deviance in Growth: Study Results
The reader is referred to Annex 1 for the full report on this interesting study that was presented in
the CNIP 1998.

1.5.3 – Diarrhoeal Diseases Incidence and Treatment
Data from the 2000 CDHS indicate a higher incidence of diarrhea overall in boys (20%) than in
girls (17%). The total prevalence is 18% for the two weeks preceding the survey. There is a
seasonal difference (peak in rainy season), but this could not be confirmed by CDHS as it was
conducted for only one round.

Overall, the use of Oral Rehydration Solution (ORS) is low at 17% (plus 3% who use
recommended home fluids); 40% use rice water. 56% of mothers give their children a western
medicine for diarrhea (CDHS 2000).




                                                                                                  14
                      CHAPTER 1: Analysis of the Nutrition, Trends and Causes


1.6 - Access to and Utilization of Health Services
The immunization status has a positive influence on nutritional status. 47% of the children
surveyed by CDHS had immunization cards. 33% of the children under 1 year were fully
immunized. 41% had been given the measles vaccine before their first birthday. DPT coverage
(three doses) was 42%, BCG 66%. There was no information collected on polio immunization
in the MICS. These rates are lower than those reported by the Ministry of Health.

Like in many other countries, the majority of quality health care is found only in the capital city.
Information from the 1996 National Health Statistics Report shows that the number of health
workers in Phnom Penh was much greater than in any other area of the country, and the ratio of
health worker to population in urban areas is significantly higher than in rural areas.

Only 37% of all pregnant women had some kind of Ante-Natal Care (ANC) in 2000 and only 9%
had more than three visits (CDHS).

1.7 - Water and Sanitation
The CDHS survey provided some information regarding drinking water sources and sanitation
practices in Cambodia. For drinking water, 27% of the households use safe surface water.

There is a relationship between safe drinking water and both stunting and wasting. Stunting is
definitely less prevalent in children who have access to safe drinking water.

Overall, 79% of the households visited by the CDHS had no toilet facilities. It appears that good
sanitation has a bigger impact on underweight status than good drinking water, because bad
sanitation contributes to the contamination of foods.

1.8 - Conclusion
The nutritional situation of children in Cambodia is poor and the factors involved are many. On
an average 45% of children under 5 years are underweight, 44% stunted and 15% wasted. It is
obvious that malnutrition starts very early in life. A large majority of young children are
malnourished by 13-14 months of age and finally by 45-50 months of age 52% are underweight
and 58% stunted. Some children are born with malnutrition in the form of low birth weight due
to poor maternal nutrition.

To overcome the problem of malnutrition, it is necessary to address all causal factors during
pregnancy and the first two years of life. Causality is difficult to determine, although factors such
as, feeding of colostrum, exclusive breast-feeding, and commencing adequate complementary
feeding, as well as IDD, VADD, low immunization coverage, and access to health services and a
hygienic environment are certainly important in addressing malnutrition and poverty as a basic
cause. These problems are mostly related to poor access to health care, education, food, incomes
together with a lack of knowledge of maternal and child caring practices. The care and
consumption aspects of malnutrition in Cambodia are more complex and are related to
Cambodia’s tragic modern history. There is neither a simple nor a quick solution to the high
rates of stunting and underweight found throughout the country. However, this CNIP offers
some promising alternatives to improve nutrition and the quality of life of Cambodians.




                                                                                                  15
                     CHAPTER 1: Analysis of the Nutrition, Trends and Causes


From a strategic and investment perspective, the main conclusions here are:
•  The primary nutritional problems that need to be addressed are protein energy malnutrition
   (PEM) and the vitamin and mineral deficiencies of vitamin A, iodine and iron.
•  PEM is a widespread problem in Cambodia, affecting about 45% of children between the age
   of 6-59 months and at least 20% of the women.
•  Although rural areas are much more affected than urban areas, the lowest prevalence of
   malnutrition, at 35% in Phnom Penh (CDHS), is still very high.
•  Both girls and boys are equally affected.
•  When comparing growth of children from male and female-headed households, it was found
   in 1996 that age of the household head is a factor in child nutritional outcomes. The most
   vulnerable group is households headed by females under the age of 35 years. Children from
   households headed by a woman over 35 were best off nutritionally.
•  The main underlying causes of malnutrition are not primarily related to food availability, but
   rather to caring practices and access to health and environmental sanitation. Poverty is the
   main basic cause, and for poor people access to food can be a problem.
•  The study of positive and negative deviance in nutrition found that children whose mothers
   start complementary feeding later then six months and who are breast-feeding exclusively
   beyond six months, tend to be at greater risk of malnutrition than others where
   complementary food is introduced at around 6 months of age.
•  Children whose mothers are not breast-feeding exclusively before they reach the age of 6
   months also tend to be at greater risk of malnutrition than those who are exclusively breast-
   feeding.
•  Children who are growing well despite lower family incomes (positive deviants) are less
   likely to have diarrhea than other children. Whereas children who are not growing well
   (despite higher family incomes) receive more or the same amount of liquids less often than
   other children with diarrhea.
•  Children who are taken to the clinic, health worker or hospital more regularly when they
   have a fever or a blocked nose, grow better than others.
•  It appears that ownership of assets is related to good child growth. For example, children
   who are positive deviants more often come from families with a motorbike while children
   who are negative deviants tend to come from families who own a cart.
i Children who are negative deviants most often are from families who spend significantly
   more money on food, house furnishings, medical care, and personal care products and
   services.




                                                                                              16
                          CHAPTER 2: Assessment and Analysis of Programs



                                       CHAPTER 2

           ASSESSMENT AND ANALYSIS OF PROGRAMS
2.0 - Introduction
There are good chances for the inclusion of nutritional components in the current SEDP II under
discussion. Suggestions in writing were already made by the National Council for Nutrition for
SEDP II to include nutrition concerns more explicitly.

In February 2002, 1,621 Commune Councils are being instituted in all communes in the country.
The Commune Councils will receive a budget and will have some independence in preparing
their own plans and using the money for socio-economic development. As of mid-2001, 43% of
villages already have Village Development Committees (VDC) and are preparing Village Action
Plans (VAP); these are being discussed at Commune Development Councils (CDCs). The
upcoming challenge will be to have CDCs to proactively interact with the new Commune
Councils so that nutrition plans for each commune get funded by the new decentralized funds
being made available after February 2002. This genuine community-based mechanism is
expanding and should cover 70% of villages by 2005. This CNIP will support all efforts in this
direction and propose to train the new council members. UNICEF, UNDP and various NGOs and
their respective central and local counterparts already have significant experience in organizing
the institutional and human infrastructure required for these developments.

There are currently more than 200 international NGOs in the country. For those registered in the
1997 Cooperation Committee for Cambodia (CCC) directory. Table 2.4 outlines the number and
distribution of programs related to food security and nutrition, by province, regardless of
intensity.

Most programs with a training component have been classified as capacity building programs.
Most of those listed under food security are programs related to food production in the form of
home gardening. There are also a number of programs involving rural credit schemes, usually as
part of an integrated community development program; these were not included in the table.
Capacity building, community development and primary health care are the primary sectors with
the greatest number of programs being implemented today.

Phnom Penh receives more than its share of international assistance based on its contribution to
the total population while several provinces are under-served.

Seila and Seth Koma activities are now being expanded; Seila is already active in some 3,000
villages and is scheduled to become national over the coming years.

Seth Koma will cover 1,100 villages in six provinces by 2002 and is negotiating with Seila to
provide training to the VDC’s in topics related to health/nutrition/hygiene/education and credit
etc. Moreover, in the near future, Seth Koma wants to focus its expansion efforts on including
more communes in the six provinces it already covers. These two community-based programs
and the EU-sponsored PRASAC (Program de Rehabilitation et d’Appui du Secteur Agricole au



                                                                                              17
                           CHAPTER 2: Assessment and Analysis of Programs


Cambodge) which together support more than 6,000 VDC’s, plus other NGO’s using similar
approaches, are targeted to receive 80% of this CNIP’s resources in an effort to replicate and
expand their activities.

If to this, one adds the new decentralized Commune Councils, the synergism emerging from
these developments gives this Cambodia Nutrition Investment Plan a future outlook that no other
nutrition plan has had in the past.

Numerous donor-financed investment programs are addressing the issue of household-level food
security:
•  The World Food Program provides major support to the Ministry of Rural Development for
   an extensive national food for work program.
•  AusAID is engaged in developing agricultural extension programs for small farmers.
•  The World Bank supports strengthening the central agricultural and rural development
   ministries, supports a large social funds project, and has developed an integrated rural
   development initiative for under-served areas.
•  The ADB supports programs in agriculture and rural development that include rural roads,
   small irrigation development, generation of employment opportunities and micro credit.
•  GTZ supports the implementation of the Integrated Food Security Project (IFSP) Kampot, a
   six-year work plan initiated in 1996 to improve self-reliant food and nutrition security at a
   household level in the province of Kampot. This program will be continued with some
   changes as a Rural Development Program starting in April 2002.

Programs addressing care and health considerations are more diffused. The health care system is
being rebuilt and much of the emphasis of donor-assisted programs is on communicable disease
prevention and control, combined with strengthening the central ministry and outreach services.
NGOs support a wide variety of health and integrated programs. Maternal, child feeding and
nutrition practices are being addressed by UNICEF and several NGO programs.

2.1 - Micronutrient Deficiencies

2.1.1 - Iodine Deficiency Disorders (IDD)
Presently, only a small fraction (14%) of the salt in Cambodia is iodized, and this is in part from
external sources (Thailand and Vietnam). Since about 80% of the salt in Cambodia is produced
in the province of Kampot, a salt iodization program has been implemented there. To date,
UNICEF has purchased seven medium sized iodization machines, eight smaller machines have
been purchase by WHO and another two smaller machines by Helen Keller International (HKI).
The total number of machines available by late 2000, now have the capacity to iodize nearly all
the salt produced in Kampot with potassium iodate. In 2002, UNICEF has taken action to
procure three additional iodized salt plants as some of the machines have broken down and salt
iodized production is still limited.

Universal Salt iodization has received support from UNICEF, Helen Keller International (HKI),
USAID, Canada for International Development Agency (CIDA) through the Micronutrient
Initiative (MI), the US National Committee for UNICEF and Kiwanis International.




                                                                                                18
                            CHAPTER 2: Assessment and Analysis of Programs


The current situation and problems are as follows:
The National Sub-Committee for Control of IDD (NSCIDD) has been formed with three
working groups on: Salt iodization; Information, Education and Communication (IEC), and
monitoring and evaluation.

The Ministry of Planning has established a Provincial Nutrition Coordination Committee in all
24 provinces with multi-sectoral involvement chaired by the Provincial Governor. The role of
these committees is to coordinate and facilitate any activities related to nutrition issues in their
area.

Public awareness campaigns through direct contact and interpersonal communication at the
household level with communities and market retailers were carried out in Kratie, Kampong
Speu, Kampong Cham provinces and the Phnom Penh municipality through one local NGO and
local authorities with support from UNICEF. Rural development staff in three provinces were
trained in IDD and iodized salt awareness and they will use this knowledge to improve family
education in the communities they support. In Battambang, health center staff were also trained
in IDD problems and the benefits of iodized salt consumption. TV and radio spots, posters and
leaflets for community use have been produced and distributed to families.

One Ministerial Circular sent out by the Government recommends that all salt producers and salt
sellers iodize all edible salt before distribution to the markets. The strength of this circular alone,
is not enough to control the process and to stop the importation of non-iodized salt by some
companies.

2.1.2 - Vitamin A Deficiency (VADD)
The only component of a national program in place is the distribution of vitamin A capsules,
supported by UNICEF, WHO and HKI since 1995. The capsule distribution is linked to the EPI
Program. In 2000, it was estimated that 983,500 children of 12-59 months (63% of target
children) received at least one vitamin A capsule in March and 464,300 children of 12-59 months
(30% of target children) received at least one vitamin A capsule in November through routine
EPI outreach work. In addition, through immunization campaigns carried out throughout
Cambodia, 42,000 children of 12-59 months received a vitamin A capsule at some point in the
first semester and 131,900 children received a vitamin A capsule during the second semester.

These coverage rates collected through the routine reporting system have in the past years been
challenged by surveys that indicate substantially lower coverage rates in certain areas. The
results from CDHS 2000 show that only 29% of the children aged 0 to 59 months received a
vitamin A capsule in the six months preceding the survey and only 10% of women postpartum
got a vitamin A capsule.

In 2000, Helen Keller International carried out the Cambodian National Micronutrient Survey
(CNMS) which included assessment of serum retinol levels. The preliminary results on vitamin
A capsule coverage indicated figure which varied from 10% to 55%. The results also
acknowledge that in all provinces, vitamin A supplementation reduced a child’s risk of night
blindness by more than two times, irrespective of the prevalence of night blindness in the
particular provinces.



                                                                                                    19
                                 CHAPTER 2: Assessment and Analysis of Programs


The figures showed a reduction of night blindness rates compared with the 1993 MOH/HKI
survey results in the overlapping provinces where these two surveys were carried out.

1993 and 2000 MOH/HKI survey Night Blindness Rates from Overlapping Provinces
Target age-group for 1993 MOH / HKI survey was 12-71 months
Target age-group for 2000 MOH / HKI survey was 18-60 months

       10

       8
                                              1993       2000
       6

       4

       2                                                        WHO cut-off 1%
       0
            Kg.Thom   Koh Kong      B. Bang          R.kiri




Night blindness is the first sign and a well-recognized indicator of VADD. The Cambodia
Demographic and Health Survey 2000 assisted by USAID, UNFPA and UNICEF showed that
8.4% of the women reported night blindness during their last pregnancy. The Cambodian
National Micronutrient Survey (CNMS) of 2000 found the prevalence of night blindness was
above 1% among children 18-59 months of age in six out of ten provinces surveyed.

Challenges in this program include increasing the access to the outreach budget so that outreach
teams can reach all villages around the month of March and November. This requires additional
social mobilization and availability of vitamin A capsules at the district level. The high turnover
of health staff at the operational level needs to be addressed as staff trained in vitamin A policy
and guidelines move to work in other health institutions and are replaced by untrained new staff.
The current strategy to provide the lactating women with a high dose of vitamin A capsule within
eight weeks post partum will also need to be redefined to allow health staff to take vitamin A
with them every time they go for outreach work.

2.1.3 - Iron Deficiency Anemia (IDA)
Apart from iron/folate supplementation of pregnant women during ANC, current programs that
address the problem of iron deficiency anemia in Cambodia are limited in scope and scale
compare to the magnitude of the problem. For every pregnant woman in the last five years, four
ANC visits and 90 tablets of iron/folate are recommended. However, the CDHS 2000 reported
that 55% of mothers don’t have an ANC, 13 % visit AN Clinic once, 22% two to three times and
only 9% four times. This is mainly due to the poor access to health centers, cultural factors and
lack of knowledge about the dangers of IDA. Very few pregnant women receive iron/folate
tablets, and even those who do receive them do not take them as recommended, as they are
unaware of the importance of iron/folate supplements.

The National Nutrition Unit/NMCHC, with the support of WHO and UNICEF, is currently
conducting a pilot project to assess the effectiveness of preventive weekly iron/folate
supplements in women of reproductive age. This study is being conducted in garment factories in



                                                                                                20
                           CHAPTER 2: Assessment and Analysis of Programs


Phnom Penh and in secondary schools and rural villages in two districts of Kampong Speu
province. The results of the pilot study will be available in August 2002.

Control of hookworm and malaria are also important ways to address the problem of anemia.
The National Center for Malaria Control (CNM), in collaboration with WFP, provides
mebendazole tablets to school children and also distributes bed-nets for malaria control.

2.2 - Agriculture
The Cambodians’ diet depends primarily on rice production. Vegetables are the second largest
crop produced in Cambodia. More than 30 government, UN, regional and non-governmental
organizations have been or are currently involved in projects related to vegetable production.

95% of the food consumed by rural Cambodians (by weight) is rice, with the other 5% being fish
paste, vegetables, some coconut, tamarind, fish, or other meat (Mak, 1997). Farmers also raise
animals and catch fish, but eat predominantly the rice while using the others mainly as a source
of income. When they harvest rice, they save some, and sell the rest for cash. Later on, they buy
rice at a much higher price. This can lead to the need to borrow money and be burdened by
interest payment and debt.

2.3 – Actions currently being implemented and planned for the near future that are in line with
this CNIP’s suggested areas of intervention implemented by relevant Government agency, donor
organization and NGO are presented in chapter 2 and 3.

2.4 - Brief Profile of Major Current Activities by Agency

2.4.1 - Food and Agriculture Organisation (FAO)
FAO in Cambodia is supporting the UN Theme Group on Agricultural and Rural Development
for Sustainable Food Security and Poverty Eradication. In collaboration with the Ministry of
Agriculture, Forestry and Fisheries, FAO provides technical assistance through the Special
Program for Food Security (SPFS) and the Women in Irrigation, Nutrition and Health Project
(WIN). This project aims to strengthen agricultural production by contributing to the
empowerment and participation of women in the management of irrigation and water resources,
the improvement of the food and nutritional situation of the local people, the promotion of health
care and the introduction of time-saving technologies in domestic tasks.

SPFS and WIN introduce appropriate agricultural technologies, nutrition, health care and gender
issues at a household level through the Integrated Farmer Field Schools, regular monitoring and
field demonstrations. Both projects are implemented in a total of ten pilot sites in the provinces
of Takeo, Kampot, Siem Reap and Kampong Cham.

The project outputs are: improvement of water management and empowerment of women in
irrigation and water resources management, crop diversification and intensification and increase
of farm income, incorporating health care and capacity building in nutrition and public
awareness.




                                                                                               21
                           CHAPTER 2: Assessment and Analysis of Programs


2.4.2 - SEILA PROGRAM
Seila is a program of the Royal Government of Cambodia (RGC) which began in 1996 and aims
to contribute to poverty alleviation through the strengthening of local governance in the context
of decentralized and de-concentrated strategies and systems. During the first phase of Seila
(1996-2000), the RGC has designed and tested decentralized and integrated management
structures and systems for planning, financing and managing local development. Decentralized
support to communes during this period increased from 20 in 1996 to 220 communes in 2000
and to 318 communes in 2001 in 11 provinces, and one municipality each in Banteay Meanchey,
Battambang, Siem Reap, Pursat, Ratanakiri, Takeo, Prey Veng, Kampong Cham, Oddar
Meanchey and Pailin municipalities. By 2005, coverage is expected to reach 1,216 communes in
16 provinces. The Partnership for Local Governance Project provided technical advice and
support to the Seila Program in all provinces and in Phnom Penh.

Table 2.1     Seila Geographical Coverage:
                   Name of province        Number of communes covered
 1. Ratanakiri                                          34
 2. Siem Reap                                          65
 3. Banteay Meanchey                                   63
 4. Pursat                                             49
 5. Battambang                                          57
 6. Takeo                                               5
 7. Kampong Cham                                        5
 8. Prey Veng                                            5
 9. Oddor Meanchey                                     17
 10. Pailin Municipality                                8
 11. Kampot                                             5
 12. Kampong Thom                                       5
                   Total                               318

2.4.3 - UNICEF
The objective of UNICEF’s Program of Cooperation with the Royal Government of Cambodia
for the period 2001-2005 is to improve the nutritional status, as well as the poverty situation of
rural communities. With respect to direct support to nutrition, UNICEF’s program of assistance
is directed at three strategic areas:
•   Policy and strategy development.
•   Support to nutrition interventions at both the national and community level.
•   Development of a nutrition information system.

In the area of policy and planning, UNICEF has provided strategic and technical leadership in
the development and adoption of a National Nutrition Plan of Action (NNPA) and the Regional
Technical Assistance (RETA) study which have resulted in the development of this document.
UNICEF thinks that the acceptance to form a National Council of Nutrition (NCN) within the
Ministry of Planning, as part of the implementation of the NNPA, will provide an excellent
infrastructural support for the implementation of the Cambodia nutrition investment plan
proposed in chapter four.



                                                                                               22
                           CHAPTER 2: Assessment and Analysis of Programs


UNICEF’s assistance to interventions at the national level is mainly in the areas of micronutrient
deficiencies and the promotion of breast-feeding and the Baby Friendly Hospital Initiative.
UNICEF was instrumental in the formation of a national multi-sectoral committee for the control
of IDD, procurement of machinery and supplies for salt iodization including technical support
and the mobilization of relevant partners and resources towards the elimination of IDD. In
addition, in 1999, UNICEF supported iodization of well water in the provinces of Kratie and
Stung Treng through the NGO Partners for Development (PFD). For VADD, not only has
UNICEF mobilized partners and resources, but has also supported vitamin A supplementation
through the National Immunization Days integrated into the EPI. The major micronutrient
challenge left for UNICEF and Cambodia is iron deficiency anemia. There are plans for
addressing this problem in the near future. Food based strategies are implemented at the
community level through the Seth Koma Program (UNICEF community development project).
Public health measures like immunization and major efforts in prevention and case management
of diarrhea and Acute Respiratory Infection (ARI) which are mainly, supported by UNICEF also
have a positive impact on the nutrition situation.

It is at the community level, through the Seth Koma Program, that UNICEF provides major
support to nutrition-relevant interventions. The model used is based on UNICEF’s global
experience with integrated community-based programs using the holistic UNICEF Nutrition
Strategy, which was adopted by the UNICEF Executive Board in 1990. Seth Koma is conducted
within the framework of the Convention on the Rights of the Child (CRC) and the Convention on
the Elimination of All forms of Discrimination against Women (CEDAW).

Seth Koma is a cross-sectoral program being implemented with support from several ministries,
notably the ministries of Planning, Rural Development, Women and Veteran’s Affairs,
Agriculture, Education, Health, Social Affairs, and Interior (in charge of local government). The
idea is to enhance the capacity of the community by focusing on Village Development
Committees (VDCs), civic organizations, and NGOs for achieving the basic social goals of the
community as measured in time. This process of “building from below” is supported by
national, provincial, district and commune structures of government in the relevant ministries.
The process used by UNICEF for the formation of VDCs through a gender-sensitive, free and
fair election and involving training of VDC members was adopted by the Ministry of Rural
Development in 1997 as the model approach. The development of Village and Commune Action
Plans (VAPs/CAPs) through which services are delivered, makes the approach demand-driven.

The Seth Koma Program, planned at a total budget of US$ 15 million for the period 2001-2005,
uses nutrition as its outcome indicator. Its five main components,[(1) Community Empowerment
& Capacity building; (2) Community Education and Care; (3) Water & Sanitation, Food, and
Environment; (4) Health, Hygiene and Caring Practices; (5) Improved Economic Opportunities
& Protection of Vulnerable Children and Women;] address the three main underlying
determinants of nutritional status: household food security; care for children and women; and
health, water and hygiene.

Although there is national support for each of the five components, the present focus of the Seth
Koma Program (as of 2001) is in 1,130 villages, 120 communes and 18 districts in six provinces
(Kampong Speu, Kampong Thom, Prey Veng, Svay Rieng, Oddar Meanchey and Stung Treng).



                                                                                               23
                           CHAPTER 2: Assessment and Analysis of Programs


The total number of beneficiaries is more than 700,000. From the estimated costs for 2001, the
cost per beneficiary ratio for the entire program is as follows:

Table 2.2 – Costs per Beneficiary of Seth Koma Program, 2001.
 Beneficiary group         Total population in       Cost/beneficiary/year
                           Seth Koma                 (USD)
 Children < 5 years        103,150                   $ 16.35
 Women & children (< 5) 165,480                      $ 10.20
 Total population          700,000                   $ 2.41

The well-known UNICEF-supported Family Food Production (FFP) project was incorporated
into the Seth Koma Program. There is evidence for several of its components to be sustainable,
especially the family fishponds and home gardens in areas where the program has already
withdrawn.

The third area of UNICEF support is in nutrition information systems. UNICEF supported the
Multiple Indicator Cluster Survey (MICS) which was conducted in 1996 and provided the first
nation-wide information on the nutrition situation of children under 5 years of age. UNICEF also
supported the first National Goiter Prevalence Survey for IDD and the VADD survey in 1998 (in
collaboration with HKI). Also, UNICEF supports the Health Information System (HIS) which
provides information relevant to nutrition and has the potential to report on health facility-based
growth monitoring. There are plans to assist the Government in developing a system for
monitoring the UNICEF assisted Program of Cooperation which includes the development of a
nutrition information system. Already, the Seth Koma Program has started developing a
nutrition-relevant database for use with Geographical Information System (GIS) software for
analysis.

2.4.4 - World Food Program (WFP)
The WFP contributes to increase the knowledge on food insecurity and nutrition issues in the
Kingdom as well as supporting a variety of activities to address such issues. The WFP VAM
(Vulnerability and Analysis Mapping) Unit compiles and processes information for the targeting
of food insecure areas through surveys and existing data, significantly contributing to the
knowledge base of food security in Cambodia. WFP participates actively in the current UNDAF-
exercise and chairs a Foods Security and Nutrition Working Group with the local donor
coordinators on social sector issues. Envisaged are the design of a food security strategy and a
comprehensive food-based safety net program.

Currently WFP has two ongoing operations: PRRO 6038.01 (Protracted Relief and Recovery
Operation) and the Quick Action Project QAP 6188.00 (Supplementary Feeding of Mothers and
Young Children in Food Insecure Areas).

PRRO 6038.01, Food Aid for Recovery and Rehabilitation in Cambodia
The PRRO places emphasis on a sustained WFP presence and a diversity of projects, mainly in
remote, highly vulnerable, low-potential areas. WFP is working towards developing a holistic
program approach through:



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                           CHAPTER 2: Assessment and Analysis of Programs


•   An integrated approach in targeted commune clusters that offers a comprehensive package of
    recovery activities, including Food For Work (FFW) schemes complemented by WFP
    assisted social support projects for particularly vulnerable groups. Furthermore, benefits
    accruing to one set of villages add to those of another (e.g. schools, market access (roads)
    and irrigation schemes);
•   Participation in commune development plans through Seila, the decentralized local planning
    process; and
•   Partnerships in rural development: WFP will, in cooperation with the Government, expand
    links with effective partners, including UN agencies, as well as the World Bank, Asian
    Development Bank, European Union (EU) and NGOs in areas where integrated rural
    development projects are planned during the period of this PRRO.

QAP 6188, Supplementary Feeding of Mothers and Young Children in Food Insecure Areas
WFP initiated its Supplementary Feeding Project in September 2000 to address the
intergenerational effects of early malnutrition among vulnerable groups in Cambodia
(specifically pregnant and lactating women and children under 5 years of age) at critical times in
their lives. Approximately 35,000 children under 5 years of age and 6,500 pregnant and lactating
women benefit from monthly take-home rations, growth monitoring and nutrition education. The
project is currently implemented in 30 health centers in the six provinces of Battambang,
Banteay Meanchey, Siem Reap, Kampong Thom, Kampong Speu and Kratie. The project is a
joint venture between NGOs, provincial government and the WFP which allows the beneficiaries
to benefit from a wide range of health and nutrition related interventions.

The supplementary food is provided in the form of fortified Corn-Soya Blend (CSB) which is
rich in vitamins and minerals. Children under 5 years of age receive 6kg CSB per month while
mothers receive 3kg per month. Vitamin A fortified oil (0.3kg) and sugar (0.75kg to children) are
also provided.

WFP emphasizes the importance of nutrition education. Every growth monitoring session and
food distribution within this project includes nutrition education. Health center staff, village
volunteers and NGO staff provide information on breast-feeding, appropriate complementary
feeding practices, hygiene and sanitation, disease management and reproductive health.
Immunization, vitamin A supplementation and de-worming programs are also implemented in
most health centers.

The experiences and results of the Supplementary Feeding Project will guide the possible
expansion of supplementary feeding in Cambodia.

2.4.5 - World Health Organization (WHO)
A WHO Nutrition Advisor has been working with the National Nutrition Unit (NMCHC) since
early 1999. WHO strongly committed to support capacity building of Cambodian national staff
working in the field of nutrition, providing full time technical support and training opportunities
to the Nutrition Unit (NMCHC). International WHO nutrition experts in food safety, food
fortification, breast-feeding counseling and micro-nutrient deficiencies also provide regular
consultancies and training to support and develop the work of the National Maternal and Child
Health Center and the MOH.


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                           CHAPTER 2: Assessment and Analysis of Programs


WHO also supports the MOH in the National Integrated Management of Childhood Illness
Strategy (IMCI), the National Immunization Program, Health Sector Reform, Human Resources
for Health, Malaria and Dengue Haemorrhagic Fever Control, Essential Drugs, HIV/AIDS,
Environmental Health, Prevention of Blindness, Mental Health, Leprosy and Blood Transfusion
Services.

WHO plans to continue to support the RGC's efforts to address nutrition problems in Cambodia
through the technical support of the National Nutrition Unit, particularly in areas of policy
development, program planning and implementation and monitoring and evaluation. As well as
support to the IMCI, areas of particular concern will be micronutrient deficiencies, breast-
feeding promotion and the prevention of malnutrition in women and children under the age of 5.
WHO also works in close cooperation and collaboration with other MOH departments, UNICEF,
WFP, FAO and NGOs involved in nutrition interventions.

2.4.6 - GTZ
Assessments show, that about 80% of the food deficit households were concentrated in four of
the eight districts covered by GTZ. A prioritisation process leads to the identification of almost
20,000 families living in some 90 villages. Among the target groups at food risk, special
attention was given to farmers with very little land, landless families, women headed households
and Khmer Rouge defectors.
Main Problems and Areas of Intervention:
An initial nutrition survey in 1996 revealed that 43% of the children under the age of 5 suffered
from chronic malnutrition (stunting) and 21% from acute malnutrition (wasting). Now, the entire
year average prevalence of acute malnutrition is down to 7%, and chronic malnutrition among
the children has been reduced to 35%.
Based on a participatory problem analysis with affected villages, different dimensions of food
security and their underlying causes were identified. Acute malnutrition was due to seasonal food
deficits, unsafe drinking water, diarrhoea and infectious diseases; while chronic malnutrition was
found to be linked to more structural reasons. These included low agricultural production, low
income, indebtedness, poor rural infrastructure, unbalanced diets and food taboos as well as a
lack of appropriate health care services.
Based on the analysis the project developed six key intervention areas:
•   Agricultural and Livestock Production - to tackle low rice production (a deficit of often more
    than six months) through the formation of self-financing Village Livestock Agents and the
    promotion of appropriate cultivation and crop diversification practices.
•   Additional Income Opportunities Promotion - through skills training aimed at relieving the
    low-income situation.
•   In Kind Credit – provided for members through self-managed village based rice banks, aimed
    at serving short-term food and credit needs and helping to overcome the spiral of poverty and
    indebtedness plus feeding village owned social funds.
•   Village Infrastructure Development - especially rural roads, water supply, small irrigation
    structures, and fish ponds through food-for-work, combining immediate interventions in food
    deficit periods with long term productive investments.



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                           CHAPTER 2: Assessment and Analysis of Programs


•   Health Services and Nutrition Education - aimed to improve drinking water and sanitation
    conditions (wells, latrines etc.) as well as propagating better diets, especially for children
    (nutrition education, home gardens etc.). Family planning was also included as a response to
    a great demand articulated by women.
•   Self-help Capacity Strengthening of Villagers - a key issue for sustainable development
    through participatory village planning sessions, the support of village development
    committees and the democratic election of user groups.
Project Strategy:
The Integrated Food Security approach focused on direct achievements at village level and on
human resource development of relevant institutions at a provincial, district, commune and
village level. The pursued strategy focused on:
•   Community-based, participatory processes for the identification, implementation and
    monitoring of project activities.
•   Integrated system of project measures complementing each other in the different areas of
    intervention (infrastructure, agriculture, income generation, finance, and health).
•   Social mobilisation of project beneficiaries through enhancing their self-help capacities.

2.4.7 - PRASAC II: From Emergency Relief to Sustainable Development
To help rebuild Cambodia after decades of civil war, the European Commission is supporting
rural reconstruction and rehabilitation through the Support Program for the Agriculture Sector in
Cambodia (PRASAC). All activities are dedicated to increase the income of the farming
communities and to nourish a prospering life in the rural villages. Established in 1995, PRASAC
is a joint project of the European Union and the Royal Government of Cambodia.

Now in its second phase (1999 – 2003), the project is supporting rural development in the
provinces of Kampong Speu, Takeo, Kampong Cham, Kampong Chhnang, Prey Veng and Svay
Rieng. The executing agencies are: Ministry of Rural Development (MRD), Ministry of
Agriculture, Forestry, Fisheries (MAFF), Ministry of Water Resources and Meteorology
(MoWRAM).

PRASAC addresses the main priority areas found throughout the rural sector in Cambodia,
namely:
1. Improving agricultural production: Food security, diversification of production and increased
   access to local and international markets.
2. Rehabilitating rural infrastructure: Improved roads, rehabilitated irrigation systems, and a
   good supply of clean water to households.
3. Providing access to rural credit and promoting micro-enterprises: Finding a balance in the
   rural money lending system by providing cash to people living in remote areas, and bringing
   down exaggerated interest rates of individual moneylenders.
4. Strengthening government and village-level institutions: Participatory involvement of the
   communities in all development operations in the villages, combined with appropriate
   support to the partner institutions in the provinces.




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                           CHAPTER 2: Assessment and Analysis of Programs


   Changing from emergency relief to sustainable rural development, thus making a valuable
   contribution to "good governance"
5. Establishing data and information systems to steer development: Sharing knowledge is
   sharing power - involving communities and partner organizations in planning, monitoring
   and evaluation of the project activities

PRASAC is one of the most important projects of its kind in Southeast Asia. To ensure a tangible
impact on the lives of the rural population, project investments (in million Euro) are substantial:

       1995 – 1999     PRASAC I:                   39.8
       1999            Transition period:          6.8
       2000 – 2003     PRASAC II                   32.2


Table 2.3      By March 2001 the Project had Achieved
 Wells                                 >4,000
 Tanks, Jars, Ponds                    >1,800
 Large irrigation systems              19 (>25,000 ha)
 Farm to market roads                  70 km
 Improved rice seeds                   1,770 tons
 Extension outreach                    > 115,000 households
 Saving and Credit Associations        882
 Credit since 1995                     52 Billion Riel to 26,800 clients
 Entrepreneurial support               >9.000 initiatives
 Training Centres                      2
 Community Based Organizations         >2,400
 Capacity Building RGC                 >650 staff

In the second phase of PRASAC, the achievements are consolidated and routine activities are
transferred gradually to the executing agencies, the beneficiaries themselves and/or the private
sector to ensure post-project sustainability for the benefit of the rural population.

2.4.7.1. - Improving Agriculture Production
Food security, diversification of production and increased access to local and international
markets are the fundamentals of PRASAC’s activities in the agricultural sector.

Agricultural productivity is improved in a sustainable way:
•  Accelerated growth in agriculture through better technologies and higher yields at reduced
   costs while safeguarding the natural resource base.
•  Modernizing agriculture through intensification and diversification so that the farmer can sell
   to the market and get profits.
•  Crop production is improved through better seeds, fertilizer, and plant protection.

Better breeds, fodder/feeds, and veterinary care are the main factors to achieve increased
productivity for livestock and fish production.



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                          CHAPTER 2: Assessment and Analysis of Programs


PRASAC support consists of:
• Seed production and multiplication (rice and other cash crops).
• Needs-based input applications (mainly fertilizer), and integrated pest management.
• On-farm testing and demonstrations to be carried out by farmers.
• Agricultural extension, in particular developing concepts of organization, working methods,
  and logistics for the extension service.
• Training of extension workers and qualified instructors:
  - Elaboration of extension subjects providing appropriate and feasible solutions to existing
     problems
  - Development of extension materials and instructions.

The project builds the farmers’ capacity to identify their own farming priorities and extension
needs and to actively participate in the integrated village extension program. Farmers, trainers
and technicians receive:
•  Training in technical and skills building topics of their own choice to support production,
   post production and marketing activities
•  Opportunities for field trips to other project areas to learn from each other’s experiences.

More than USD 8 million have been invested in agriculture since the beginning of the project.
With better skills and better technologies to make use of their land and aquatic resources, over
50,000 farm families in the target areas are enabled to improve their food and income situation
and participate in the on-going development of the rural areas.

2. 4.7.2 - Rehabilitation Rural Infrastructure
PRASAC regards improved roads, rehabilitated irrigation systems, and a good supply of
domestic water to the households as major and significant contributions to successful social and
economic development:

•   Rural Roads, including bridges, culverts, drainage systems (ditches) are important to the
    social and economic development and help to alleviate poverty in Cambodia’s rural areas.
•   Together with villagers who have contributed labor and other inputs, PRASAC has built
    more than 70 km of farm-to-market roads, often in cooperation with Food-for-Work actions.
•   Irrigation schemes and Farmers Water User Community Support.
•   Rice production is the main source of income in many rural households. Construction,
    rehabilitation and maintenance of 15 schemes that cover an irrigated area of more than
    30,000 hectares to support agricultural production and productivity have led to a more than
    twofold, sometimes threefold, increase in rice yields and better household income.
•   15 Farmers Water User Communities (FWUCs) are supported to ensure sustainable scheme
    operations, including the ground water irrigation and pumping systems.
•   Domestic water supply is improved through the provision of drilled wells (3,700), dug wells,
    ponds and nearly 3,000 rainwater catchment systems (jars, tanks). This helps prevent various
    water-born diseases.
•   Water user groups and water point committees are established and supported with training in
    operation and maintenance, water sanitation and hygiene. Regular water tests control the
    quality of drinking water.




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                          CHAPTER 2: Assessment and Analysis of Programs


Altogether, about USD 15 million have been invested in rural infrastructure since the beginning
of the project. Already many installations have been handed over to the users who operate and
maintain the infrastructure on their own.

2.4.7.3 - Providing Access to Rural Credit
PRASAC credit balances the rural money lending system - it provides cash to people living in
remote areas, and brings exaggerated interest rates of individual moneylenders down. These
enormous economic benefits are highly appreciated by the farmers and entrepreneurs who want
to develop their own small businesses.

PRASAC’s promotional measures for credit and micro-enterprise (ME) are aimed at:
• Providing loans to village communities and rural micro-entrepreneurs (actual as per March
  2001):
  - A total of Riel 52 billion had been disbursed as group and individual loans to villagers
     and rural micro-entrepreneurs.
  - The PRASAC Credit Program has helped to establish 830 Savings and Credit
     Associations (SCAs) with an average capital per SCA of Riel 2.7 million.
• Supporting alternative income generating activities:
  - More than 11,000 new micro-enterprise activities have been supported in all provinces
     resulting in increased cash income for the entrepreneurs’ families. Two Micro-Enterprise
     Centers (MECs) were set up in Prey Veng and Svay Rieng during Phase I.

The Micro-Enterprise centers help to:
•  Identify the area’s entrepreneur’s needs and priorities.
•  Prepare business packages and informative material to support existing and potential micro-
   enterprises.
•  Identify appropriate skills responding to market demands, and to regularly update curricula
   and training materials.
•  Train entrepreneurs by providing upgraded selected theoretical and practical skills to
   improve production efficiency and quality.
•  Link with the private sector to facilitate job placements for trainees who seek employment.

In total, about USD 9 million have been invested in credit and micro-enterprise promotion since
the beginning of the project. Much needed cash and training to spur economic activities was
provided to rural households that otherwise would not have had the opportunity to participate in
the rural development process.

2.4.7.4. - Strengthen Government and Village Level Institutions
PRASAC ensures that the villagers are enabled and the partner organizations have the
administrative, managerial and technical capability to continue project activities after the
termination of special EC funds in December 2003.

Respective support measures include:
•  Training and capacity-building of staff from partner organizations:




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                           CHAPTER 2: Assessment and Analysis of Programs


    500 seconded staff members received on-the-job and other formal training. This pool of
    human resources significantly boosts the capacity of PDAFF, PDoWRAM, and PDRD.
    Selected non-seconded key staff are also trained in a systematic capacity-building program.
•   Handing over of materials, equipment and vehicles to the partner organizations:
    Gradual handing over of materials, equipment and vehicles to support and encourage partner
    organizations in carrying out field activities on their own.
•   Logistic support for provincial planning, organization and management:
    Logistic and technical support for planning and M+E for provincial partner institutions
    (computers and peripherals, software, and basic office equipment)
•   Supporting community-based organizations at village level:
    Enabling community-based organizations to own and operate the rural infrastructure put in
    place with the help of PRASAC.

Altogether, over 1,000 VDCs, nearly 5,000 Water Point Committees (WPC), and over 800
Saving and Credit Associations (SCA) have been established and strengthened. Thousands of
members of the rural communities have been trained and empowered to steer village
development on their own.

In self-reliant villages, PRASAC moves out, and the community-based organizations participate
in the local planning process and link up with government agencies and/or NGOs to get funds
and other assistance for village development.

The villager’s participatory involvement, combined with appropriate support to the partner
institutions in the provinces are PRASAC's key to the change from emergency relief to
sustainable rural development, and constitute a valuable contribution to "good governance".

2.4.7.5. - Establishing Data and Information Systems
Sharing knowledge is sharing power. This motto guides PRASAC’s involvement of the
communities and participation of the partners in planning, monitoring and evaluation of the
project activities. The project’s support for participatory monitoring and capacity building in the
partner organizations is paving the way for continued activities after the end of 2003.

Since the beginning of the project, more than USD 5 million has been invested in strengthening
the project’s partner organizations and the village-level institutions. These investments have
contributed to create an enormous human capital, which constitutes the most important resource
of all for rural development.

2.4.8 - Helen Keller International (HKI)
HKI began work in Cambodia in 1992 when it initiated its first project to assess the extent of
vitamin A deficiency disorders (VADD). With VADD being a problem of public health
significance, initial efforts were concentrated on providing technical assistance to the Royal
Government of Cambodia to develop a National Vitamin A Program. HKI played an important
role in the development of the first national vitamin A policy and has since been active in the
revision of vitamin A policy, as well as the development of policies for other micronutrients



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(iron and iodine). HKI has two program initiatives to improve vitamin A and nutritional status
among women and children:
•   The first initiative aims to improve the coverage of vitamin A capsules (VAC) by creating
    awareness and demand among households and communities and by improving training,
    supervision, logistics, and other essential support activities to the VAC/Immunization
    outreach activity. HKI is working closely with the Nutrition Unit/MOH on the National
    Vitamin A Program. A project to improve the VAC coverage is being piloted in three
    operational districts (ODs): OD Prey Kabas in Takeo, OD Kampot in Kampot, and OD
    Chhlong in Kratie province. This pilot is for the period 2001-2002.
•   The second initiative aims to improve availability, access, and consumption of vitamin A rich
    foods by expanding the HKI homestead food production to reach more households and to
    broaden the program to include poultry activities. As part of this focus, key partnerships have
    been formed with the Government and also local and international Non-Governmental
    Organizations. HKI provides technical assistance to partner agencies in the form of staff
    capacity building and educational materials for program use. Monitoring is an important
    component of program activities. This is done regularly and results are disseminated to the
    relevant parties. This program is being conducted in Phnom Penh and in seven provinces:
    Kampong Thom, Kratie, Takwo, Kampong Speu, Kampong Som, Battambang, and Kandal.

The main funding agency for the current program is the United States Agency for International
Development (USAID). Total budget for 2001 – 2002 is $650,000.

2.4.9 - CARE International
CARE International’s project The Jivit Thmey (New Life) is a maternal and child health project
intended to support the National Coverage and Action Plan of the Ministry of Health in
Cambodia. The project’s goal is the establishment and utilization of selected preventative and
curative services for the rural population of forty communes (235,000 people) in the provinces of
Banteay Meanchey, Pursat, and Kampong Chhnang. Staff consist of a minimum of five
government employees: One mid-wife, one EPI/immunization person, two curative care
providers, and one secondary nurse.

CARE is providing both formal and on-the-job training to Department of Health commune staff
in the areas of MCH, ANC, PNC, EPI, and birth spacing components, along with curative care.
Activities promoted by CARE include the following:
•   Increase ANC visits at Health Centers (HC) including iron tablet distribution (95-2002).
•   Support Vitamin A distribution (2002).
•   Distribute supplemental food and monitor growth in malnourished children (2000-2002).
•   Grow demonstration gardens at selected HCs (1999-2001).

The number of clients in the 26 established commune clinics ranges from 350-600
clients/month/clinic. The total cost of this program, which is funded by USAID and CARE, is
$1,300,000 over three years. Assuming 500 clients are visiting each clinic per month, and 26
clinics are already operating, the cost per beneficiary is less than 2.8 US dollars per month.
While the future of CARE International’s funding from USAID is not known, CARE is
interested in complementing Jivit Thmey’s services-delivery approach to improved health with a
more community-based focus on adapting and strengthening child caretaker behaviors at the


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                           CHAPTER 2: Assessment and Analysis of Programs


household level. CARE is currently seeking the technical expertise and financial resources to
undertake a positive/negative deviance study on child growth, which would help to identify
positive childcare practices within communities. Such a study would enable CARE to use
community experiences to design a broader child survival approach to community health,
enabling poor communities to identify, cross-learn, and adopt affordable, lasting solutions to the
chronic maternal and childcare problems in Cambodia.

2.4.10 - World Vision – Cambodia (WVC)
World Vision Cambodia have health sector and community development programs with
nutritional components. The USAID funded Child Survival project in Kean Svay OD of Kandal
Province implements reproductive and child health interventions, including nutrition,
micronutrients and breast-feeding. This project has been running for five years and is funded
until September 2003. In three districts of Kompong Thom OD, Kompong Thom Province,
WVC manages a night-blindness prevention project funded by World Vision Canada. This
project completed its first two-year phase in September 2001 and achieved a significant
reduction in the prevalence of night-blindness in children from 11% to 3.1%. A second phase
has been funded in the same geographical area until September 2003.

WVC has 23 Area Development Programs (ADPs) which are community development based and
usually operate for 10 to 15 years. These are located in 12 operational districts in six provinces
(Battambang, Kompong Chhnang, Kompong Speu, Kandal, Takeo and Kompong Thom) and are
funded by private sponsorship funds. Each of these programs address community concerns that
include food security, education and health. The CNIP will be a very useful document in helping
these programs prioritize interventions and resources. One ADP in Kandal Stung District of
Kandal Province will be implementing a ‘No Hungry Children’ initiative from World Vision
Canada with a focus on nutrition in children under 5 years of age. A baseline survey will be
conducted in early 2002, followed by selected interventions.

All the above projects (Child Survival, Night-Blindness Prevention and ADPs) are strongly
community based and rely on effective use of Village Health Volunteers and Village
Development Committees.

WVC also manages four HIV/AIDS prevention and care projects along National Highways 1,2,
3, 4 and 5 and in Phnom Penh. The nutritional needs of children affected by AIDS, people living
with HIV/AIDS and their families and communities have been recognized as increasingly
important.

2.4.11- Health Net International (HNI)
The focus of Health Net International is Health System Development and General Community
Health. It operates in Prey Veng, Svay Rieng and Kratie provinces. Although these activities are
not specifically nutrition oriented, they include some nutrition activities. For example, in Svay
Rieng, HNI contributes to the distribution of micronutrients to pregnant women (vitamin A and
iron). In Kratie, HNI collaborates in the Supplementary Nutrition Action Program (SNAP)
supplementary feeding distribution and promote growth monitoring and promotion in all three
projects.
2.4.12 - Population Services International (PSI)



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                          CHAPTER 2: Assessment and Analysis of Programs


Since 1994, PSI/Cambodia has been very active in HIV prevention and Reproductive Health
programs. In the coming years, PSI/Cambodia plans to expand its activities to include nutrition
programs. PSI worldwide has implemented a variety of nutrition projects and PSI/Cambodia
feels that similar projects will be successful in Cambodia and with help improve the nutritional
status of the Cambodian population.

2.4.13 - Food for the Hungry International / Cambodia (FHI)
Food for the Hungry does not currently have any specific activities related to nutrition.
However, at the commune level, simple lessons on basic nutrition are sometimes included with
other related activities of FHI/C’s projects. These include health and hygiene lessons in FHI’s
Water and Sanitation Project and Child Development Project. National information may also be
included in FHI’s Agriculture Project activities related to vegetable gardening and animal
raising. FHI has no nutrition activities at the national level.

2.4.14 Other International and Local NGOs Involved in Activities Related to Nutrition
       Improvement in the Country

Table 2.4 below provides a list of INGOs and local NGOs and brief description of activities
implemented.

Table 2.4 – INGOs and Local NGOs and Brief Description of Activities Implemented
   Name of           Areas of                            Activities
     NGO         Implementation
 International NGOs
 CIDSE          Kampot, Kandal,  Improve local people’s capacity to improve their
                Ratanakiri and   standards of health, education, food security and level of
                Svay Rieng       income by facilitating community based integrated
                provinces        development programs targeted at women, landless, and
                                 ethnic communities.
 Lutheran       Kandal, Kampong  Working with VDCs on seven components:
 World          Speu, Battambang  - Community Development and Human Rights
 Services       and Takeo         - Home Gardening and Livestock
 (LWS)          provinces         - Income Generation
                                  - Water Supply and Sanitation
                                  - School Rehabilitation, Non-Formal Education and
                                    support for children from poor families
                                  - Family Planning, Immunization, and HIV/AIDS
                                    Education and Awareness
                                  - Tree Nurseries
 Partners for   Stung Treng and  Work with VDCs in four areas:
 Development Kratie provinces     - Community Organization and Development
 (PFD)                            - Rural Water Supply
                                  - Environmental Sanitation
                                  - Health Education




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                       CHAPTER 2: Assessment and Analysis of Programs


PADEK         Prey Veng, Svay        Work with Village Development Committees and
              Rieng, Kampong         Commune Development Committees in a bottom-up
              Speu, Siem Reap,       approach to development.
              and Phnom Penh
PACT          Through out            Working through several local NGOs to support
              Cambodia               integrated community development projects.

Local NGOs

Chivit        Eigth villages in      Work with VDCs in five areas:
Thmey         Battambang              - Rice Banks, Credit Schemes, Fertilizer Banks
              province                - Family Gardens, Fishponds
Samakee       Three communes in      Work with VDCs in five areas:
              one district of Svay    - Primary Health Care
              Rieng province          - Birth Spacing and HIV/AIDS Education
                                      - Food Production, Family Gardens & Fishponds
                                      - Water Supply
                                      - Income Generation (village bank and loan)
CHED          Battambang and         Development of IEC materials for health education and
              Phnom Penh             establishment of a health information data bank.
Cambodian     Phnom Penh             Areas of work:
Women’s                               - Vocational Training
Development                           - Credit Banks, Cow Banks
Association                           - Literacy Classes and Day Care Centers
Buddhism    Battambang and           Areas of work:
for         Banteay Meanchey          - Community Development
Development provinces                 - Rice Banks, Mobile Village Banks
                                      - Rotating Cow Banks, Mobile Health Units
                                      - Two Kindergartens for underprivileged children
                                      - Families running a cooperative shop
                                      - Agricultural and Environmental
                                      - Fruit Tree Nurseries
                                      - Vegetable and Seed production
                                      - Food for Work for irrigation and road construction
Kasikar       One district in        Areas of work:
Thmey         Kampong Cham            - Commercial Poultry Production and Training
              province                - Commercial Vegetable Production
                                      - Rice Banks and Revolving Loan Programme
Khmer Rural One district in          Areas of work:
Development Battambang                - Income Generation (small businesses, rice banks and
Association province                    pig banks)
                                      - Vegetable Gardens
                                      - Health Education, Vocational Training
Kratie        One district in        Areas of work:
Women’s       Kratie province         - Construction (schools, dams and wells)
Welfare                               - Credit Programmes and Savings Banks



                                                                                              35
                           CHAPTER 2: Assessment and Analysis of Programs


 Association                            - Family Planning Education
                                        - Family Food Production
                                        - Literacy, Hygiene Education
 MODE            One district in        Areas of work:
                 Kampong Thom           - Distribution of Mosquito Nets to poor families
                 province               - Assistance in building latrines
                                        - Agriculture Programs, Credit Schemes
 Rachana         Takeo province         Areas of work:
                                        - Primary Health Care Education
                                        - Rice Banks and Animal Bank Programs
                                        - Credit Schemes


Please see Annex 2 for table containing some examples of nutrition related activities prepared by
pertinent Ministries and selected NGOs.

2.5 – Conclusions
Several conclusions can be drawn from this chapter:
•   There are many programs with nutrition-relevant components although their scope and scale
    is limited. They are uncoordinated and nutrition is not always addressed explicitly as an
    outcome. A notable exception is the Seth Koma Project that is integrated, relatively large and
    has an explicit nutrition goal.
•   A community-based strategy supported by a national level strategy like this CNIP offers the
    best scenario for an improved nutrition strategy for Cambodia.
•   All nutrition-specific interventions are supported by and largely driven by donor agencies
    and/or NGOs. This CNIP 2003-007 proposes the Cambodian Government also mobilize its
    own resources to explicitly address the problem of malnutrition.
•   Current and future nutrition-relevant programs need to be more coordinated and should move
    current small-scale community-based programs with nutritional relevance to critical scale.
•   The lack of an information system to capture nutrition trends calls for the setting up of a
    sentinel system as proposed above to guide the fine-tuning of this CNIP.
•   A major weakness noted in the current programs is their poor link with research and training
    institutions. In fact, there is no institution in Cambodia that offers any training in nutrition.
    An important consideration for the CNIP is to include the development of a nutrition
    curriculum and the appointment of a specific institution for nutrition training.




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                      CHAPTER 3: Addressing Malnutrition Through Public Policy



                                       CHAPTER 3

  ADDRESSING MALNUTRITION THROUGH PUBLIC POLICY
3.0 - Introduction
Cambodia has already begun using policies that are in line with modern development best
practices. They serve as a guide to international agencies to negotiate their inputs.
Decentralization is an example of a major policy in progress. This CNIP fits in and contributes
to a decentralized approach to development. The challenge will be to find the mechanisms to
adopt and implement this proposed plan and to actually contribute to the enforcement of the
complementary decentralization policy.

3.1 - Government Policies and Programs
The first Socio-Economic Development Plan 1996-2000 (SEDP I) has been completed. A second
one is in the advanced stages of completion. It is expected that both the SEDP II and the
upcoming PIP will include and fund nutrition-relevant interventions.

SEDP II envisages a total capital investment of US$1.75 billion. It has a major thrust towards
social development and poverty alleviation. This is reflected in the emphasis given to the
development of the rural areas and the relatively high indicative budgetary allocations to the
social sector.

SEDP II proposes a direct attack on poverty through health and nutrition programs, rural water
supply and sanitation programs, primary education and the targeting of vulnerable groups who
may be bypassed by economic growth. In the case of health, a District Primary Health Care
Approach is envisaged. In education, the emphasis is on equitable access to at least nine years of
basic education addressing rural-urban and gender disparities. The plan gives prominence to the
elimination of food insecurity by the provision of agricultural extension through the introduction
of improved rice varieties to expand and increase productivity.

The Ministry of Rural Development has been designated as the lead agency in promoting a
system of decentralized, participatory rural development, based on new administration structures
and Village Development Committees (VDCs). This has created a conducive framework for
channeling resources, including those of international agencies and NGOs, for development. As
said earlier, this will now be complemented by the creation of Commune Councils.

The NPAN, elaborated with the support of UNICEF, WHO and FAO and adopted by Cabinet on
January 8, 1997, essentially adapted the international commitments made by the 1990 World
Summit for Children, the 1992 International Conference on Nutrition (ICN) and the 1996 World
Food Summit. Twelve priority areas were chosen:
1. Incorporating Nutrition Objectives, Considerations and Components into the Policies and
   Programs of the Other Relevant Sectors.
2. Improving Household Food Security.
3. Protecting Consumers through Improved Food Quality and Safety.
4. Prevention and Treatment of Infectious Diseases.



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                        CHAPTER 3: Addressing Malnutrition Through Public Policy


5. Better Maternal, Infant and Young Child Feeding.
6. Caring for the Socio-Economically Deprived and Nutritionally Vulnerable.
7. Controlling Micronutrient Deficiencies.
8. Promoting Appropriate Diets and Healthy Lifestyles through Nutrition Education.
9. Operations Research, Assessment, Analysis, and Monitoring of the Nutritional Situation.
10. Water Development for Household Consumption and Irrigation.
11. Institutional Feeding.
12. Human Resources Development in relevant agencies and at grassroots level.

These priority areas are still relevant today.

A very important adoption by the Council of Ministers was the formation of a National Council
for Nutrition (NCN) as the lead agency and nucleus for the formulation of a nutrition policy.
The NCN is supported by the Inter-Ministerial Technical Committee (IMTC). The Ministry of
Planning has set up a ten-person committee as the Permanent Secretariat to work on CNIP. The
NCN and the inter-ministerial committee have not met regularly because the 1998 CNIP was
never funded. The respective functions of the IMTC and the Permanent Secretariat are
complementary and will be defined in writing.

The Ministry of Planning with the assistance of UNICEF and selected donor agencies will
support the function of the NCN endorsed structure for the follow up of this Cambodia Nutrition
Investment Plan (CNIP).

The third Public Investment Program (PIP) 2002-2004 allocates resources to projects with the
highest rate of economic and social return. Addressing malnutrition in all its forms offers a great
opportunity to improve lives and accelerate development at low cost and in a short period of
time. From a nutrition perspective, the PIP is thus an important document.

When reviewing the allocations of the current PIP, the CNIP-relevant budget, including water
supply and sanitation, health, education and training, and social and community services, has a
combined allocation of US$ 329 million. The MOP should lobby for the PIP 2003-2005 to have
an explicit budget line for the community-based component of their CNIP.

While government policy positions with regard to nutrition now seem clearer than they were a
few years ago, they have not yet been explicitly linked to government led strategies and
programs. Part of the problem lies with low human resource capacity and negligible government
resources being allocated to such programs. So far, there has also been a lack of government
capacity to monitor and evaluate the impact of such policies and programs. The MOP will now
take up this role and the Permanent Secretariat will follow the CNIP closely.




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                       CHAPTER 3: Addressing Malnutrition Through Public Policy


Chart 3.1 - Programmed Level Sector Allocation: PIP 2002 - 2004


                                     Social and Community                Special Prgrammes
                                            Services                            1.5%
                                                      Tourism
                     Environemtn and          7.6%      0.2%                   Agriculture
                      Conservation                                               8.0%
                           2.6%
                                           Health                                  Transport
                                           17.8%                                    21.9%
                       Water Resources,
                       Water Supply and                                       Communications
                          Sanitation                                              4.1%
                            12.4%                                              Energy
                                          Administration
                                                                                2.4%
                                             5.6%
                                                                         Trade and Industry
                                                                               1.3%
                                      Religion and Culture
                                              0.7%           Education
                                                              13.8%




As said, many important public policies have been approved, but their implementation and
enforcement is lacking. The government has been very accepting of new policy proposals and
the implementation of this CNIP has a good chance for a positive impact on nutrition in
Cambodia, especially for the most vulnerable groups.

The country’s economy is still donor-driven and the government should lobby and make all out
efforts to seek funds for cost effective interventions.

3.1.1       - The Social Fund of the Kingdom of Cambodia
The Social Fund was established by Royal Decree in December of 1994 as an autonomous
government agency. The Social Fund reports directly to the Prime Minister who appoints the
Board of Directors. The objectives of the Social Fund are to support the Government in its
efforts to reduce poverty through:
•   Financing of projects for the rehabilitation and reconstruction of social and economic
    infrastructure, and other socially productive activities;
•   Creation of short-term employment opportunities, and
•   Expansion of community opportunities to identify local development needs and manage
    small-scale development projects.

In appraising projects, the Social Fund focuses on two key criteria: (a) benefits to the poor, and
(b) technical feasibility and efficiency. The Social Fund began its operation in December 1995
with the assistance of an IDA credit from the World Bank. As of December 1996, The Social
Fund has provided grant support for social sub-projects with a total disbursement of US$ 3.13
million.




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                       CHAPTER 3: Addressing Malnutrition Through Public Policy


3.1.2 - A Review of the Current and Planned Nutrition-Relevant Activities of Several
Individual Ministries is Useful in Providing Greater Detail to the Scope of this CNIP.

A. Ministry of Agriculture, Forests, and Fisheries (MAFF)
The Ministry does have a 1998-2001 Food Security Plan and three members of this Ministry
participate in the Inter-Ministerial Technical Committee on Nutrition. An important part of their
work is geared to increase the rice yields per hectare and to help find solutions for pockets of
food insecurity. They are also involved in promoting vegetable gardens and small animal
husbandry projects. PRASAC, one of the community-based projects this CNIP is interested in
strengthening, works more directly with the MRD; MAFF has also expressed an interest for
more contacts and collaboration with PRASAC.

Later this year, following this CNIP, MAFF wants to organize a Nutrition Working Group with
staff from its agronomy, forestry, fishery, veterinary and agricultural extension departments. The
group would propose nutrition-relevant plans for needy districts and would seek CNIP seed
funding.

Another area MAFF feels it is important to become more active in is rural credit. Existing credit
outlets are too often usury (high interest rates) and a MAFF scheme could make capital available
to farmers at more reasonable rates.

MAFF is already involved in creating agricultural cooperatives in three provinces; they feel
existing community-based programs (Seila, Seth Koma, PRASAC) could be of great help to
them to discuss with farmers the benefits for them to join such cooperatives. On the other hand,
the Ministry is willing and prepared to respond through its Provincial Officers to requests from
the same community-based programs for all that is related to inputs from the agricultural sector.
It is now up to those programs to engage the local agricultural officers.

B. Ministry of Health (MOH)
Protein Energy Malnutrition (PEM):
Staff in health centers are not well trained in growth monitoring (weighing, plotting, counseling).
They also need general nutrition training. The best approach will be to train a cadre of TOTs
from the Ministry. Curricula have been developed (MPA module), but the Ministry is not
satisfied with them (e.g. the nutrition components of the Minimum Package of Activities
curriculum). The Ministry will make a final decision on such a curriculum by March 2002. They
will then set up a working group to prepare a two-year master plan for the training of health staff
in the country covering all logistical and geographical aspects, as well as preparing detailed
budgets. Training supervision will also be included. The activity will start with training a core
group of trainers involving continuing education coordination. The minimum set of topics to be
covered will include breast-feeding, complementary feeding, feeding during illness, nutrition
during pregnancy and lactation, growth monitoring, VADD, IDD, and IDA. Given potential
overlaps, the Nutrition Unit of the MOH will coordinate this activity through Human Resources
development with officers in charge of IMCI.




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                       CHAPTER 3: Addressing Malnutrition Through Public Policy


Overall, MOH efforts in PEM will include the promotion of growth monitoring for children
under the age of two, ante-natal and post-natal services for women including the monitoring of
weight gain during pregnancy, and renewed efforts to collect information on low birth weights.

•    Infant and Young Child Feeding:
Education and Communication efforts on Behavior Change Communication (BCC) on infant
feeding practices have been focused on the promotion of correct infant and young child feeding
(IYCF) practices through mass media and interpersonal communication at community level. The
first promotional campaign on IYCF practices was launched during World Breastfeeding Week,
2001. IYCF Messages were inserted in the two-hour popular live TV show, reinforced by
messages in local newspapers.

Two pilot TV spots were pre-tested, and one was selected with some corrections. It is planned to
produce two more TV spots in 2002. In addition to TV spots, other printed materials have been
developed such as posters and leaflets.

The initiative to control the advertising of breast milk substitutes is being implemented through
the development of the National Code of Marketing Breast Milk Substitutes.

Micronutrients:
Iron: Guidelines for iron supplementation of pregnant women is available at the health centers.
Guidelines for volunteers will be prepared in 2002. Working with the WHO and UNICEF an
iron/folic acid supplementation pilot study using weekly doses is under way. It has started with
factory workers in Phnom Penh and will be expanded in 2002 to secondary school girls and
women in the community. Plans are also being considered to pilot this approach with boys and
girls in primary school. The pre-school age group is also being considered, but policy guidelines
on daily doses still need to be developed.

As relates to the promotion of the consumption of iron-rich foods, the MOH plans to prepare
Information Education and Communication (IEC) materials for nationwide use.

A consultant completed the first step of a feasibility study for iron fortification in October 2001.
He recommended the immediate setting of standards for fortification levels of imported products
such as instant noodles. In a second phase, he recommended further investigation into the in-
country feasibility of fortifying wheat flour and fish sauce with iron. CNIP should follow up on
this.

Vitamin A:
For VADD, the MOH has already approved guidelines. The distribution of vitamin A capsules is
now being carried out during health center outreach activities. During 2001, the MOH gave more
funds to health centers to include the distribution of vitamin A capsules to their monthly outreach
activities. It is also suggested that health center staff need more training on VADD to better
understand its importance.




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                       CHAPTER 3: Addressing Malnutrition Through Public Policy


Mothers are given vitamin A capsules through the outreach program when they come to
immunize their young children. Now it is necessary to include vitamin A supplements for
lactating mothers during all outreach visits.

Suggestions have been made to enroll Traditional Birth Attendants (TBAs) in the distribution of
vitamin A for a post-partum dose, but as yet no decision has been reached.
Post-partum vitamin A supplementation is only done in one major maternity in Phnom Penh.
This activity needs to be expanded to all maternities in the country. In the coming five years, the
MOH would also like to get involved in the preparation of a Cambodian Food Composition
Table and the setting of national dietary guidelines.

C. Ministry of Rural Development (MRD)
The Ministry of Rural Development is one of the CNIP’s prime partners since it is charged with
the setting up of VDCs. An important part of their work will be coordinating with the Ministry of
Interior who is responsible for the setting up of the Commune Councils. The MRD strongly favor
lobbying these councils, once established, to fund as a matter of priority, nutrition-relevant
interventions.

The MRD proposes that CNIP funds be used to train and sensitize the members of the new
Commune Councils. The MRD is PRASAC and Seila’s main partner (who are going to increase
their existing coverage of 12 provinces by five in 2002) and believe that the target of 70% of the
villages (9,100 in number) having functioning VDCs by 2005 may be surpassed.

The MRD strongly suggested that this CNIP be revised and prepared for a five-year span starting
from mid-2002. Their reasons were related to projecting targets both the Government and donors
could better commit to.

In addition they emphasized two things:
•   The implementation of the CNIP must be closely followed by an effective monitoring
    system.
•   The emphasis that CNIP should give to capacity building, not only at the district level and
    below, but also at the central level in the ministries where qualified manpower is
    indispensable and scarce.

At this time it appears that there is growing support for the Village Development Committees.
The development of this Cambodia Nutrition Investment Plan offers a great opportunity for the
Government to become a major and more pro-active player.

D. Ministry of Education, Youth and Sport (MoEYS)
This Ministry has integrated health and nutrition related issues into the primary and secondary
education curricula (from grade 1 to grade 12) which follows the new education structure reform.
Since 1994, the Ministry has totally reformed the curricula for all subjects, completing this
reform in 2001. Health, foods, the environment and nutrition have also been integrated into the
subjects of social sciences, science, Khmer language, vocational skills and family economy.
UNICEF, UNESCO and the Asian Development Bank (ADB) have supported all these changes.
Although, the Ministry still considers that more changes need to be made to properly support



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                       CHAPTER 3: Addressing Malnutrition Through Public Policy


teacher and student needs. In order to fill the missing gaps, it has tried to attract NGOs like
UNICEF to fund the printing of posters on the four food groups including food hygiene and
health education. In addition, the Ministry conducted a pilot training for primary school teachers
and students on diarrhoea home care and diarrhoea prevention in two cluster schools in
Kampong Thom province.

This effort will then require funding for an in-service training program for the nearly 90,000
teachers in Cambodia and for incorporating this training into the pre-service training curriculum
of teachers.

The Ministry has also showed an interest in getting more information about the Institute of Child
Health in London‘s Child to Child Program, for possible inclusion in the Cambodian school
system.

The MoEYS continues to be interested in school and pre-school feeding programs, but see their
value more in supporting school attendance and school performance of pupils, rather than as
nutrition programs. However, the Ministry realizes that these programs do play a role in
providing better nutrition for children, because some pupils in the countryside come to school
without breakfast. The Ministry has requested NGOs and WFP to support the feeding program in
some provinces.

The Ministry is willing and prepared to respond through its Provincial Officers to requests from
the existing community-based programs for all inputs from the educational sector. It is now up to
those programs to engage the local Education Officers. (This fits very well with Seth Koma’s
intentions to get more involved with the schools in the areas where they operate). Finally, the
Ministry is involved and continues to be interested in ECCD activities and supports linking these
more closely with early childhood nutrition.

Goals:
•  The Ministry of Education, Youth and Sport will create an inter-department working group
   on nutrition.
•  It will train the teachers in provinces.

Request: The Ministry of Education, Youth and Sport needs a nutrition consultant/expert.

E. Ministry of Industry, Mines and Energy (MIME)
The Ministry of Industry, Mines and Energy is responsible for the control of food quality. The
Ministry is also responsible for Salt Producers.

The Ministry feels that it has three areas in which it seeks cooperation with this CNIP:

Salt Iodization: This is an industrial process with very poor quality standards. The Ministry
seeks funding to intervene in this issue. They already have equipment in their lab to test salt for
iodine content, but need more contact with the producers that are iodizing.




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                       CHAPTER 3: Addressing Malnutrition Through Public Policy


Iron Fortification: A UNICEF consultant recently (October 2001) completed a preliminary
feasibility study and suggests two possible phases to fortify instant noodles, flour and fish sauce
(the latter also with iodine). Standards have to be set for some of these foods that are imported so
fortification is done at source and checked when imported. Then, more detailed food technology
and marketing studies have to be carried out to start iron fortification in Cambodian food
companies. The Ministry is interested in pursuing these suggestions.

Vitamin A Fortification: The Health Information System shows that vitamin A deficiency is
one of the main public health problems in Cambodia. The Ministry of Industry, Mines and
Energy will prepare a plan for a feasibility study for the vitamin A fortification of food items.
Financial and technical support from international NGOs is needed to establish cooperation
between the Ministry and a private food product company.

The Ministry has already prepared a proposal and costing to upgrade their existing industrial
laboratory to cover food safety issues. They feel it is their obligation to start with product quality
controls from the national food industry. If an agreement is reached with the MOH, this could be
expanded to cover samples from public markets and eateries. They also aim to strengthen laws
to allow import of iodized salt only.

F. Ministry of Women’s and Veteran’s Affairs (MOWVA)
The Ministry of Women’s and Veteran’s Affairs has considerable experience in grassroots social
mobilization, early child education and development, literacy, life-skills, community education
and the components of care and organization of micro-credit, all of which have an important
bearing on improving the health and nutritional status of women and children. The investment
plan will support the strengthening of these activities and ensure that lessons learned are used to
guide the development or revision of national policies in these areas.

In the past, this Ministry was indirectly involved in nutrition-relevant activities mostly, but not
only, collaborating with the MOH. They believe nutrition is a top priority for their female
constituents and thus for the Ministry.

Recently, they trained and deployed 800 volunteers in eight provinces (who, as an incentive, get
10 kg of rice/month from WFP). These female volunteers visit households and give education
and advice on a number of issues that address women’s needs and concerns, including nutrition.
These volunteers have received some training in nutrition, but need more. Additionally, the
Ministry has trained and deployed 58 male volunteers in two provinces.

The MOWVA requests the CNIP provide them with new funds to increase the number of their
volunteers to cover more provinces and that the volunteers be given more in-depth nutrition
training.

G. Ministry of Social Affairs, Labor, Vocational Training and Youth Rehabilitation
    (MOSALVY)
The Ministry is involved in work with children in special circumstances (street, addicted,
disabled, trafficked, delinquent), as well as with vocational schools and with elderly in difficult
circumstances. In its work with street children it is collaborating with UNICEF.



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                       CHAPTER 3: Addressing Malnutrition Through Public Policy




The Ministry has identified three areas in which it wants to link with the CNIP:
•  Support for institutional feeding in all the institutions MOSALVY runs (orphanages with
   children from birth to 18 years, half-way-houses for young delinquents, safe houses for
   trafficked-girls, vocational schools).
•  Health and nutrition teaching in their vocational schools with preparation of curricula and
   training of teachers.
•  Street children feeding interventions similar to those of the NGO Friends.

H. Ministry of Information (MOInf)
Information dissemination through a variety of means is a powerful tool to raising the awareness
of policy makers and the public at large with regard to nutrition-relevant issues. This Ministry
has an important role to play in this aspect through the use of television, radio, news-magazines
and newspapers.

I. Ministry of Justice (MOJ)
This Ministry is responsible for developing the legislation that ensures the child’s and mother’s
right to good nutrition. It works within the framework of the Convention on the Rights of the
Child (CRC) and the Convention on the Elimination of all forms of Discrimination Against
Women (CEDAW), both of which have been signed by the Government. Salt iodization
legislation and legislation to regulate the marketing of breast milk substitutes are to be followed-
up by this Ministry.

J. Ministry of Interior (MOI)
Local government is key to the implementation of the community based strategy for improved
nutrition. This Cambodia Nutrition Investment Plan will liaise with the Ministry of Interior
through the new Commune Councils to have them help fund community-based nutrition-relevant
strategies.

K. Ministry of Economic and Finance (MOEF)
The Ministry of Economic and Finance plays a crucial role in the allocation of financial
resources for this CNIP. It is expected that the Ministry will allocate new funds for the
implementation of this nutrition investment plan and make it part of the three-year rolling Public
Investment Plan (PIP).

L. Ministry of Planning (MOP)
This Ministry has a crucial role to play in the CNIP. It is responsible for the management of the
Nutrition Information System and monitoring and evaluation of the CNIP. The Ministry is also
responsible for the Socio-Economic Development and Public Investment Plans. As a major
public policy making ministry it is also responsible for policy analysis which is an important
component of the nutrition strategy. The National Nutrition Plan of Action places the National
Council for Nutrition (NCN) under the Ministry of Planning; it coordinates the Cambodia
Nutrition Investment Plan and incorporates nutrition-relevant actions into Public Investment
Plans (PIP).




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                       CHAPTER 3: Addressing Malnutrition Through Public Policy


M. International Agencies and NGOs
Multi-lateral and bilateral donors including international finance institutions and NGOs will play
a crucial role in the implementation of the CNIP both as donors and implementers as allowed by
their respective mandates. The CNIP will insist that this be done in such a way that local
capacity is developed, local communities are empowered and nurtured and sustainability is
ensured. For details of their current and planned activities see table 2.4.

3.1.3 Possibilities for Synergy
There are good possibilities for more collaboration between ministries and donor agencies to
incorporate strategies for nutrition improvement are promising. This CNIP will definitely be a
step in that direction. For instance, nutrition education and teaching of caring practices can be
incorporated more often with other activities. Seth Koma encourages VDC leaders to discuss
good child health and nutrition practices and treatment of childhood illnesses during their growth
monitoring sessions, bringing the concepts to the household and community levels.

The Integrated Management of Childhood Illnesses (IMCI) program supported by WHO and
UNICEF is quickly growing in the country and represents a perfect match with this CNIP,
particularly in Component 3 on interventions at the community and household level. 14 key
family practices have been identified that, if practiced, will have a great potential to affect child
health, nutrition and survival. The IMCI activities fall within the scope of the CNIP.

3.1.4- Political Constituency
The Ministry of Planning is taking the main initiative in coordinating and monitoring this
Cambodian Nutrition Investment Plan. It will be the key high level ally of the CNIP in working
with and influencing other ministries, and influencing the Government’s planning and budgeting
cycles. Government staff are eager to receive direction on programs such as nutrition and health,
which are designed to improve the quality of life of the Cambodian people. The MOP will help
channel those efforts and give such a direction.

3.2 – Conclusion
The two main gaps the Cambodian Nutrition Investment Plan will need to fill are:
•   The gap between approved plans and their implementation, and
•   The capacity for ongoing policy analysis and formulation.

Bridging the gap between plans and their implementation signifies increasing the Government’s
allocation of resources and institutional capacity for their implementation. A system of
monitoring and evaluating both processes and establishing outcome indicators is also crucial.

Another major requirement is the capacity building of adequate human resources at all levels to
ensure that staff have the knowledge to translate plans into specific programs and activities,
implement and monitor those programs and activities, and analyze policy-relevant experiences
and lessons learned in order to influence future public policy.




                                                                                                  46
                       CHAPTER 4: An Improved Nutrition Strategy for Cambodia



                                       CHAPTER 4

    AN IMPROVED NUTRITION STRATEGY FOR CAMBODIA
4.0 - Introduction
The timing for launching this CNIP 2003-2007 is considered very good. The CDHS has provided
very recent reliable data, the SEDP II is about to be finalized and the new three-year PIP will be
discussed shortly. Moreover, the major community-based projects have recently been evaluated
with positive results and are expanding coverage. The government is providing a conducive
environment for the implementation of community based plans with a very active MOP who
having taken the initiative for the revision of the 1998 CNIP.

It is expected that the Government will allocate in some new funds for coordination, monitoring
and implementation of the current CNIP. UNICEF will assist some of the monitoring and
coordination functions in collaboration with selected INGOs and donor agencies. The existing
policy framework and the upcoming Socioeconomic Development and Public Investment Plan
support a progressive village-based development approach. Investing in nutrition is a major
strategy to ensure that the overall overseas development assistance (ODA) the country is getting
does, in fact, improve the nutrition and other conditions of the poor. This Cambodia Nutrition
Investment Plan thus mobilizes both domestic and external resources for nutrition-relevant
actions.

4.1 - Strategic Objectives and their Monitoring
The objectives of the five-year Cambodian Nutrition Investment Plan (CNIP 2003-2007) are:
•   To incorporate nutritional considerations in the second National Socio-Economic
    Development Plan as well as in the Poverty Reduction Strategy Paper;
•   To reduce the levels of Protein Energy Malnutrition (PEM) in children under 5 years of age
    by 10% in five years from the current (2000) level of 45% (underweight);
•   To virtually eliminate deficiencies of iodine and vitamin A over five years and to reduce by
    10% the current levels of anemia in children under 5 years (63% -CDHS), under 2 (70% -
    HKI) and women of reproductive age (58% - CDHS) and pregnant women (65%- CDHS).
•   To reduce the levels of malnutrition of women of reproductive age from 20% to 15% in five
    years as measured by a body mass index (BMI) of below 18.5 kg/m2.
•   To increase the coverage of ANC so that weight gain during pregnancy can be monitored and
    to increase by 20% the number of women gaining 9 kg or more during gestation as compared
    with estimated levels of 2000.
•   To reduce the level of low birth weight (LBW) from the current estimated 15% to 10% in
    five years.
•   To increase to 25% of mothers giving their infants colostrum in the first hour of life and
    those that exclusively breast-feed for six months by 2007.

The achievement of these objectives will be monitored through:
•  The incorporation of nutrition indicators into the monitoring and evaluation systems of socio-
   economic development and into analyses of macro-economic policies.




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                       CHAPTER 4: An Improved Nutrition Strategy for Cambodia


•   Monthly anthropometric monitoring of children under 2 years, quarterly for those 2-3 years
    and semiannually for those 4-5 years; women of reproductive age will also be measured and
    weighed to follow their BMIs as is now done by the Seth Koma program;
•   Representative surveys on IDD, VADD, and IDA at four-year intervals. For IDD, surveys on
    median rates of urinary iodine excretion will be carried out in addition to ongoing monitoring
    iodine levels in salt and iodized salt use, which the CDHS has shown to be unacceptably low.
    For VADD, children between 6 months and 6 years of age and women of reproductive age,
    especially pregnant and lactating women, will be followed up with respect to their increased
    frequency of feeding of vitamin A-rich foods and vitamin A capsule supplements. Trends in
    the prevalence rates of night blindness, and whenever possible of serum retinol levels, will be
    followed as well. For anemia, hemoglobin levels will be the main indicators. Recording birth
    weights on the growth card of the child and following the trends of representative sentinel
    sites is considered crucial and the only way of measuring the achievement of the Low Birth
    Weight (LBW) goal.
•   As was said earlier, CNIP also needs to follow the accomplishment of process indicators,
    especially but not only in the area of community mobilization and empowerment. Processes
    related to making nutrition-relevant actions truly community-based will also have to define
    clear and monitorable indicators. No later than mid-2002, the MOP will set up a task force to
    define these process indicators; the Ministry will then use these when setting up its CNIP
    monitoring operations.

4.2 - Proposed Nutrition Strategy in Cambodia
The strategy will have five basic orientations. The CNIP 2003 –2007 will address:
1. Nutrition in the context of poverty (following the orientation of the SEDP II and PRSP).
2. Nutrition as a human rights issue. This means CNIP 2003-2007 will aim at empowering
    families to claim services and resource inputs from relevant duty bearers (local and national
    service providers) for them to find workable solutions to community problems.
3. Nutrition throughout the life cycle. Placing more emphasis on the proper nutrition of girls,
    adolescent girls, adult and pregnant women. Also starting breast-feeding within one hour of
    birth, exclusive breast-feeding from birth to 6 months of age and adequate and timely
    complementary feeding, ensuring frequency, amount, density and utilization according to the
    (FADU) approach.
4. Monitoring both processes to be used and outcomes to be achieved. Nutritionists use varied
    nutrition outcome indicators (e.g. birth weight, young child anthropometry, BMI and one or
    two indicators for every major micronutrient deficiency). The CNIP 2003 – 2007 will now
    need to set process indicators, e.g. for social mobilization, VDC participation, and
    empowerment. Monitoring activities will then focus separately on both types of indicators.
5. The principles of “convergence” and “phasing’’. This means that several sectoral efforts will
    be directed to center around the same communities to solve a greater range of their multiple
    problems and these efforts will be applied sequentially according to the receptive capacity of
    the same communities before moving on to cover further communities. UNICEF has had a
    good working experience with both, they have concentrated their actions in six provinces.

Unless this experience is used and coverage expanded in a phased manner this will create
problems with the Human Rights approach which says that all children have the right to have




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                       CHAPTER 4: An Improved Nutrition Strategy for Cambodia


optimal growth and development and the people have the right to demand their problems be
solved right away.

The strategy proposed focuses 80% of efforts and resources from the village to the district level.
At the community level, Cambodian villagers in over 5,500 villages have already begun a
journey of self-help and development through their Village Development Committees (VDCs).
However, they are in dire need of additional financial resources and trained human resources.
Nutrition being considered more and more a priority in the VAPs. Other than assuring adequate
supplies of staple foods, VAPs need to also consider agricultural diversification to produce
enough food for the family, as well as focusing on better health, breast-feeding, complementary
feeding, caring and sanitation practices, as well as on income generation activities focused on
women. Much community-based education/capacity building is needed to achieve all these.

At the national and provincial levels, this National Investment Plan for Nutrition will address
micronutrient interventions, the issues of capacity building in nutrition, as well as the need to
establish an institutional capacity capable of advocating for and monitoring the nutritional status
of Cambodians. In addition to collecting nutrition-relevant information, such a unit will be able
to analyze data and provide timely feedback to decision-makers.

The proposed CNIP takes up the recommendations of the National Plan of Action for Nutrition
adopted by the Royal Government of Cambodia in January 1997.

The community-based component of the strategy will support integrated household/family and
community-based interventions that:
•  Will progressively become national in scope covering both rural and later urban areas, and
   will move quickly from small scale to large-scale impact programs.
•  Will focus on improving household food security, care for children and women, breast-
   feeding and complementary feeding, health, water and sanitation, and on basic determinants
   for instance by making micro-credit available to women.
•  Will also give priority to early child development particularly the development of cognitive
   and mental faculties.
•  Will have strong components of social mobilization, communication, community education
   and advocacy and will promote people’s use of existing public health services, creating a
   demand.
•  Will use nutrition as an outcome indicator through a monthly community-based growth
   monitoring and promotion approach reinforced by a cyclic process of assessment, analysis
   and action; and
•  Will utilize food-based strategies including food fortification and public health measures
   including de-worming in addition to pharmacologic supplementation in addressing the
   problems of micronutrient deficiencies.

The national level programs will:
•  Provide technical and logistic support to the National Council of Nutrition a selected training
   institution (before mid-2002), and the Inter-Ministerial Technical Nutrition Committee.
•  Develop human resources through in-service and residential training in public nutrition, and
   ad-hoc curricula, as well as a capacity for operations research.



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                                  CHAPTER 4: An Improved Nutrition Strategy for Cambodia


•   Develop a sentinel Nutrition Information System that will improve decision-making at all
    levels.
•   Continue providing support to essentially vertical nutrition-relevant programs that address
    micronutrient deficiencies (iodine, vitamin A, iron and folic acid) and to the Baby Friendly
    Hospital/Baby Friendly Community Initiative (BFHI/BFCI).
•   Advocate for all actions that improve child feeding practices, particularly correct breast and
    complementary feeding with safe foods ; and
•   Provide some support to sectoral ministries to include nutrition activities into their policies
    and plans mostly channeled through the major national community-based programs.
•   Prepare guidelines for the management of severe malnutrition and the upgrading of facilities
    to do so.

4.2.1 - Community-Based Strategies and Activities
Over the last two years, Cambodia has gained some important experiences in implementing
community-based strategies for overall socio-economic development. Some of these have used
child nutrition status as the outcome indicator within the framework of child and women rights
(CRC and CEDAW).

A major program in this respect, is the Seth Koma Program (former CASD) supported by
UNICEF since 1996. As of July 2001, the program reached more than 700,000 people in 1,130
villages in 120 communes in six provinces. The program supports the improvement of
institutional and human resource capacities at various levels and plans for the delivery of
services through village action plans.

The graphs below provide information on key indicators that show a significant improvement
between the Baseline Survey in 1998 and the Follow up Survey carried out in 2000.

                                               Vaccination Coverage Among Children Age 12-59 Months

            120




            100                                          98

                                                              90
                       84                 85
                                    79
            80
                  72         71                                                70
                                                                          64
                                                                                                                        CASD 98
            60                                                                      55                                  CASD 00
                                                                   52                                                   CDHS 00
                                                49

                                                                                               41 40
            40                                                                                                     38

                                                                                          30



            20
                                                                                                       12
                                                                                                             10



             0
                       BCG               DPT3              POLIO3          MEASLES             ALL          NONE




                                                                                                                                  50
                                                  CHAPTER 4: An Improved Nutrition Strategy for Cambodia


                                                                            CASD 2000
                               10%                                                                    Diarrhoea                      20%
  Stunting prevalence
                                                                            CASD 1998                 prevalence                                             54%
        – severe                      16%


                                                                                               Mothers with low                14%
  Stunting prevalence                                     38%                                        BMI                               25%
  – at least moderate                                           44%
                                                                                                                                                                           72%
                                                                                             Anaemia – children
                                                                                                                                                                                 80%
     Underweight               9%
  prevalence - severe                 17%
                                                                                                Anaemia – non-                                                57%
                                                                                                pregnant women                                                           68%

        Underweight                                                   49%
      prevalence – at                                                                                                          15%
                                                                              60%               Low birth weight
      least moderate                                                                                                                   25%


                        0%    10%         20%     30%    40%         50%     60%    70%
                                                                                                                    0%   10%    20%        30%   40%   50%    60%        70%    80%    90%




   Care seeking for                                            43%
   acute respiratory                                                                      Children receiving                                                                    74%
      infections                            23%                                               vitamin A
                                                                                            supplements                                                        58%


   Use of sanitary                  14%
  means of excreta
      disposal                9%
                                                                                                                                           30%
                                                                                              Contraceptive
                                                                                               prevalence
                                                                                                                                 22%
Use of safe drinking                                                        58%
       water                                                    45%

                                                                                                                                                                          67%
                                                                                             Literacy rate –
                                                                46%                         female spouses
     Antenatal Care                                                                                                                                                59%
                                                        36%


                       0%    10%     20%        30%     40%      50%        60%     70%                        0%    10%   20%        30%        40%   50%    60%         70%    80%
        .

        Therefore, the aim of the proposed community-based strategies and activities is to ensure that
        households become the basic institutional unit for promoting good nutrition. The basic strategy
        is to support interventions which will build capacity, are empowering, derive from participatory
        triple-A processes and are, therefore, sustainable. Maternal and child nutrition status will be
        used as the outcome indicators. Process indicators will also be identified shortly and selected for
        regular follow-up. Interactions between households and community institutions particularly the
        VDCs, primary schools, pagodas, locally based NGOs and civic groups will be promoted.

        One of the main activities to be supported in the investment plan will be those that can be done
        by the households and community institutions by themselves with minimal external assistance.
        These are likely to be those that influence positive nutrition behavior, especially those related to
        care and health seeking behavior (this is the perfect nexus to link up with ongoing IMCI
        activities). In addition, essential basic services (health, education, safe water and sanitation) will
        be supported and promoted to strengthen access and utilization. Microcredit for women will also
        be an important area for support to ensure that women have reasonable access to financial
        resources.

        As relates to care, six categories of behavior to improve nutrition will be promoted:
        1. Care for pregnant and lactating women;



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                       CHAPTER 4: An Improved Nutrition Strategy for Cambodia


2.   Breast-feeding and safe complementary feeding practices;
3.   Positive psychosocial behaviors
4.   Food storage and safe preparation behaviors;
5.   Hygiene behaviors and
6.   Health promotion including growth monitoring and promotion of young children health care
     seeking behaviors.

The nutrition of girls from childhood to adolescence will be given special attention to ensure
births of normal weight babies and safe motherhood in adult life.

Exclusive breast-feeding will be promoted for the first six months. Preparation of adequate
locally available complementary foods and active feeding will be promoted after six months to
increase feeding frequency, feeding adequate amounts, of proper nutrient density and close to
100% utilization by the body (FADU). It is important that the introduction of complementary
feeding is not delayed beyond the recommended period for exclusive breast-feeding as it leads to
malnutrition.

Caregivers will be motivated to actively respond to the child’s cues with attention, affection,
involvement and encouraging the child to become autonomous, explorative and a learner.
Positive aspects of safe food preparation behaviors to be encouraged will relate to gathering of
fuel and water, food production and procurement, safe household food processing and cooking
and those related to food storage and hygiene. The possibility of piloting cooperative day caring
will be explored as a means for the child to get stimulated while the mother is in the field.

Particular attention will be paid to both personal and household hygiene, emphasizing simple
solutions like hand washing, mother and child bathing and toilet practices, disposal of family
wastes, access to safe water and sanitary facilities and containing domestic animals. With
respect to health care seeking behavior, emphasis will be laid on growth monitoring and
promotion and birth spacing and home management of simple illnesses, use of ORS, utilization
of both curative and preventive services like antenatal care, deliveries and immunization. Home-
based protection from vectors (e.g. use of impregnated mosquito nets), accident prevention and
the prevention of abuse and violence will also be advocated.

4.2.1.1 - Building Capacity to Address Nutrition Issues at Household Level
In order to accomplish the objectives outlined above, training of facilitators and mobilizers will
be needed. At the district and commune levels, facilitators will be trained to train and supervise
household level mobilizers. Each facilitator will supervise between 10-15 mobilizers and each
mobilizer will cover one village. There are about 100 families of about five people per village.

The main task of the facilitator is to ensure that the mobilizers have adequate capacity to promote
household level activities that ensure that households in their area conduct activities and adopt
lifestyles and behaviors that positively impact on child and maternal nutrition. HIV/AIDS
prevention activities are also key here.

Mobilizers will promote literacy courses, the adoption of FADU, crop diversification and
consumption including fruits, de-worming at schools and household level and the actual



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                       CHAPTER 4: An Improved Nutrition Strategy for Cambodia


consumption of micronutrient supplements. They will focus on “life skills” training and the
dissemination of information like “Facts for Life”. Guidelines, manuals and other tools to
implement the Integrated Management of Childhood Illness (IMCI) at the household and
community level will be distributed to facilitators and mobilizers.

4.2.1.2 - Development and Implementation of Village Action Plans (VAPs)
Training of the Provincial, District and Commune Development Committee members and of
VDC members has proven invaluable in the Seth Koma Program. VDCs are now capable of
developing and implementing their own plans based on a participatory process of assessment and
analysis. Facilitators and mobilizers assist VDCs to develop village action plans for social
development with nutrition improvement as the outcome indicator.

The village action plans show two things: Actions that household/families will take to improve
nutrition, and actions that the village needs to take to improve and strengthen the capacity of
households to foster proper child growth.

VAPs usually include household and village actions to:
• Access health and education services, safe water and sanitation, adequate food including
  micronutrient-rich foods and supplements, and access to micro-credit programs.
• Promote early childhood care and development.
• Mobilize local human, financial and organizational resources.
• Access information on life skills; and
• Improve their capacity to assess, analyze and act at their level.

In this effort, CNIP funds will be used as seed money to access other governmental, NGO and
donor-agency systems. There are, for example, more than 70 organizations providing micro-
credit, which can be accessed.

A village approach which implements education and nutrition-relevant activities will address
some of the household food insecurity problems. But difficult issues also need to be addressed.
For instance, there are many people growing vegetables and raising livestock, but selling their
harvested crop to purchase non-food items for the household. Supporting VDC activities,
especially through training programs that address nutritional issues, are the best way to reach the
Cambodian people. As of 2001, there were over 5,700 VDCs either currently supported by
development organizations, or targeted for support by these organizations. This represents a
total of 43% of all villages in Cambodia. The Cambodia Nutrition Investment Plan will,
therefore, primarily support the organizations currently involved in community organization to
continue their work and deepen it in its nutrition components.

4.2.1.3 - Village Level Nutrition Information Systems
In many of the Seth Koma villages, village monitoring systems have been established. Among
the indicators collected are maternal and child nutrition status, maternal and child mortality,
immunization rates and school enrollment rates. In some cases, there is also a good linkage
between the VDCs and the cluster and satellite schools, and health centers. This Cambodia
Nutrition Investment Plan will support the scaling up of the village monitoring systems in order




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                        CHAPTER 4: An Improved Nutrition Strategy for Cambodia


to improve decision making at the family, village and commune levels (links are also foreseen
with the new Commune Councils).

4.2.2 - National Level Strategies
National level strategies will support five categories:
1. Control of micronutrient deficiencies (iodine, vitamin A, iron and folic acid);
2. Promotion of appropriate breast-feeding and complementary feeding practices with safe
    foods, and support to the Baby and Mother Friendly Hospitals and Health Units.
3. Strengthen the Nutrition Monitoring and Coordination Unit (MOP) and support the setting of
    focal points and their functions.
4. Nutrition Information systems; and
5. National Sectoral Strategies.

4.2.2.1 – Control of Iodine Deficiency Disorders (IDD)
In order to sustain the elimination of IDDs over the course of the five-year plan, salt iodization
will be fully supported. According to the DHS, only 14% of households were using iodized salt
in 2000, and some of this salt was imported. The plan is to achieve universal salt iodization
(USI) by 2005. Table 4.1 presents 2001 plan of action for the universal iodization of salt.

Currently the national program in IDD has planned activities for 2001 with a budget of
$143,000. The budget planned for 2002 is US$280,000.

Table 4.1 Plan of Action for Universal Salt Iodisation (2001)
Major Activity                                        Cost         Responsibility
IDD National Action Planning Workshop                     $2,760   UNICEF/WHO
Procurement of additional salt iodisation plant          $22,250   UNICEF
Procurement of Rapid Test Kits and Reagents               $7,900   UNICEF
Development , production, and distribution of
                                                         $13,990   UNICEF/NSCIDD
IEC/PSC materials
Training and orientation on IDD/USI awareness QC &
                                                                   UNICEF, MOH, MOIME,
ME of: salt producers group, Health Workers, Custom      $10,000
                                                                   MRD, NSCIDD
and Commerce Officials, and mass media.
Micronutrient curriculum in primary schools               $2,000   MOEYS, UNICEF, NSCIDD
IDD Promotional Campaign                                 $44,800   UNICEF, NSCIDD
Project implementation and planning activities
                                                         $39,300   NSCIDD
including field monitoring and evaluation
Total Costs                                            $143,000

4.2.2.2 - Vitamin A Deficiency (VADD)
The major focus of the vitamin A deficiency elimination strategy will be to provide universal
supplementation of vitamin A capsules to children aged 6-60 months and to lactating women
within eight weeks of delivery. In addition, educational strategies to improve the consumption of
vitamin A-rich foods will be promoted through a mass media campaign and a village-based
nutrition communications strategy.




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                       CHAPTER 4: An Improved Nutrition Strategy for Cambodia


Current vitamin A capsule coverage (28% of children in the six months preceding CDHS) is
inadequate despite the distribution alongside the outreach activities through the Ministry of
Health. The CNIP will support the ad-hoc MOH working group to improve this situation.

4.2.2.3 - Iron Deficiency Anemia (IDA)
Iron Deficiency is the most neglected micronutrient deficiency to date. There is no major
initiative to address this problem despite the high rates of anemia (63% in children and 58% in
women). The MOH (Nutrition Unit, NMCHC) is currently conducting a pilot study to assess
the effectiveness of weekly supplementation of iron and folate to women of reproductive age in
factories, secondary schools and villages in selected areas. If this initiative is successful, the
MOH hopes to scale it up to reach larger groups of women.

(i)     Pregnant and lactating women:
Iron and folate deficiency anemia will be addressed through tablet supplementation of pregnant
and lactating women. Increasing knowledge and creating demand among women, supported by
family members is necessary and the VDC can play a major role on health and women’s issues.
The Ministry of Health needs to focus at the training of health workers, as well as communities
on the ill-effects of IDA and the importance of iron supplementation. The iron/folate
supplements are currently available as a part of the minimum package of services at the health
center level. Compliance is a problem in most developing countries so strict training of health
volunteers at the village level, as well as community-wide education can provide a better village
based monitoring and support group for the pregnant and lactating women in the community.

(ii)  IDA control among children under 5 years:
No plan exists. A plan of action has to be developed now, with strategies and village level
awareness and education programs on the production and consumption of iron-rich foods. The
MOH is to appoint an ad-hoc task force in the first half of 2002.

(iii)   Iron food fortification:
A first consultation has identified the possibility to enrich fish sauce and wheat flour with iron.
The Government and the Ministry of Industry, Mines and Energy will look at the possibility to
pilot this scheme.

4.2.2.4 - Promotion of Appropriate Breast and Complementary Feeding Practices
The issue of certain breast-feeding practices in Cambodia, (late initiation, not feeding often
enough), and poor practices concerning the introduction of safe complementary foods, will be
addressed in two ways. First, a national campaign will be launched through the media (radio,
TV, newspapers, and video), and hospitals and clinics that promotes proper breast-feeding
practices. It has been proven in-country that promotion of good breast feeding practices can
result in the adoption of better habits by women. The media campaign will also address issues of
decreased duration of breast-feeding in women in urban centers and the use of breast milk
substitutes.

And secondly, through the Village Development Committee activities. There are many
opportunities to educate women at the village level as a part of literacy classes and/or growth
monitoring activities. Village volunteers will be trained in teaching proper breast-feeding and



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                        CHAPTER 4: An Improved Nutrition Strategy for Cambodia


safe complementary feeding practices as with the TBAs, who are in a position to promote
immediate initiation of breast-feeding, and overcoming the aversion to colostrum.

Another issue to be considered is the vertical transmission of HIV through breast milk. There is
a new consensus position under discussion by both WHO and UNICEF that in areas where child
mortality and malnutrition rates are high the policy is to promote appropriate exclusive breast-
feeding for six months. Women who have tested positive for HIV should be counseled and only
if they can easily afford substitutes should these be considered.

4.2.2.5 - Development of a Nutrition Focal Point at the National Level
Apart from the Nutrition Program Unit at the Ministry of Health whose staff members are
responsible for coordinating and training health staff on breastfeeding, growth monitoring and
promotion and micronutrient deficiencies. There is currently no other technical agency fully
responsible for nutrition research, nor is there an established Nutrition Training Institute.

The National Council for Nutrition in the MOP aims to have nutrition issues properly addressed
through the involvement of ten ministries including the Ministry of Health. The Ministry of
Health is the key technical agency to guide actions to address nutritional problems such as PEM
and micronutrient deficiencies and to achieve the objectives of the CNIP. The collaborating
agencies such as the Ministry of Rural Development and Women’s Affairs have infrastructures,
which reach village level and have significant capacity to support nutrition education and
nutrition improvement plans in the community.

Therefore, training of health staff and staff outside the health sector on nutrition becomes a major
challenge and a critical input for the successful implementation of the CNIP. The MOH has
limitations over training its own staff due to lack of structural support and clarity of
responsibilities to implement a wide variety of nutrition-related tasks. These include nutrition
research, policy development, training, education, monitoring, social mobilization and food
fortification. To do most of this, the MOH needs significant strengthening both in administrative
and technical areas, if CNIP is to achieve its objectives. Limited MOH guidance can lead to
inappropriate training/ education materials and messages. This has to be avoided at all costs as it
can cause more problems than it solves.

Further, the MOP needs to be strengthened with an Executive Technical Secretariat also to be
housed in the MOP. It will be charged with the close follow-up of the implementation of this
CNIP. The MOP will need to hire a nutrition expert in the short term and later have staff trained
with the capacity of monitoring all nutrition plans.

In addition, there is a need to incorporate nutrition into the higher education system in
Cambodia.

Given the void in nutrition competencies within national institutions, medium and long-term
training in nutrition will be needed. But, to begin with, after identifying the appropriate
institution in early 2002, short diploma courses will be organized to quickly close the void.
(Twinning operations with academic nutrition training institutions are an option to explore).




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                       CHAPTER 4: An Improved Nutrition Strategy for Cambodia


Training suggested:
To start with, short orientation training is needed for the members of the Inter-Ministerial
Technical Committee and the three MOP Officers in the MOP that will monitor the CNIP. This
will be scheduled for just two to three days before the launching of this CNIP in early 2002. At
least the MOP, MOH, MoEYS, MOWVA, MAFF and MRD will select one experienced trainer,
not necessarily the current focal point for nutrition to get this training. UNICEF is ready to
support this. Once these cadres are sensitized/trained at a very basic level, they will be asked to
replicate this short training for the Provincial Committee for Nutrition Coordination as a very
first preparatory step for the CNIP. Every year thereafter, these cadres will get more in depth
training and they will, in turn, give refresher workshops to the Provincial Committee for
Nutrition Coordination.

During year one of the CNIP a two-three months intensive in-country training for mid-level
cadres will be organized by the chosen academic institution. Flexibility should exist for
conducting the course in two-week modules with two weeks between them. Requirements will
be external assistance for the training, as well as per diems and other costs.

Additionally, in year one, long-term trainees for masters’ degrees in public/community nutrition
will be sent overseas for training.

4.2.2.6 – Sentinel Nutrition Information System
Nutrition information is a powerful tool in making nutrition-relevant decisions. A sentinel
nutrition information system that will provide nutrition-relevant information to support the
community-based and national level strategies will be supported. This will be supplemented with
operations research and periodic surveys every four years.

The Nutrition Information System called for by this CNIP will use the CDHS 2000 data as a
baseline. It is proposed to set up a Nutrition Sentinel Surveillance System with sites in selected
locations where CDHS data was already collected. Selected data that the CDHS collected in
2000 will be followed longitudinally to give an idea of trends. A budget for technical assistance,
training, monitoring and data analysis will be needed for this. Special attention should be given
to resolve the problem of expanding the recording and reporting of reliable birth weight data.

A Geographic Information System (GIS) can become a component of the nutrition surveillance
system. It can be a major planning tool for integrated community development. Support for the
use of this resource is recommended.

Routine reporting systems of sectoral programs already exist. An agricultural production
monitoring system exists (MAFF/FAO). The MOH has a routine Health Information System.
Currently it includes little nutritional data and much of it is from clinics at the district level.

Market price index surveys are tracked by CDRI/NIS. Many items available in the market (food
and non-food) are included. This monitoring system limits itself to Phnom Penh. The WFP has
some data on rice prices and a few other commodities. It does not appear that other market
information systems exist at present. However UN agencies and NGOs, working with Village
Development Committees, are tracking the weekly prices of rice in some provincial markets.



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                        CHAPTER 4: An Improved Nutrition Strategy for Cambodia


Since the market structure is not well developed beyond the district level it might be a
consideration to establish a market data collection system at the provincial level in conjunction
with the Ministry of Rural Development.

At this time, there is also no routine central data source for nutritional status data although Seth
Koma and a few NGOs do collect and analyze growth-monitoring data. School based growth
data is also not being collected. The School Hygiene Program Section at the Ministry of
Education should establish a school health strategy program that includes annually measuring all
children in schools and developing a data collection, analysis and reporting system. There is a
need for these various information systems to be coordinated so that they complement each
other, provide linkage opportunities, and collect information that is needed for the planning and
evaluation of national policies and programs. The Ministry of Planning will manage this through
its Permanent Secretariat.

To do this some technical resources will be required. These will include:
•  Computer equipment and software capable of data management and analysis.
•  Laptop computers for the counterparts in the field.
•  Digital Scanner.
•  Laser printers.
•  Internet and e-mail linkages.

In addition, the following human resources will be required:
•   One long-term person to coordinate the nutrition information system’s activities
•   and train additional staff from the unit.
•   Two associates with good links with the line ministries; they will be trained to manage and
    analyze the data sets and to help manage the Nutrition Information System; and
•   Three assistants to be trained in nutrition information systems who will enter and analyze
    data, will coordinate field efforts and will provide support to associates in the field.

4.2.3 - Sectoral nutrition-relevant Plans
Refer to the agency by agency table 2.4 and the paragraphs on each agency’s nutrition-relevant
activities in Chapters 2 and 3.

4.3 - Costing the Strategies

4.3.1 - Costs of Community-Based Strategies
The community-based strategy is the main strategy within this investment plan. Of the total
$41.1 million proposed for the investment plan, $32.4 million or 79% will be allocated to this
strategy because of its proven track record of getting relatively quick and sustainable results. The
remaining $8.7 million or 21% will be allocated to national level strategies that complement the
community-based strategy. The strategy will simultaneously address both malnutrition and
poverty in the short and long-term.

This CNIP calls for the different sectors and ministries to plug into existing and working
community mobilization schemes such as those from Seth Koma, Seila, PRASAC and many
NGOs. [MRD estimates that 5,600 of the 13,000 villages in the country (43%) will have already



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                        CHAPTER 4: An Improved Nutrition Strategy for Cambodia


established VDCs by mid-2001 and have conservatively set a target of 70% of villages for 2005;
with the rapid expansion of Seila, this target may be surpassed].

Ministries should therefore not start their own new sectoral community participatory processes
for improving nutrition and learn community mobilization skills from scratch. The above
projects have learned from their mistakes. They have the know-how and have active
communities already engaged. They have the vocation and have already trained the trainers;
they are ready to expand, discuss new technical tasks/proposed interventions with the organized
community and to scale-up. Their costs per beneficiary have dropped dramatically to reach
recurrent cost levels of as low as $1.78 per child (Seth Koma).

By utilizing the existing framework and expanding the geographic program operation scope,
while actively enhancing collaboration and coordination amongst them, coverage may be almost
completed by 2007.

The costs of running a program vary by organization. The start-up costs and the costs of
expanding these community-based programs are both high, but the recurrent costs thereafter fall
steeply. As a rule of thumb, and based on current experience, it is empirically estimated that start
up costs per new commune are high the first year; from the second year on, only 27.5% of the
initial investment is needed. Much of the initial investments are “one-time” and are primarily for
hardware and initial widespread training.

The costs of the strategy will depend on both coverage and intensity of expansion. In terms of
coverage, by the end of 2001, about 5,600 Village Development Committees (VDCs) will have
been established. These form the basic structure to facilitate community-based strategies for
development.

This Cambodia Nutrition Investment Plan conservatively foresees a phased strategy to expand
the coverage of trained VDCs producing their own VAPs by 1100 per year for a total of 5500
new VDCs by 2007. If one adds this to the existing 5,600 already operating, the country could
end up with 11,100 working VDC’s by 2007 (85% of the approximately 13,000 villages in the
country). This effort is additional to the ongoing support and strengthening of those VDCs
already operating.

It is thus proposed that the commune becomes the basic unit for costing this part of the CNIP.

A reasonable estimate of the capital and recurrent costs of such an approach is to base it on the
already existing program experience.

There are 1,621 communes in the country. Roughly 43% of villages already have a VDC: 5,600.
This CNIP proposes adding 1,100 villages every year. At an average of ten villages per
commune, 110 new communes will have to be added every year for the next five years. Seth
Koma has estimated that roughly $ 20,000 is needed in the first year to start up a commune
(roughly $2,000 per village in average: $500 to organize and train and $1,500 to contribute
funding to the first VAP).




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                         CHAPTER 4: An Improved Nutrition Strategy for Cambodia


 Total start up costs will thus be (110 x 5) 550 x $20,000 = $11 million and yearly start up costs
 110 x $20,000 = $2.2 million.

 From year two onwards, this plan proposes subsequent annual contributions of $5,500 per
 commune (27.5% of the initial cost). The experience is that villages and communes seek more
 resources elsewhere. One new source of funding to be tapped will be the new Commune
 Councils. On this basis, the costs and phasing of the community-based strategy is expected to be
 as shown in the table below.

  Table 4.2 Tentative Costs for the Community-Based Strategy (US$, millions)
                                                 Years
                                                 Costs in millions of $
Cost per commune                                 1     2       3      4 5             Sub-total
1. New communes at $20.000 for the first
                                                 2.2 2.2 2.2 2.2 2.2                  11
year. (110/year)
2. All communes from year two on at 5,500/yr
(27.5% of initial costs). (i.e. the existing 560 3.0 3.7 4.3 4.9 5.5                  21.4
communes plus 110/year from year 2 on)
Total                                            5.2 5.9 6.5 7.1 7.7                  32.4

 4.3.2 - Costs for the National Level Strategies
 The detailed costs of operationalizing the National Council for Nutrition (and Secretariat) and
 the micronutrients were estimated using the PROFILES software developed for IDD and anemia.
 It is estimated that over the five-year period, financial allocations will be as shown in Table 4.5.

 Table 4.3 Estimates for National Level Strategies in $ (millions)
 Strategy
                                                                     5 years cost
 1. Support National Council for Nutrition                                      0.5
 2. Control of micronutrients                                                   4.6
 3. Policy analysis                                                             0.1
 4. Nutrition Information System                                                0.6
 5. Monitoring and reducing PEM/LBW                                             1.1
 6. Promotion of Breastfeeding and complementary feeding                        1.0
 7. Operations Research                                                         0.2
 8. Sectoral Support to 13 ministries                                           0.6
 Total                                                                        * 8.7

 * This amount surpasses the levels of funding these activities are getting at present, so it makes
 more resources available to these strategies/activities.

 The total proposed CNIP budget thus is $ 41.1 million over 5 years.

 This amount does not represent all new money since a part of this is already in the pipeline.
 It is to be noted that CNIP funding is new funds, in addition to health sector investment funds.


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                       CHAPTER 4: An Improved Nutrition Strategy for Cambodia


4.4 - Framework for the Management of the Investment Plan
Seth Koma’s institutional framework provides a good example of the way the investment plan
will be managed. For the community-based strategy, the VDCs will be the main implementers at
the village level. Village Action Plans (VAP) will be included in Commune Action Plans
(CAPs) whose implementation will be supported by all the pertinent sectors (ministries) mostly
from their provincial resources (human and other). Additionally, the new Commune Councils
will support selected parts of the VAPs. (See diagram in next page).

At the national level, the Ministry of Planning will be the coordinator through the National
Council for Nutrition. The day to day follow up will be done by the MOP’s Nutrition Secretariat.
Nutrition focal points have been appointed in relevant ministries. Working closely with the
Ministry of Planning, their main responsibility is to make sure their Provincial Officers liaise
with the community-based programs so as to incorporate the specific ministry sectoral plans into
the VAPs and CAPs, i.e focal points support the community-based strategies from their
particular sectoral vantage point. It is expected that in this way, all sectors will learn from the
implementation experience of the community-based programs. The MOP will lobby for the PIP
2003-2005 to explicity allocates funds for CNIP’s activities.

To ensure programs complement one another, UN agencies, NGOs and other grassroot
organizations working in nutrition will be encouraged to use the institutional framework being
set up locally for their interaction with CNIP-sponsored programs and activities. It is possible
that the Government may experience problems in promptly absorbing and efficiently disbursing
funds made available by this investment plan. Such delays can easily jeopardize the CNIP’s
thrust and potential success. A quick disbursement to the provincial level may avoid many
frustrations and bureaucratic delays.




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                     CHAPTER 4: An Improved Nutrition Strategy for Cambodia


                       Integrated Planning
                             National level
                            Sector Ministries


                        PAC / PAS
                                                                                       Province
                    PRD, PWA        POE              PHD            Others...




                                                                                           District
                    DRD, DWA        DOE              OD              Others...




                        District Integration Workshop


                                                                                            Commune
                                      Commune Council
                                                                          Cluster School
Commune Action Plan

                                 COMMUNES (CDC)

 Village Action Plan                                                                        Village

                                               VDC

Family Activities                         FAMILY                    Health center
                                       women & children




                                           Community
                                                                                                 62
                          CHAPTER 5: Financing Child Nutrition in Cambodia



                                       CHAPTER 5

            FINANCING CHILD NUTRITION IN CAMBODIA
5.0 - Introduction
The proposed improved nutrition strategy for Cambodia in Chapter 4 estimated a financing level
of US$ 41.1 million over a five-year period. The major questions that may arise in the minds of
policy makers include the following:
•   Why spend so much money on nutrition?
•   What are the benefits?
•   Where will the money come from?

This chapter provides some possible answers to these questions.

5.1 – Why Invest in Nutrition?
There are three mutually reinforcing arguments for public financing of nutrition in the
Cambodian context. The first is biological, the second is human rights based and the third is
economic. The proposed Cambodia Nutrition Investment Plan is based on all three premises.

5.1.1 - The Biological Rationale
The biological argument is based on the importance of nutrition for early child survival and
development. It stresses the negative physiological, metabolic and immunological consequences
of malnutrition and links this to the negative effects on the economic and social development of
whole societies over generations when a large section of the population is affected, as in
Cambodia. The biological consequences of malnutrition are depicted in terms of reductions of
mental and physical growth and increased morbidity and mortality at both the individual and
societal level.

Thus, the major bio-social effects of under-nutrition are mediated through a vicious cycle which
erodes the human resource base by reducing its survival, protective and developmental potential.
This also affects learning and productive capacity. Because under-nutrition mainly affects
children and women, it is argued that a vicious intergenerational effect is created where
malnourished women produce malnourished children who, as adults will produce malnourished
children. Based as they are on mutually reinforcing processes, these vicious intergenerational
cycles can be turned into virtuous intergenerational cycles through appropriate investments in
nutrition. In other words, investing in nutrition is an investment into the future. In support of
this conclusion, the bio-social argument provides evidence of the negative mental and physical
growth consequences of poor nutrition and links to reduced capacities for learning and
productivity. There is also evidence of intergenerational improvements in nutrition when
children, especially the girl child, enter the reproductive age with good nutritional status and
improved living conditions. This will avoid under-nutrition in infants with all its attendant
consequences.

When under nutrition occurs in infancy, it leads to reduced brain growth and neural complexity
which may be carried to adulthood, severely compromising learning and earning capability.



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                          CHAPTER 5: Financing Child Nutrition in Cambodia


Children who are undernourished fail to begin learning during the crucial years of childhood
when language is acquired and spatial relationships are learned, because the child has too little
energy to play, interact with and explore the environment. In addition to reducing mental
capacity, mild to moderate protein-energy malnutrition can increase the risk of childhood death
by as much as four times. In Cambodia the contribution of protein-energy malnutrition to the
under five-child mortality is greater than 66% percent. Links between nutrition and growth in
children persists to adulthood. For men and women at all ages, greater height is associated with
greater survival. Stunted adults are at particular risk to heart diseases and obstructive lung
disease.

Deficiency of iodine can reduce intelligence by as much as 13-21 IQ points and, if it occurs
during pregnancy, can result in a severe form of mental deficiency known as cretinism, which is
irreversible. Worldwide, IDD is the most common cause of mental retardation. In adults, iodine
deficiency can result in diminished physical and mental processes that result in losses in
productivity and learning capacity.

Children who are anemic learn poorly in school and their intelligence can be reduced as much as
five to ten IQ points. Studies have shown that iron supplementation in young children can lead
to improvements in cognition and educational achievements. Anemic adults tire easily and,
consequently, have lower productivity. In addition, hemorrhage due to anemia is the leading
cause of maternal deaths resulting in tragedy for the child and remaining family members.
Reducing levels of anemia can decrease maternal mortality by a significant proportion.

Children with vitamin A deficiency are often plagued with frequent infections that, if severe,
may ultimately cause death. Vitamin A deficiency is the leading cause of preventable childhood
blindness and is indirectly responsible for a large proportion of child mortality. It is
acknowledged that vitamin A supplementation, on average, can decrease the under five child
mortality by as much as 23%, with some studies from India showing decreases of up to 54 %.
Recent studies in Nepal show that low dose vitamin A supplementation (25,000 IU daily)
reduces maternal mortality by 44% and carotene supplements by as much as 52%. Vitamin A
supplementation reduces the severity and, in some cases, the frequency of illnesses. High
incidence of morbidity can result in increased school and work absenteeism, increased costs of
custodial care and overall reduction in the learning of children and productivity of adults.

For those mentally affected by malnutrition, recovery of intelligence in later life may not be
complete, making under-nutrition one of the most horrific “brain drain” factors in developing
countries, and a major challenge to development. This is serious because success in the 21st
Century will be mainly determined by science and technology, where the competitive ability of
individuals and societies in general to act on complex systems based on accurate and updated
information will be crucial. It will be a century where creativity and innovation will be
paramount and will require the performance of every individual to be at a level that is as near to
their potential capabilities as possible. The current trends towards globalization, democratization
and decentralization where “thinking has to be global but action local” will determine the
competitive edge of whole societies. If Cambodia is to meaningfully participate in the world of
the 21st Century, then addressing malnutrition in children and women must be an overriding
priority.



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                          CHAPTER 5: Financing Child Nutrition in Cambodia


5.1.2 - The Human Rights Based Argument
The second argument for investing in nutrition in Cambodia is one of human rights. In the
Cambodian context, this is explicitly reflected in:
•   The Constitution of the Royal Kingdom of Cambodia.
•   Accession by Cambodia to the Convention on the Rights of the Child (CRC).
•   Signing of the Convention on the Elimination of All forms of Discrimination Against
    Women (CEDAW).
•   The endorsement of the 1990 World Declaration and Plan of Action of the World Summit for
    Children (WSC), the 1992 International Conference on Nutrition (ICN) and the 1996 World
    Food Summit (WFS) and more recently,
•   The National Nutrition Plan of Action (NNPA, 1997).

The second five-year Cambodian Socio-Economic Development Plan explicitly aims at poverty
eradication, through economic growth with justice as the overarching objective of the plan. The
words with justice underpin an ethical and moral position implying that basic rights will be
observed to ensure that the fruits of economic growth are equitably shared.

The main argument for the human rights-based approach is that, while the primary responsibility
for nourishing the child rests first with the parents and child’s family, the community and the
government should bear some responsibility. Childhood nutrition should, therefore, be one of
those issues for which a recognized government obligation is explicitly enshrined in law to
respect, protect and fulfill the basic needs of children. The premise is that, good nutrition is a
basic human need. Through social and political processes, this need should be transformed into
claims and the claims into rights. But for rights to be meaningful, they must be translated into
law and the law must be enforced. The transition from rights to law involves political
negotiation. Examples include some specific nutrition laws like salt iodisation and national
codes for the marketing of breast milk substitutes. These are laws that are easy to develop and
give the child the right to get enough iodine and prevent unethical advertising by the infant
formula industry. Both laws have not been enacted in Cambodia. Their development is included
as part of the operationalisation of the NNPA and the proposed nutrition investment plan. In the
Cambodian context, the challenge is not only to translate the acclaimed rights into law, but also
to enforce the law and monitor the impact.

5.1.3 - The Economic Rationale
The economic argument sees human capital as the engine for economic growth. It argues that
improving nutrition is an economic investment with high direct and indirect returns in terms of
productivity, efficiency and equity. In Cambodia, this argument has been used to justify
investments in the social sector in SEDP II and the National Nutrition Plan of Action. These
documents emphasize the eradication of poverty and equitable economic growth as the main
government objectives.

The human capital argument takes people as agents through which economic growth can be
pursued. Usually the objectives of economic growth and national development aim at achieving
two inter-related broad goals:
•  Growth in productivity in order to expand the potential consumption of goods and services;
   and



                                                                                               65
                          CHAPTER 5: Financing Child Nutrition in Cambodia


•   Equitable distribution of such goods and services among members of society.

Improvements in nutrition will contribute to these broad goals through enhanced health,
education and labor productivity.

This argument is supported by the conclusions from recent studies and reviews which have
shown substantial economic benefits from relatively modest investments in nutrition. The
benefits have been proven in terms of improved worker productivity as measured by the quantity
and quality of work output and wages earned. Additional benefits include increased income
generating capacity; reductions in child and maternal mortality, reduced morbidity and nutrition
related disabilities that avert losses in earnings and reduction of health costs because of fewer
illnesses and complications. Improved learning capacity and school performance and attendance
are other important benefits.

Many agencies use the economic argument to justify investments in nutrition as a poverty
alleviation measure. In the World Development Report 1991: The Challenge of Development,
the World Bank underscored improved quality of life as the broadest developmental challenge.
It acknowledged that, while a better quality of life generally calls for higher incomes, it involves
much more. It encompasses, among others, higher standards of health and nutrition. Investing in
nutrition is backed by the fundamental economic argument that resources put into nutrition are
an investment with significant returns, today and in the future. Improving nutrition directly
addresses some of the worst consequences of being poor. It concretely improves the well being
of populations and it offers the promise of increasing future incomes by boosting productivity.
Investment in nutrition can help workers produce more, and children learn more in school.

UNICEF’s “State of the World’s Children” and “The Progress of Nations” use the rates of
malnutrition in children under five years of age to measure the developmental distance between
nations. In particular, the use of the National Performance Gaps in Nutrition (NPGN) which
relate to the wealth of nations on the basis of GNP per capita and the expected levels of
malnutrition has underscored the importance of public investments in addressing the problem of
malnutrition. Countries that have invested in nutrition have a positive NPGN indicating that
their nutrition situation is better than one would expect from the level of their wealth. Cambodia,
with minus 23 points, had the highest negative performance gap in nutrition in South East Asia
three years ago, indicating a skewed distribution of wealth in favor of a few, a conclusion which
is confirmed below, in the analysis of equity in Cambodia.

5.2 - The Costs of Reducing Malnutrition
So how much does malnutrition cost Cambodia? This is a difficult question to answer as it
would involve putting a price tag on the lives of people. But there is no doubt that the costs of
malnutrition in a country like Cambodia can be great. However, the benefits from reducing
PEM, VADD, IDD and IDA, in terms of lives saved and productivity can be even greater. It has
already been mentioned that addressing malnutrition has the potential to reduce under five child
mortality by over two thirds.




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                                CHAPTER 5: Financing Child Nutrition in Cambodia


5.2.1 - Benefits, Costs and Benefit to Cost Ratio
Table 5.1 below outlines the benefits, costs and the benefit to cost ratio of reducing malnutrition
in Cambodia. This was calculated specifically for Cambodia in 1998 using the PROFILES
software from the Academy for Educational Development in Washington DC.

Table 5.1 - Benefits, Costs, and Benefit to Cost Ratio ($ million)
             Problem                Benefit (B)       Reduction Cost                         B:C
                                                              (C)
 Iodine Deficiency                         68                   5                            13
 Protein-Energy
                                           67                  12                             5
 Malnutrition
 Iron Deficiency Anemia                    67                   6                            11
 Total                                    202                  23                             9

The benefits of reducing malnutrition in Cambodia are thus clear. These are measured in lives
saved, benefits in productivity, not to mention costs for secondary medical problems, which
result from malnutrition.

5.2.2 - Lives Saved
Chart 5.1 shows a projection of the logarithmic increase in lives saved over a ten-year period
from reducing vitamin A deficiency and PEM prevalence in Cambodia.

Chart 5.1: Cambodia: Children's Lives Saved by Reductions of VADD and Underweight

  50000
  45000
  40000                                                                              9521
  35000                                                                      8101
  30000          underweight           VAD                           6821
                                                             5642
  25000                                              4550
  20000                                      3533                                    35684
  15000                            2580                                      31375
                                                                     27269
  10000                    1679                              23260
                                                     19329
                    822                      15450
   5000                            11604
           0       3901    7764
      0
          1998     1999    2000    2001      2002    2003    2004    2005    2006    2007
                               Year of Program Implementation



5.2.3 - Productivity Gains
The extremely high levels of stunting found in Cambodia are detrimental to the productivity of
the country as a whole. Studies have shown increases in productivity as levels of stunting are
reduced. This is especially important in Cambodia where the majority of the population is
engaged in some type of physical activity in order to survive. Another important aspect of
reductions of stunting is in lower levels of obstructed labor in women.




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                                                         CHAPTER 5: Financing Child Nutrition in Cambodia


Chart 5.2: Cambodia: Value of Gains in Productivity from Reducing Stunting ($ million)
                           15

                                                 moderate              severe
     Millions of Dollars




                           10
                                                                                                                                     $10.38
                                                                                                                            $9.15
                                                                                                                  $7.96
                           5                                                                        $6.80
                                                                                         $5.67
                                                                                $4.54
                                                            $2.29    $3.41
                                  $0.00     $1.16           $0.72    $1.07      $1.42    $1.78      $2.13         $2.50     $2.87    $3.25
                           0                 $0.37

                                  1998           1999       2000     2001        2002     2003          2004      2005      2006      2007

                                                                      Year of Program Implementation



Chart 5.3. Cambodia: Millions of Dollars Gained from Reduction of Anemia, IDD, and
           PEM
  $210
  $180
                                                                                                                    $67.5
  $150
                                          PEM               IDD         Anemia
  $120
                                                                                                                    $68.3
   $90
   $60
   $30                                                                                                              $67.5
    $0
           1998                 1999      2000      2001      2002    2003      2004    2005     2006      2007     Total

                                                        Year of Program Implementation


5.3 - Financing Strategy
Where will the funds to finance the nutrition investment plan come from? It is expected that the
upcoming PIP will secure some new funds for nutrition-relevant interventions. Domestic and
external funds in the form of grants and soft loans will be mobilized. To better understand the
financing strategy, an analysis of government expenditure patterns, efficiency and equity
analysis and expected resource availability is necessary.

5.4 - Current National Expenditure Pattern
Current expenditures are unbalanced reflecting a high civil service wage bill that is crowding out
non-wage operation and maintenance. Added to this is the problem that government wages are
low and do not provide incentives to work efficiently and retain skilled and trained personnel in
the public sector. The average government worker earns between US$25 and US$80 per month.
Consequently, most government employees are either involved in business or hold a second job.

Table 5.2 Education and Health: Budget as % of National Budget
                                    1999            2000                                                                            2001
 Health         Budget               7.3             9.2                                                                             10
 Education      Budget               12              14                                                                              16


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                          CHAPTER 5: Financing Child Nutrition in Cambodia


5.4.1 - Efficiency and Equity Analysis
So called poverty alleviation programs often benefit the non-poor and provide limited benefits to
the poor once the cost of their participation and behavioral responses are factored in.

Since 1999, average per capita consumption was about US$215 per year with a high share for
food expenditures of 62%. The average energy consumption was 2,100 calories per person per
day. The poverty line can be calculated using the food poverty line plus a non-food allowance.

Based on the Cambodia Socio-Economic Survey (CSES) of 1997, the food poverty line for
Cambodia was calculated; the cut-off points expressed as per capita annual income were US$246
for Phnom Penh, US$190 for other urban centers and US$163 for rural areas.

By using per capita consumption as a measure of equity, there was a fairly large disparity, as
much as twice real per capita consumption expenditure, between Phnom Penh and rural areas
and 50% in other urban areas. Phnom Penh, and the coastal provinces of Sihanoukville and
Kampot were the best off, in that order. Lowest consumption levels were found in the far-west
border provinces near Thailand and in the East near Vietnam. The northern border provinces
along the border with Vietnam, Laos and Thailand were excluded from the survey.

Inequality in consumption expenditure was higher in urban than in rural areas. The poorest 10%
of the population consumed less than 3% of the total consumption expenditure, while the richest
10% consumed ten times as much, (30%). The Gini coefficient ranges from a maximum of 0.44
in other urban areas to a minimum value of 0.27 in rural areas with a national average of 0.38.
The Gini coefficient is a measure of inequality, with zero value showing complete equality,
while 1.0 is complete inequality.

Regional comparisons of the overall poverty lines showed that at 11%, Phnom Penh had the
lowest prevalence of poverty, rising sharply to 37% in the other urban areas. As expected, at
43%, the rural areas had the highest incidence of poverty. For Cambodia overall, the poverty
incidence was calculated at 39% of the population. Comparison of poverty by employment,
level of education and gender showed that:
•   The highest rate of poverty, 47%, was found in households with uneducated heads of
    household, while the incidence of poverty dropped to about 30% when the head of household
    had completed secondary education.
•   In production, the highest poverty rate (46%) was found among people living in households
    headed by farmers. Households headed by somebody working in the government were least
    likely to be poor (20%).
•   Among male-headed households, it was 40% as compared to 35% among female-headed
    households.
The implication of this is that policies aimed at alleviating poverty and, therefore, improving the
nutritional status of the population must give high priority to raising the educational attainment
of the population and enhancing the income generating capabilities of the agricultural sector.

From a regional perspective, Cambodia seems to exhibit similar low degrees of overall inequality
as its Indochina neighbors. Although current estimates are not available, the general observation
is that the gap between the rich and the poor has widened, especially between the urban and the



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                           CHAPTER 5: Financing Child Nutrition in Cambodia


rural areas. Cambodia’s economic growth is inequitable and marginalizes the most vulnerable
especially those at risk from malnutrition.

The nutrition situation in Cambodia differs fundamentally from that of other South East Asia
(SEA) countries in three respects. First, the absolute proportional levels of malnutrition are
typical of those of South Asia (average of about 60%) rather than South East Asia (average of
about 30%). Second, unlike some of the other countries of SEA (Thailand, Malaysia, Myanmar
and Vietnam) where the trend is of rapid progress, Cambodia’s trend seems to be slower. Third,
it is only recently that some community-level action for nutrition improvement has started in
Cambodia, as compared to the other countries where community level nutrition and health
programs coupled with rapid economic growth have been taking place over the last decade.

With an economic growth rate of 6.1% (MoEF 2001) and a GDP per capita of $287 projected for
2001, a socio-economic polarization, as it relates to the nutrition situation, is already occurring in
Cambodia. Levels of malnutrition are higher than would be expected from Cambodia’s level of
wealth. The point being made here is that the economic trickle down effect cannot be relied upon
to address health and nutrition problems. Deliberate health and nutrition efforts are needed to
target and invest in those who for one reason or another are not captured by economic growth.
An investment plan for nutrition is an important way to address the growing inequity.

5.4.2 - Expected Resource Availability
When reviewing the CNIP and its projected budget, it becomes apparent that there are some non-
financial national resources available, but not financial ones. Most of the development work is
being funded by international organizations. However, the Government has started investing
some of its own funds in nutrition-relevant interventions

5.4.2.1 - Central Government
Presently, the Government contributes human resources, facilities, and infrastructure. Overall, it
is still uncertain (and early) as to what to expect from the central Government as new financial
support, but this CNIP definitely calls for some new allocations in the upcoming PRSP and PIP.

5.4.2.2 - Local Government
At the local level, there are numerous government employees who already actively work with the
various UN organizations, NGOs, and IOs in community development. Again, these resources
are more important in terms of human resources, facilities and infrastructure rather than finances.
So far, the most important institutional resource, as far as implementation of the community-
based strategy is concerned, is the VDC. But now this will change with the decentralization
expected with the election of the Commune Councils.

5.4.2.3 - NGOs and Bilateral Donors
In Cambodia, NGOs, both international and local, provide a large amount of support relevant to
nutrition although data on the financial value of the many NGOs in operation is difficult to
obtain. A large proportion of their financial contributions come from bilateral and multilateral
organizations that channel their funds through them as part of their assistance to the country.
The financial contribution is just one aspect of their work. Another important aspect is their
efforts to build capacity and empower communities, especially the disadvantaged. NGOs thus



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                          CHAPTER 5: Financing Child Nutrition in Cambodia


provide an excellent channel for the implementation of community-based programs. The sector
is and will provide its own funds for nutrition-relevant actions: - health; education and training;
community development; agriculture, animal husbandry, fisheries and forestry; water and
sanitation; women-focused projects; child-focused projects; other vulnerable groups, rural credit,
de-mining and a number of rural development projects. Approximately a third of the NGO
finances has been going to the health sector, while another third is equally divided between
education, training, and community development. In general, about 70% of NGO finances go to
social development projects. A significant and valuable feature of NGO activities is their wide
geographical coverage and outreach, particularly in the rural areas.

5.4.2.4 - Private Sector - External Finances
Cambodia is currently receiving considerable donor support. The most significant bilateral
donors include Japan, Australia, France, U.S., Sweden, the Netherlands, UK, Canada, Germany,
Thailand, Denmark, Austria, Norway, Belgium, New Zealand, European Union, Switzerland and
China. The ADB, International Monetary Fund and the World Bank have provided large
amounts of low interest loans. Fiscal reform, development of the private sector and rural
development have been centerpiece strategies advocated by these agencies. The government has
aggressively pursued them. Cambodia already has a significant debt. Loan activity has often
grown faster than grants. The reliance on soft loans will lead the country into further debt.

To a very large extent Cambodia’s huge aid flow reflects the concern and determination of the
international community to bring Cambodia into a development path in the 21st Century. While
there has been some concern regarding the undesirable effects of this aid, there are also concerns
about efficiency, transparency, management and accountability that the government is currently
addressing. Coupled with competition for assistance in emergencies in other countries, it is
conceivable that the present level of external aid will decline throughout the five-year period
proposed by the nutrition investment plan.




                                                                                                71
               Annex 1- Positive and Negative Deviance in Growth

A preliminary investigation of positive and negative deviance in child growth in
Cambodia using the MICS 1996 survey data has provided a unique opportunity for
investigating the importance of CARE in determining the nutritional status of children
throughout the country. A data set was created from the original survey result, which
includes records for more than 5,600 children. Variables in the data set include all
anthropometric indices as well as household level information on expenditure,
household composition, and access to clean water and sanitation as well as
information on health practices and ownership of material goods. This information
has been analyzed and is incorporated into this as an investigation into reducing
childhood malnutrition.

In studies of nutrition interventions, it has been shown that increases in household
income can have a positive impact on child nutrition. This is also shown at the
national level where the prevalence of malnutrition decreases as GNP per capita
increases for most countries. The term positive deviance has been defined as
“adaptive responses for satisfactory child growth under harsh economic
circumstances, such as food scarcity” while negative deviance is described as “the
failure of children to grow satisfactorily, even under good economic conditions”
(Zeitlin, Ghassemi, and Mansour, 1990). The idea of investigating positive and
negative nutritional deviances in the Cambodian context is to identify characteristics
of the households in which these children live. If these preliminary findings provide
enough evidence of measurable child caring practices associated with child growth,
then further investigation may be warranted to identify such practices more
specifically. Behaviors associated with positive deviance may then be promoted
through the Village Development Committees (VDCs) while behaviors that are
associated with negative deviance may be identified and, ideally, modified.

Several studies have supported the UNICEF conceptual model for child nutrition in
which the care behaviors for both child and mother are included as underlying factors
to the two direct determinants of child nutrition and also directly impact child growth
(Kumar et al, 1997). Therefore caregiving behaviors, in combination with household
access to resources are inputs in the process of household production of child
nutrition. A study by Shekar, Habicht, and Latham (1992) refer to positive deviants
as those children who consistently have better growth than the norm for the
population. Most importantly, they determined that positive deviance and negative
deviance are not necessarily mirror images of each other, and their determinants may
be different.

This preliminary analysis was based on a paper by Kumar Range, Naved, and
Bhattara of IFPRI entitled “Child Care Practices Associated with Positive and
Negative Nutritional Outcomes for Children in Bangladesh: A Descriptive Analysis
(1997). In the paper, they describe the endogeneity of childcare, citing categories of
factors and resources that influence the quality of psychosocial care (Engle, Menon,
and Haddad, 1996):
        •  caregiver knowledge, education, and beliefs;
        •  health and nutrition status of the caregiver;
        •  mental health, lack of stress, and self-confidence of caregiver;
        •  caregiver’s autonomy and control of resources;
        •  workload and time constraints of the caregiver;
        •  social support received from family and community

In the Cambodian context, the endogeneity of childcare takes on a special light, given
                                                                                    72
                   Annex 1- Positive and Negative Deviance in Growth

the recent history of political turmoil and societal upheaval. In most countries child
care behaviors and practices are endogenous to cultures, households, and individuals,
being taught over successive generations. In Cambodia, it is likely that the continuity
of passing down traditional knowledge has been broken and many families and
communities are in the process of piecing together their personal history. Through
the VDCs and in using the UNICEF strategy of protection, support and promotion
aimed at the caregiver, the family, the community, and the government, successful
nutritional interventions can be implemented in Cambodia. The activity of protection
involves the identification and elimination of harmful practices or trends while
support and promotion involve the identification and reinforcement of good practices.

The IFPRI study used household data from a nutritional survey in rural Bangladesh
which collected particular information only from children who were 6 to 18 months of
age at the time. In order to determine positive and negative deviants, they identified
outliers in child growth after controlling for child’s age and household income. They
created a model of estimating child weight based on age and household income and
found the difference between predicted weight and actual weight. They then added or
subtracted an estimate of the normally distributed error term and then classified
children as either positive or negative deviants. Among their 111 children, 13.5%
were positive deviants, and 15.3% were negative deviants while the rest were termed
‘median’ growers.

From the Cambodian 1996 MICS data, only the children aged 6 to 18 months were
used. The children’s weights were predicted using a regression model and controlling
for child age and total monthly expenditure per capita (a proxy of income). Then the
children were classified as positive deviants if their predicted weight was less than the
actual weight, minus the standard deviation of the distribution of differences, and
negative deviants were identified as those whose actual weight plus the standard
deviation was less than predicted weight.

Out of 1295 children aged 6 to 18 months in the data set, 189 or 14.6% were
classified as negative deviants, 185 or 14.2% were identified as positive deviants
while 921 or 71.1% were median growers. The following charts and tables provide
an overview and discussion of the comparison of the groups.

Table 1.9 shows that the per capita monthly expenditures differ significantly between
the negative deviant children and the median growth children. The main premise of
the study is to investigate reasons why children grow well despite poor economic
conditions and also to identify factors that may contribute to poor growth outcomes in
situations of relative economic prosperity. Therefore it is expected that the children
in the negative deviance group would have the highest per capita monthly
expenditures.

Table 1.9 - Household and Demographic Characteristics of Positive and Negative Deviant Groups
Variables                                Negative          Median          Positive              All
                                         deviance                          deviance
Per capita monthly expenditure (USD)       19.42 a          13.49            14.96              14.56
Child’s sex
          Male (%)                          40.8             48.8             56.8               48.8
          Female (%)                        59.2             51.2            43.2                51.2
Child’s age (months)                        12.11           12.10            11.97              12.08
Child’s weight-for-age (z-score)           -3.44ab          -1.74c           -0.07              -1.75
Child’s height-for-age (z-score)           -3.64ab          -1.98c           -0.87              -2.07

                                                                                                        73
                    Annex 1- Positive and Negative Deviance in Growth

Child’s weight-for-height (z-score)              -0.88ab             -0.34c   0.91   -0.24
Average household size                            5.97                5.73    5.70    5.76
Head literate? (%)                                69.0b               68.9c   80.5    70.6
Head age < 35 years                               50.1a               60.0    60.1   58.5
Female headed household                           15.6                15.1    11.9   14.7
HH head female < 35 years                         14.0b               11.6c    1.6    10.4
HH head female > 35 years                         17.2                20.4    27.4   20.8
Member of household (%)
           reads paper daily                       8.6               6.4      8.0    7.0
           listens to radio daily                 51.5               49.7     50.2   50.0
           watches TV daily                       58.6a              47.3     54.4   50.0
Village distance from major road (%)
           half km                                 19.6              19.5     24.0   20.2
           1 km                                    26.5              26.5     29.6   26.9
           2 km                                    37.0              33.4     40.2   34.9
           more than 5 km                          45.8              48.5c    38.8   46.7
Notes: Statistically significant at < 0.05 for:
           aComparison between negative deviance and median growth
           bComparison between positive and negative deviance
           cComparison between positive deviance and median growth



•    The distribution of children by sex shows that more boys tend to be positive
     deviants (56.8%) while there is a higher percentage of girls in the negative deviant
     group (59.2%). This is contrary to the overall prevalence rates for children 6 to
     18 months of age, where 47.4% of boys are underweight and only 34.3% of girls
     have weight for age z-scores 2 standard deviations below the mean. The mean
     scores for anthropometry follow an expected pattern of being lowest in the
     negative deviance group and increasing through median to the positive deviance
     group.

•    There are similarities in household size but no information on number and ages of
     children in the household. Literacy of the household head is a significant finding
     for the positive deviant group with more than 80% being literate as compared to
     69% for the median and negative groups. Younger heads of household are more
     common in the negative deviance groups (50.1%) with a significant finding of
     younger (< 35 years) female headed households being rare in the positive
     deviance group, at less than 2 percent of children.

•    Exposure to media is another group of variables to consider. The only significant
     difference found is that where at least one member of a negative deviant
     household watches significantly more television daily than that of the median
     group.

•    The distance a child’s village is from a main road in Cambodia was investigated
     using Map-Info and the GIS codes for the village. It was determined that there
     were more children in the positive deviance group who lived in villages within 5
     kilometers from a main road (61.2%) as compared with the median growers
     (51.5%).

•    In Table 1.10 it is shown that the only information on child feeding practices was
     for exclusive breastfeeding and breastfeeding duration. The average months
     breastfed for each group does not differ much. However, the length of time of
     exclusive breastfeeding is significantly different for each group, with the negative
     deviants averaging 6.25 months, median growers at 5.3 months and positive
     deviants with the shortest duration of 4.3 months.
                                                                                             74
                    Annex 1- Positive and Negative Deviance in Growth




Table 1.10 - Care, Health and Hygiene Practices Among Positive and Negative Deviance Groups
Variables                                                    Negative      Median      Positive    All
                                                             deviance                  deviance
Months breastfed                                                  11.11      11.68      12.00     11.64
Months exclusive breastfeeding                                    6.25ab      5.33c      4.30      5.31
Health workers/square kilometer*                                    24          19        21        20
Health workers per capita                                           17          18        17        18
Primary midwives/square km                                         1.49       1.52      1.59      1.53
Primary nurses/square kilometer                                    8.95       8.29      7.99      8.34
Percent with safe drinking water                                   21.5       24.4       24.2      24.0
Percent with toilets                                               5.6b        8.7c      19.2       9.7
Mother/caretaker washed hands after defecation                      9.0        8.1      10.6       8.6
Diarrhea prevalence                                                45.0       46.5      37.9      45.0
During episode, gave more or same:
              liquid                                              92.0ab      97.8      100.0     97.2
              food                                                 80.4       76.8      76.6      77.3
Have vaccination card                                             54.7a       67.1       61.4     64.6
Mean doses DPT                                                     1.43       1.67       1.57     1.62
Received BCG vaccine                                              48.0ab      67.9       65.5     64.8
Received measles vaccine                                           51.6       59.7       58.9     58.4
Ever received Vitamin A capsules                                   37.0       38.7c      46.9     39.7
When your child is ill with cough and/or cold, what signs or symptoms would lead you
to take him/her to the clinic, health worker, or doctor? (percent yes)
has blocked nose                                                  36.2ab      47.8       46.4     45.9
has difficulty breathing                                           15.8       15.8       19.7     16.4
has fever                                                         49.0b       51.2c      63.6     52.7
is breathing fast                                                  12.6       12.8       10.5     12.4
is ill for a long time                                              5.3        4.0        7.0      4.6
other                                                               7.7        8.7c       3.3      7.8
Don’t know                                                         11.1       11.3       9.1      10.9
Notes: Statistically significant at < 0.05 for:
           aComparison between negative deviance and median growth
           bComparison between positive and negative deviance
           cComparison between positive deviance and median growth



•    The access to health care was compared using presence of health workers in the
     Province as a proxy measure. There were no significant differences between
     groups although a slightly greater number of primary midwives per square
     kilometer is associated with the positive deviant group.

•    Sanitary practices were investigated by comparing the access to safe water (piped,
     bottled, tube/bore holed wells), presence of a sanitary toilet facility, and mother’s
     hand washing after defecation. There were significant associations of good
     sanitary conditions with positive deviants, when compared with both the negative
     deviants and median growers. These are also found when controlling for safe
     water. There are no associations with mother’s hand washing after defecation.

•    Diarrhea prevalence is much lower in the positive deviant group. Significant
     treatment differences are found with the giving of more or the same amount of
     liquid during diarrheal episodes, with 100 percent in the positive deviant group.

•    Measures of preventive health practices include the presence of a vaccination card
     and immunizations. The negative deviance group had significantly fewer children
                                                                                                         75
                    Annex 1- Positive and Negative Deviance in Growth

     who had vaccination cards as compared to the median growers. They also had
     lower immunization coverage for BCG (48%) when compared to the median
     (67.9%) and positive (65.5%) growers. There was no difference in DPT or
     measles vaccination rates. Lastly, a significant percentage of the positive
     deviance children had ever received a Vitamin A capsule (46.9%) as compared to
     the median growers (38.7%).

•    A series of questions was included in the MICS survey which aimed to measure
     symptoms of child illness which would lead to the decision for the mother to seek
     professional medical treatment. Significantly fewer mothers in the negative
     deviance group would seek treatment for a blocked nose (36.2%) when compared
     to the other groups (47.8% and 46.4%) and fewer mothers in the positive deviance
     group would seek treatment for other reasons. However the most significant
     finding in this series of questions is the fact a significantly greater number of
     mothers in the positive deviant group would seek treatment for fever (63.6%) then
     mothers in either median (51.2%) or negative deviance groups (49.0%).

Table 1.11 – Asset Ownership and Expenditures Among Positive and Negative Deviance Groups
Variables                                                      Negative      Median    Positive     All
                                                               deviance                deviance
Ownership variables
         bike                                                        51.0     55.6       57.1      55.2
         boat                                                         7.2      7.7        4.3      7.2
         cart                                                        26.6b    20.6       16.3      20.9
         moto                                                        5.5ab    12.2       16.0      11.8
         radio                                                       38.1     37.3       40.0      37.8
         sewing machine                                               1.5     1.8c        4.8       2.2
         television                                                  15.4a    10.1c      21.0      12.4
Monthly expenditures (riels)
   Food, beverages and tobacco                                  178,520a     123,831   126,917    132,241
   Clothing and footwear                                          9277a       6720       8147       7297
   House maintenance and minor repairs                             919        1017       1218       1031
   Water, light, and fuel                                         8251       10,266    10,178       9960
   House furnishings                                              1711a        286        478        521
   Household operations                                           2250        1925       2243       2018
   Medical care                                                  46,148a     22,227c    39,686     28,211
   Personal transportation & communication equipment              8853        8004       4355       7605
   Operation/maintenance of transportation equipment              1906b       3377       4560       3332
   Transport fares and communication expenses                     5573        4556c      7781       5166
   Recreation                                                      610         434        424        458
   Education                                                      5125        3912       3782       4070
   Personal care products/services                                5549a       4265       4975       4553
   Personal effects                                               1792        1913       3278       2091
   Miscellaneous expenses                                         7320        7685       9565       7901
Notes: Statistically significant at < 0.05 for:
           aComparison between negative deviance and median growth
           bComparison between positive and negative deviance
           cComparison between positive deviance and median growth



•    Also in the MICS survey there were a number of questions asked on ownership of
     various material goods. Only those possessions which are owned by at least 5%
     of this population have been included in this analysis, with the exception of the
     sewing machine. It is interesting to note that households in the negative deviance
     group reported owning carts at a significantly higher rate (26.6%) then the median
     grower households while moto ownership was significantly lower in the negative
     deviance group (5.5%) when compared to both the median growers (12.2%) and

                                                                                                          76
                                                    Annex 1- Positive and Negative Deviance in Growth

                                  the positive deviance group (16.0%). Sewing machine ownership is significantly
                                  higher in the positive deviance group (4.8%) when compared to median growers
                                  (1.8%). Lastly, television ownership is significantly higher for both negative
                                  (15.4%) and positive (21.0%) deviance groups when compared to the median
                                  growers (10.1%).
•                                 Expenditure variables are included here to give an indication on the types of
                                  spending differences between the groups but are based on reported estimates
                                  rather than actual enumeration. Households with negative deviance growers
                                  spend significantly more per month then median growers in the following
                                  categories: food, beverages, and tobacco; clothing and footwear, house
                                  furnishings, medical care, and personal care products and services. The negative
                                  deviance households spend significantly less than positive deviant households on
                                  operation and maintenance of transportation equipment. Households with positive
                                  deviants spend more than those of median growers on both medical care and
                                  transport fares and communication.


Chart 1.10 - Cambodia: Positive and Negative Nutritional Outcomes, and Mean Weight-for-Age Z-scores (6
to 18 months) by Province (MICS, 1996)
                                  100%                                                                                                                               0
    Percent population/category




                                  80%                                                                                                                                -0.5




                                                                                                                                                                             Mean WAZ score
                                  60%                                                            negative                 median                                      -1
                                                                                                 positive       -1.5213   mean waz           -1.4482          -1.4948
                                                                     -1.5718
                                                               -1.6311                                                      -1.6305     -1.584
                                                                                            -1.6501
                                                                                                  -1.6863                         -1.6864          -1.6588
                                  40%                    -1.7851                      -1.7478             -1.7852     -1.8249                            -1.809       -1.5
                                                                           -1.844
                                         -1.9919                                -1.9284
                                                    -2.024
                                  20%                                                                                                                                -2
                                              -2.3806

                                   0%                                                                                                                                -2.5
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A comparison of types of growers by province is shown in Chart 1.10. It also
illustrates the relationship between child growth and mean weight-for-age z-score. It
is possible to see that there appears to be a greater percentage of negative deviance
growers in Phnom Penh (rural districts only) as a percentage of all children measured
there, than in any other province. Bantey Meanchey, Ratanakiri, and Kampot have
the highest rates of positive deviance growers. The lowest mean weight-for-age z-
score is found in Kampong Spueu (-2.3806) while the highest is in Kampot (-1.4482).

 Chart 1.11 illustrates the same information but by dominant land use category. It is
noted that the highest levels of both positive and negative deviance are found in the
urban/peri-urban areas. The least amount of negative deviance children are living in
the flooded forest and shrub/grassland areas. However, there are high percentages of
positive deviance children living in water surface communities.




                                                                                                                                                                                          77
                   Annex 1- Positive and Negative Deviance in Growth




Chart 1.11 - Cambodia: Nutritional Outcomes by Land Use Class: Children Aged 6 - 18 months (MICS,
1996)
          100%                                                       12.6   8.8    5.5
                                         15.7   15.6   14.3   14.0
                           29.2   26.8
          80%      39.1

          60%                                                                      78.9
                                  53.6   70.0   70.6   71.1   70.5          84.4          100.0
                   35.5                                              82.7
          40%              58.4                  negative               median               positive
          20%
                   25.4    12.4   19.6   14.4   13.7   14.6   15.5   4.6    6.8    15.5
           0%
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This section has shown that simple increases in income alone will not improve the
growth of children in Cambodia. Programs that improve literacy of household heads,
improve knowledge, attitudes, and practices in proper child feeding and treatment of
disease, especially those with younger females as heads, could improve nutrition. The
information in the above tables can help to identify those households with successful
caring practices in order to learn more from them, while also identifying child care
practices with negative impacts on child growth. In conclusion, the importance of
Care and caring practices in child growth is paramount and deserves further study.




                                                                                                        78
 ANNEX 2: NUTRITION – RELATED ACTIVITIES OF PERTINENT MINISTRIES AND SELECTED NGOs

  1. Ministry of Planning
Recommendation No. 8: Recommendations for National Level, adopt the Cambodia Nutrition Investment Plan as a component of the Public Investment Plan with the objective of
achieving the following goals in the next 10 years.
Current Activities:
      Name and brief             Ministries         Agencies    Current location of      Duration of       Sources of         Support        Support         Fund needed
        description               involved          involved      implementation          operation           fund           ministries      agencies
To promote production of      - NCN             UNICEF                                                  UNICEF            - Technical
40,000 tons iodized salt in   - NSCIDD          WFP          Country wide                   2002        WFP, HKI             support                                -
order to meet the annual                        HKI                                                     WHO               - Fund
requirement
Supplementary feeding of      - NCN             WFP, RACHA, - Kompong Thom                                                -Technical
mothers and young             - MRD             ADRA, PFD,   - Kratie                     Continue      WFP                 support                                 -
children in food insecure     - MOH             LWS, CRS     - Kampong Speu                                               - Fund
areas                         - MOWA                         - Battambang
                                                             - Banteay Meanchey
Identify strategies and       - MOP             - WFP        - Kampong Thom
mechanisms for monitoring - MRD                 - RACHA      - Kratie                     Continue      WFP               Fund                                      -
and evaluation of             - MOH             - ADRA       - Kampong Speu
supplementary feeding         - MOWVA - PFD                  - Battambang
program for mothers and                         - LWS        - Banteay Meanchey
children in food insecure                       - CRS
areas


Recommendation No. 12: Recommendations for National Level. Make operational the National Council for Nutrition and develop a National Nutrition Information System links to
the National Health Information System to basic strategies at the community and national level, and monitor and evaluation on the progress in reducing malnutrition on women and
children.
Proposed Activities:
   Name and brief            Ministries to be      Agencies to be        Location for            Proposed     Expected funding Technical support                    Barriers to
     description                involved              involved         implementation            duration           source                 needed                implementation
National survey on      - NCN                                                                                                        -Technical support
nutrition sector        - MOH                                            Countrywide                                                 - Fund
Data collection         - National Council
system for nutrition      for Nutrition (NCN)                            Countrywide
sector
Prepare malnutrition    Ministries which are                                                                                         - Fund
Commune Map             member of the NCN                                Countrywide                                                 - Consultancy




                                                                                                                                                                          79
Recommendation No. 13: Recommendations for National Level. Include nutrition- related into the national budget and appropriate policies in the next five-year Socio-economic
Development Plan.
Proposed Activities: Recommendation of Administrative Circular No. 5 dated 25 May 2002
     Name and brief        Ministries to be   Agencies to be       Location for          Proposed        Expected funding Technical support Barriers to implementation
       description              involved         involved        implementation           duration            source                 needed
Include the budget NCN -National Council for                   Permanent                2002            National Budget
operation into the       Nutrition (NCN)                       Secretariat of NCN
national budget


Recommendation No. 14: Recommendations for National Level. Build the capacity and competence of relevant institutes to address the problem of Malnutrition, chronic food
insecurity, and food deficit through relevant program, training and research.
Proposed Activities: Recommendation of Administrative Circular No. 5 dated 25 May 2002
   Name and brief              Ministries to be      Agencies to be         Location for  Proposed    Expected funding Technical support Barriers to implementation
     description                  involved               involved         implementation  duration          source                  needed
Training Course at       - NCN                       - UNICEF                            2002-2003   - UNICEF                - Technical
National Level on        - IMTC                      - WFP                                           - WFP                      support
nutrition and            - Secretarial of NCN        - HKI                                           - HKI                   - Fund
coordination             - NSCIDD
techniques


Recommendation No. 3: Recommendations for Community Level. To raise awareness among the population about nutrition issues (food is more than just rice)

Proposed Activities: Recommendation of Administrative Circular No. 5 dated 25 May 2002
  Name and brief           Ministries to be     Agencies to be     Location for      Proposed          Expected funding      Technical support          Barriers to
     description               involved           involved      implementation       duration              source                  needed             implementation
Education program      -NCN                                                                                                 -Technical
on nutrition           -Provincial coordination                    Countrywide         2002                                   support
                       committee for nutrition                                                                              - Fund
World IDD Day          - NCN                                                                                                -Technical support
                       - NSCIDD                   UNICEF           Phnom Penh          2002                 UNICEF          -Fund
Nutrition newsletters - Secretariat of NCN                                                                                  -Technical support
                       - IMTC for NCN                                                  2002                 UNICEF          -Fund
                       - NSCIDD


Recommendation No. 12: Recommendations for community evel. Advocate and support nutrition issue at the provincial level
Proposed Activity
      Name and brief        Ministries to be Agencies to be   Location for       Proposed        Expected funding         Technical support            Barriers to
        description            involved        involved     implementation        duration              source                 needed                implementation
Technical training on      -All provinces                                                                               -Technical support
nutrition for nutrition    and cities                         Countrywide       2001-2002                               - Fund
coordinating committees
of all province and cities
                                                                                                                                                                    80
 2. Ministry of Education Youth and Sport
Recommendation of Administrative Circular No. 05 dated 25 May 1999

Current Activities:
      Name and brief              Concerned          Concerned          Location in        Duration of        Source of     Support         Support          Funds needed
        description               Ministries          Agencies           operation          operation           funds       ministries      agencies
Nutrition has been           Ministry of                            Institute of
integrated into some         Education Youth and     UNICEF         pedagogical                                                                                     -
subjects related to          Sport MoEYS             UNESCO         research Phnom           5 years          UNICEF                        UNICEF
nutrition.                                                          Penh
Diarrhea Home Care           School Health Dept.                    Takeo, Kg. Thom,
education                    (SHD) of MoEYS           UNICEF        Kg. Speu provinces       3 years          UNICEF                        UNICEF                  -
Conduct the survey of IDD    MoEYS, MoH
                             National Center for                    Kratie and Stung        One month
                             Health Promotion         UNICEF        Treng Provinces                           UNICEF                        UNICEF            US$2, 006.00


Proposed Activities: Recommendation of Administrative Circular No. 05 dated 25 May 1999

    Name and brief           Ministries to    Agencies to be       Location for          Proposed        Expected funding   Technical support   Barriers to implementation
      description            be involved         involved        implementation          duration          sources USD          needed
A month IDD training                         - PHD
teachers and pupils in the     MoEYS         - PED              Kratie and Stung                             UNICEF                             Materials (poster and others)
provinces.                                                      Treng provinces
Diarrhea Disease                                                Kg. Speu, Prey
Prevention activities for      MoEYS                            Veng, Svay Ring,                             UNICEF                                    Diarrhea textbook
5 provinces.                                                    Kg. Thom, and
                                                                Stung Treng
De-worming                                   CNM                Svay Rieng                                   UNICEF                               Materials, documents on
                                                                Provinces                                                                              deworming.

 3. Ministry of Industry, Mines and Energy
Recommendation of Administrative Circular No. 05 dated 25 May 1999

Current Activities:
      Name and brief           Concerned            Concerned          Location in         Duration of        Source of     Support         Support          Funds needed
        description             Ministries           Agencies           operation           operation           funds       Ministries      agencies
Salt Iodization              MIME, MOP,                             Kampot, Phnom
                             MOC, MOH, MRD           UNICEF         Penh & Other             6 years          UNICEF         MIME           UNICEF           US$1,080,000
                                                                    Provinces
Processed food Q.C           MIME, MOC,                             Phnom Penh, All          6 years            MEF                                           US$400,000
                             MOH                                    Provinces



                                                                                                                                                                        81
Proposed Activities: Recommendation of Administrative Circular No. 05 dated 25 May 1999

     Name and brief             Ministries to    Agencies to be          Location for         Proposed   Expected funding   Technical support         Barriers to
      description               be involved        involved            implementation         duration       sources            needed              implementation
                                                                         (provinces)
Salt Iodization, Iron          MIME MOC,                          Kampot, Phnom Penh and
fortification in wheat flour   MOH, MEF            UNICEF         other Provinces              6 years        6 years
and fish sauce


4. Ministry of Social Affairs, Labor, Vocational Training and Youth Rehabilitation (MOSALVY)
Recommendation of Administrative Circular No. 05 dated 25 May 1999

Current Activities:
     Name and brief               Concerned          Concerned          Location in        Duration of    Source of     Support          Support        Funds needed
        description               Ministries          Agencies           operation          operation       funds       ministries       agencies
10-days Training on            MoSALVY/             UNICEF          All 24 Provinces
Alternation Care for           CHILD                                and Municipalities     2001-2005
Children                       WELFARE                                                                     UNICEF       MoSALVY          UNICEF           US$9,240
3-days Workshop on             MoSALVY/CHIL         UNICEF/FHI/     All 24 Provinces
Family and Community           D WELFARE            Impact          and municipalities     2001-2005     UNICEF/FHI/
Based Care and Support         DEPARTMENT                                                                  Impact       MoSALVY          UNICEF           US$9,789
for Orphans and
Vulnerable Children
Reintegration and Follow       MoEYS, MoH
Up Program for Vulnerable      Technical Team       UNICEF          All 17 Provinces       2001-2005       UNICEF       MoSALVY          UNICEF          US$17,048
Children.                                                           and Municipalities
5- Day Training on             MoSALVY                              All 24 Provinces
Planning Strategy for          Technical Group      UNICEF          and Municipalities     2001-2005       UNICEF       MoSALVY          UNICEF          US$10,370
MoSALVY staff
Child Care and Food            MoSALVY                                                                                                     WFP        Rice+oil+fish=
Supplied to Orphans in the     Technical Group                      21Orphanages           12 Months     MOSALVY        MoSALVY                       379,302kg.
Orphanages                                                                                                ASPECA                        MoSALVY       US$127,088.50
                                                                                                           WFP                          ASPECA        US$334,923.07
Food Supplied to Youth            MoSALVY           WFP             Youth Center in        12 Months       WFP                            WFP           Food Supplied
                                                                    Chorm Chao
Food Supplied to Youth            MoSALVY                           Youth Center in        12 Months      MoSALVY       MoSALVY                          US$12,500
                                                                    Chorm Chao
Food Supplied to Youth            MoSALVY           ASPECA          Youth Center in        12 Months      ASPECA                         ASPECA           US$1,800
                                                                    Chorm Chao
Sewing Training                   MoSALVY                           Prey Sor Prison # 2     4 Months        NTB                                           US$2,150
Returning and                     MoSALVY                           Poipet Banteay         2001-2003        IOM         MoSALVY            IOM
Reintegration of                    IOM                   IOM       Meachey                                               IOM                                 -
Trafficking Children and
Women from Thailand
                                                                                                                                                                  82
Proposed Activities: Recommendation of Administrative Circular No. 05 dated 25 May 1999

 Name and Brief Description         Ministries to      Agencies to be         Location for          Proposed       Expecting Funding         Technical Support         Barriers to the
                                    be involved          involved           Implementation          Duration          Source + $                 Needed               Implementation
Reintegration and Follow Up          MoSAYVS                              All 24 Provinces
Program for Vulnerable Children    Technical Team         UNICEF          and Municipalities        2002-2005               UNICEF                 UNICEF
Third National Workshop on           MoSALVY                              All 17 Provinces
Reintegration and Follow Up        Technical Team         UNICEF                                      2002                  UNICEF                 UNICEF
4 Regional Training on Case          MoSALVY                              All 17 Provinces
Conference and Social Work         Technical Team         UNICEF          and Municipalities          2002                  UNICEF                 UNICEF
Returning and Reintegration of                                            Poipet Banteay
Trafficking Children and             MoSALVY                IOM           Meacheay province         2001-2003                IOM                     IOM
Women from Thailand                    IOM


 5. Ministry of Rural Development
Recommendation No. 14: Recommendation for implementation at community level. Provide support to community organisation and formation of VDC

Current Activities:
     Name and brief               Concerned           Concerned          Location in           Duration of       Source of           Support            Agency          Fund needed
        description               Ministries            Agencies          operation             operation          fund              Ministries         support
Village Development                                 - International
Committee and District                                organizations   24 provinces and         2001-2005       National                MRD                 Fund               -
Development Committee               MRD             - Community       cities                                   assistance              NGO
(DDC)                                                 Development
                                                      Department

Recommendation No. 16: Recommendation for implementation at community level. Improve access to use of clean water and sanitation

Proposed Activities: Recommendation of Administrative Circular No. 5 dated 25 May 2002
     Name and brief         Ministries to Agencies to be     Location for implementation                Proposed       Expected funding           Technical Support     Fund needed
        description         be involved     involved                                                    duration           sources                     needed
Continue the provision of                                  Battambang, Kampong Speu, Kg.
household sanitary latrines    MRD          UNICEF         Thom, Takeo, Prey Veng, Svay               2001-2005               UNICEF
                                                           Rieng, Kratie Stung Treng.
Combined well digging /                                    Battambang, Kampong Speu, Kg.
construction programs          MRD          UNICEF         Thom, Takeo, Prey Veng, Svay                2001-2005              UNICEF
                                                           Rieng, Kratie Stung Treng.
Hand-pump well digging                                     Battambang, Banteay Meanchey,
/construction programs         MRD           CHINA         Siem Reap, Pursat.                          2001-2005              CHINA
Underground Water                                          Kampong Cham, Kampong
Research Program               MRD            JICA         Chhnang                                     2000-2002               JICA
Combined well and pond
digging program                MRD          OI, NGO        All provinces and cities                    2001-2005             Government

                                                                                                                                                                                  83
Continue strengthening                                      Battambang, Kampong Speu, Kg.
village health volunteers         MRD            UNICEF     Thom, Takeo, Prey Veng, Svay       2001-2005          UNICEF
                                                            Rieng, Kratie Stung Treng.


Recommendation of Administrative Circular No. 05 dated 25 May 1999

Current Activities:
      Name and brief           Concerned      Concerned     Location in   Duration of       Source of        Ministerial       Agency support    Fund needed
         description           Ministries      Agencies      Operation     operation          fund        Support needed          needed
Cooperate in providing                                     Kg. Cham,                                    Launch Cooperated
credit for rural people and                 EU             Kg. Chhnang,                                 strategic policies
mobilize people to                          (PRASAC)       Kg. Speu,       1994-2003           EU       and staff from MRD        EU Fund        US$3,550,000
participate in establishing      MRD                       Takeo, Prey                                  and others.
credit and saving                MAFF                      Veng, Svay
association                                                Rieng.
Cooperate in training on                                                                                Cooperate launching
skills and professionals at      MRD        EU             Prey Veng,                                   strategic principles
centers to rural people          MAFF       (PRASAC)       Svay Rieng      1994-2003           EU       with MRD and              EU Fund
                                                                                                        MIME staff
Cooperate in training,                      Agri. Sud/     Kandal,                                      Cooperate launching
providing various                           Urban          Pursat,                                      strategic principles     Fund of        3,973,000 EUROS
technologies and                            Agricultural   Battambang      2000-2003        ASD/Agri.   on providing staff     ASD/Agro/Sud
encourage farmers to grow        MRD        Development                                       Sud       from MRD.
vegetable with good                         Program
quality and quantity and
facilitate in marketing
Training and building                                      Takeo,
capacity provincial credit        RD                       Kampong
groups and VDC on                                          Thom,
principles, methods, and                                   Kampong
procedures in managing                                     Speu
rural credit.
Cooperation in the                                         Battambang,
provision of credit services                               Prey Veng,
to people in rural               MRD           UNICEF      Kg. Speu,       2007-2005        UNICEF      Techniques and         UNICEF Fund        US$350,000
communities                                                Takeo, Svay                                  monitoring from
                                                           Rieng, Kg.                                   MRD
                                                           Thom




                                                                                                                                                          84
Proposed Activities: Recommendation of Administrative Circular No. 05 dated 25 May 1999

      Name and brief          Ministries to   Agencies to be        Location for         Proposed      Expected funding      Technical support needed        Barriers to
         description          be involved       involved          implementation         duration          sources                                         implementation
Trained rural credit                                            Prey Veng, Svay                                            Assistance in preparation to
services to VDC, and              MRD         UNICEF/           Rieng, Takeo, Kg.       2001-2005     UNICEF               become community credit
cooperate in provision of        MWVA         Seth Koma         Speu, Battambang,
credit to people in rural                     Program           Kg. Thom, Kratie, St.
communities                                                     Treng, Siem Reap
Strengthening VDC                                               Kampong Cham                                               Technical Assistance to
capacity and providing            MRD         AUSAID/           province                2002-2005     AUSAID               transform community credit
seed capital for rural                        CHP, PHC                                                                     activities to be credit union
communities’ revolving
funds.
Training human resources                                        Kandal, Prey Veng,                                            pure seed production
in the program of                MRD          AUSAID            Svay Rieng, Takeo.      2001-2005     AUSAID                  techniques
improving product quality        MAFF                                                                                         Product improvement and
                                                                                                                              preserving techniques
                                                                                                                              Marketing
Strengthening almost 800                                        Takeo, Prey Veng,                                          Preparation techniques to
saving and credit                 MRD         EU/               Svay Rieng,             2000-2003     EU                   transform SCA to be Credit
communities                                   PRASAC            Kampong Speu,                                              Union
                                                                Takeo, Kg. Chhnang
Training on skills for                                          Kg. Cham, Prey                                                    Business skills
household income                  MRD         EU/               Veng, Svay Rieng,       2000-2003     EU                          Preservation and
generations.                                  PRASAC            Kg. Speu, Takeo, Kg.                                              improvement
                                                                Chhnang.                                                          agricultural products.


 6. Ministry of women’s and veteran’s Affairs
Recommendation of Administrative Circular No. 5 dated 25 May 1999

Current Activities:
    Name and brief             Ministries       Agencies       Current location of   Duration of     Sources of      Support            Implementation     Total Amount
      description              involved         involved        implementation        operation       funding        ministries          Agencies with
                                                                                                                                           MWVA
Training of childcare        . Ministry of                                                                        . Ministry of
teacher on the knowledge     Women and                                               Ongoing        UNICEF        Women and                                US$263,380
related to early childhood   Veteran’s          UNICEF                                                            Veteran’s Affairs
development 22 days for      Affairs                                                                              . Ministry of
childcare teachers and 2-3   . Ministry of                                                                        Education
refreshing course            Education
Monitoring 3-7 days


                                                                                                                                                                   85
Training of literacy         . Ministry of                                                                . Ministry of
teachers 27 days per         Women and          UNICEF                         Ongoing      UNICEF        Women and                            US$226,372
course, Monitoring, 3-7      Veteran’s                                                                    Veteran’s Affairs
days per course              Affairs                                                                      . Ministry of
                             . Ministry of                                                                Education
                             Education
Community health             . Ministry of                                                  UNFPA/AU      . Ministry of
education,3-5 days to        Women and          UNICEF                         Ongoing      SAIDS         Women and                            US$643,421
district women and           Veteran’s                                                                    Veteran’s Affairs
persons responsible for      Affairs                                                                      . Mother of Child
health program               . Mother of                                                                  Care (MCH)
                             Child Care
                             (MCH)
Piloting program on          . Ministry of                Provinces of:                                   . Ministry of
distribution of              Women and          UNFPA/    Kampot and Prey      Ongoing      UNFPA/NMC     Women and                             US$73,012
contraception means for      Veteran’s            MSI     Veng                              HC            Veteran’s Affairs
birth spacing in             Affairs            OPTIONS                                                   . Mother of Child
community                    . Mother of                                                                  Care (MCH)
                             Child Care
                             (MCH)
Seeking support to the       . Ministry of                                                                . Ministry of
policy on women and          Women and          UNAIDS                         Ongoing      UNAIDS        Women and                             US$68,238
HIV/AIDS                     Veteran’s                                                                    Veteran’s Affairs
                             Affairs                                                                      . UNAIDS
Increasing income of rural   . Ministry of                17 Provinces                                    . Ministry of
women (saving credit)        Women and          UNICEF                         Ongoing      UNICEF        Women and                            US$226,418
Extension on credit          Veteran’s           GAT                                                      Veteran’s Affairs
schemes                      Affairs
Information                  . Ministry of                24 provinces and                                . Ministry of
communication on             Women and           PADV     cities               Ongoing      CANADA        Women and                PADV         US$35,227
domestic violence, 5 days    Veteran’s                                                      FUND (CIDA)   Veteran’s Affairs
per course for provincial    Affairs
and district women
service providers
Trafficking program          Ministry of                  Provinces of: Svay                              . Ministry of       . Oxfam Hong
research in 6 provinces      . WVA               IOM      Rieng, Banteay       08/2000 to   Finland       Women and             Kong           US$1,031,112
and cities and to prepare    . Education                  Meanchey, Koh        08/2003      Government    Veteran’s Affairs   . CWCC
document for advocacy        . Health                     Kong, Preah                                                         . Sanfrancisco
and information              . Social Affairs             Sihanouk Ville,                                                       University
communication                . Authorities                Phnom Penh, and
                             . Court                      Pailin
                             . Military




                                                                                                                                                       86
 7. World Vision International
Recommendation of Administrative Circular No. 05 dated 25 May 1999

Current Activities:
      Name and brief         Ministries        Agencies        Current location of      Duration of     Sources of      Support         Support     Fund needed
        description          involved          involved          implementation          operation        fund          ministries      agencies
Promotion of credit                                          Kean Svay, Kandal                                              -              -             -
funding, prevention Vit. A      MoH        World Vision                                To Sep. 03     USAID
deficiency
Strengthening VDC                                            World Vision in Kandal,
capacity and providing         MRD         World Vision      Takeo, Battambang, Kg.    On going       World Vision             -            -            -
seed capital for rural                                       Chhnang, Kg. Speu, Kg.                   funds
communities’ revolving                                       Thom
funds.

 8. CARE International
Recommendation of Administrative Circular No. 05 dated 25 May 1999

Current Activities:
      Name and brief         Ministries        Agencies         Current location of    Duration of     Sources of      Support          Support    Fund needed
        description          involved          involved           implementation        operation        fund          ministries       agencies
Increase ANC visits at HC                                    Banteay Meanchey,                                             -               -             -
inducing Iron tablet           PHD                           Pursat, Koh Kong, Kg.       95-2002        USAID
distribution                    OD                           Chhnang
Support Vitamin A            PHD,MOP                         4 provinces above                                             -               -             -
capsules distribution           OD                                                         2002         VSAID
Distribute Supplemental                                                                                                    -               -             -
food and monitor Growth         PHD                                   BMC               2000-2002     WFP/USAID
in malnourished Children.        OD

  9. PRASAC II KAMPONG CHHNANG
Recommendation of Administrative Circular No. 5 dated 25 May 1999
Current Activities:
     Name and brief    Ministries       Agencies          Current location of          Duration of    Sources of     Support         Support       Fund needed
      description       involved        involved            implementation              operation       fund         ministries      Agencies
Home gardening                                       Samaki Mean Chey, Kampong
                         MAFF          PRASAC        Tralaach, Rolea Biér, Baribout    18 months      PRASAC          PDAFF           PRASAC        US$5,400
Agriculture                                          Samaki Mean Chey, Kampong
                         MAFF          PRASAC        Tralaach, Rolea Biér, Baribout    16 months      PRASAC          PDAFF           PRASAC        US$1,200
Livestock                                            Samaki Mean Chey, Kampong
                         MAFF          PRASAC        Tralaach, Rolea Biér, Baribout    10 months      PRASAC          PDAFF           PRASAC        US$7,740
Rice Production:                                     Samaki Mean Chey, Kampong
Training                 MAFF          PRASAC        Tralaach, Rolea Biér, Baribout     18 school     PRASAC          PDAFF           PRASAC        US$2,196
Pig Raising Training                                 Samaki Mean Chey, Kampong
                         MAFF          PRASAC        Tralaach, Rolea Biér, Baribout     3 courses     PRASAC          PDAFF           PRASAC         US$414
                                                                                                                                                          87
 PRASAC II Takeo
Recommendation of Administrative Circular No. 5 dated 25 May 1999

Current Activities:
  Name and brief       Ministries    Agencies involved         Current location of      Duration of       Sources of     Support        Support           Fund
     description       involved                                 implementation           operation          fund         ministries     Agencies         needed
Vegetable                                                 Doun Keo, Koh Andeth,
demonstration            PDAFF            PRASAC          Kirivong Angkor Borei,          5 years          PRASAC          PDAFF          PRASAC
                                                          Borei Cholsa districts of
                                                          TKO province
Rice demonstration                                        Doun Keo, Koh Andeth,
and seed production      PDAFF            PRASAC          Kirivong Angkor Borei,          7 years          PRASAC          PDAFF          PRASAC
                                                          Borei Cholsa districts of
                                                          TKO province
Livestock production                                      Doun Keo, Koh Andeth,
(Cattle pig chicken,     PDAFF            PRASAC          Kirivong Angkor Borei,          7 years          PRASAC          PDAFF          PRASAC
duck)                                                     Borei Cholsa districts of
                                                          TKO province
Fish pond                PDAFF         AIT, Prek Leab     Doun Keo and Angkor Borei,      3 years          PRASAC          PDAFF          PRASAC
demonstration                         school, PRASAC      Borei districts


Recommendation of Administrative Circular No. 5 dated 25 May 1999

Proposed Activities: Recommendation No. 14 for implementation at National level
   Name and brief      Ministries to be  Agencies to be           Location for         Proposed       Expected funding    Technical support         Barriers to
     description          involved          involved            implementation         duration           sources               needed            implementation
Rice seed production                       PRASAC,        Koh Andeth, Borei Cholsa,                                      Training, follow up,   Flooded, Rats,
and demonstration          PDAFF         PDAFF, NGOs      Kirivong and Angkor           1 year           PRASAC          Evaluation             Drought, Market
                                                          Borei districts
Vegetable                                  PRASAC,        Koh Andeth, Borei Cholsa,                                      Training, follow up,   In seed pest, Market
demonstration              PDAFF         PDAFF,NGOs       Kirivong and Angkor           1 year           PRASAC          Evaluation
                                                          Borei districts
Livestock production                       PRASAC,        Koh Andeth, Borei Cholsa,                                      Training, follow up,   Disease, market
                           PDAFF         PDAFF, NGOs      Kirivong and Angkor           1 year           PRASAC          Evaluation
                                                          Borei districts
Fish demonstration                         PRASAC,        Koh Andeth, Borei Cholsa,                                      Training, follow up,   Market
                           PDAFF         PDAFF,NGOs       Kirivong and Angkor           1 year           PRASAC          Evaluation
                                                          Borei districts




                                                                                                                                                              88
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